*Purpose: The development of ascites is a poor prognostic sign for patients with cirrhosis. The factors associated with transplant-free survival at initial presentation with ascites in patients with alcohol-related liver disease (ALD) are currently unknown. We thus aimed to identify these factors in order to direct limited resources to those patients with ALD at highest risk of needing transplant or dying.

*Methods: Adult patients with ascites in the “Evaluating Alcohol Use in Alcohol-related Liver Disease prospective cohort study” (NCT03267069 clinicaltrials.gov) were identified from 2016-2020. Transplant status and death were tracked in patients’ charts from time of enrollment through June 2020. Demographic, clinical, and laboratory factors at initial ascites presentation were identified as potential predictors of transplant-free survival. Fisher’s exact test and Wilcoxon rank sum test were conducted to test the association between predictors and transplant/death status. Cox proportional hazards models were used to identify significant predictors of transplant/death status. Predictors with p<0.1 in the univariable model were included in the final model.

*Results: A total of 98 patients were identified. Median (IQR) follow up time was 2.6 years (1.5 – 4.6). By last follow up, 45/98 (46%) had either been transplanted or died. Of patients that survived without transplant, 45% had resolution or clinical improvement of ascites. Variables associated with transplant/death were non-employed status, presence of encephalopathy, number of portal hypertension complications, presence of cirrhosis on histology (p<0.01) and male sex, BMI, Model for End-stage Liver Disease (MELD) score, Maddrey’s Discriminant Function, lower ALT, higher total bilirubin, higher INR, and presence of hepatitis on histology (p<0.05). In the multivariable Cox proportional hazards model, younger age (HR 0.92, p<0.05), higher BMI (HR 1.12, p<0.01), and higher comorbidity burden (HR 2.32, p<0.005) were associated with increased likelihood of transplant/death. Mean age was significantly different when outcome groups were separated into transplant (53.2), death (62.8), and transplant-free survival (57.9) (p<0.05).

*Conclusions: Higher comorbidity index and BMI at time of initial presentation with ascites were associated with increased likelihood of transplant/death. While younger age appears to be associated with increased likelihood of transplant/death, this likely reflects the younger population of patients that are selected for transplant, as mean age of transplant patients was the lowest of all groups.

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