Multifactor Risk Stratification for Post‐Transplant Alcohol Relapse Using Abstinence, Psychosocial, and Socioeconomic Factors

Aim: Post-liver transplant (LT) alcohol relapse complicates long-term outcomes and organ allocation. The traditional "six-month abstinence rule" remains widely used, but relapse risk is also shaped by psychosocial, socioeconomic, and psychiatric factors. We examined the impact of pre-LT abstinence duration on post-LT alcohol relapse and developed a multivariable risk model integrating abstinence, psychosocial assessment, and socioeconomic status. Methods: In this single-center retrospective study, 383 adults undergoing LT for alcohol-related liver disease were included. Results: = 80). Relapse phenotypes were non-mutually exclusive: sustained alcohol use (77.5%), harmful drinking (68.8%), and recurrent ALD (46.3%). On multivariable analysis, shorter pre-LT abstinence, higher Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) scores, and higher educational attainment were independently associated with relapse. Each additional month of abstinence reduced relapse odds by 4%, whereas each one-point increase in SIPAT increased relapse odds by 3%. Cumulative risk curves demonstrated a non-linear relationship between abstinence duration and relapse, with risk peaking around 9 months and declining thereafter across all relapse phenotypes. A prediction model combining abstinence duration, SIPAT score, and education achieved an area under the receiver operating characteristic curve (AUC) of 0.70, with consistent performance on fivefold cross-validation. Conclusion: These findings support a multifactorial approach to relapse risk stratification that goes beyond a fixed 6-month abstinence rule. Incorporating abstinence duration together with structured psychosocial assessment and education level may better inform both transplant listing decisions and the intensity of post-LT addiction care for patients.