*Purpose: Early liver transplantation (LT) for acute alcoholic hepatitis (AH) has increased dramatically in the US since 2016. Due to high MELD-Na scores, AH candidates are prioritized at high waitlist (WL) positions at initial listing. Here we examine the WL candidates who were bypassed by and “alternates” to AH candidates who underwent LT.

*Methods: We identified all AH candidates who underwent LT between 2016-2018. Using UNOS status update data and timings of AH candidates’ donor liver offer (“AH offer”) acceptances, we reconstructed hypothetical match lists (based on contemporaneous allocation rules) if the AH offers were rejected. We then identified the immediate “alternates” for the AH offers and compared them to the rest of the WL.

*Results: 227 AH candidates underwent LT, 220 “alternates” (6 of whom were “alternates” to two or more AH candidates), and 38,416 remaining WL candidates were identified. Compared to “alternates,” AH candidates were younger (53 vs 40y, p<0.01) and less likely to be women (45% vs 33%, p<0.01). “Alternates” were more likely to be children (age < 18y) (13% vs 6%, p<0.01), younger (53 vs 57y, p<0.01), women (45% vs 38%, p=0.02), and of shorter height (168cm vs 170cm, p<0.01) compared to the remaining WL. “Alternates” were less likely to be listed with HCC exceptions (6% vs 10%, p=0.04) compared to the remaining WL.

At the time of the AH offer, the median MELD-Na scores were 39 (IQR 35-40) versus 35 (IQR 30-38) for AH and “alternate” candidates, respectively (p<0.01). Median times from listing to the AH offer were 5d (IQR 3-13d) and 103d (IQR 11-337d) for the AH and “alternate” candidates, respectively (p<0.01). “Alternate” candidates had a median total waitlist time of 151d (IQR 28-477d) and median time from AH offer to terminal event (= death/delisting for illness, LT, or other removal) of 13d (IQR 4-46d). In comparison, the median total waitlist time was 141d (IQR 31-312d) for the remainder of the waitlist.

For 14% (31) of the 220 “alternates,” the AH offer would have been that “alternate’s” first offer. 20% (44) of “alternates” died/delisted for illness. Of the 44 who died or were delisted, the AH offer would have been the final offer prior to death/delisting for 10 (23%) of them. Of these 10, the AH offer would have been the only offer ever for 4 (40%) of them.

*Conclusions: In a 3-year period, 44 (20% of “alternates”) candidates died or were delisted for illness on the waitlist who may have received a liver offer if an AH candidate did not supersede them. 23% of these 44 “alternates” who died never received another offer in place of the AH offer. “Alternates” were more likely to be children, women, and of short stature compared to the general WL population. The zero-sum nature of missed opportunities for vulnerable patients should be considered when considering expanding LT for AH, or any other indication for LT.

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