Liver Transplantation in Acute-On-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) represents a distinct clinical syndrome characterized by acute deterioration of chronic liver disease with systemic inflammation, organ failures, and high short-term mortality. Multiple diagnostic frameworks exist globally, including those proposed by the Asian Pacific Association for the Study of the Liver (APASL), the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) consortium, and the North American Consortium for the Study of End-Stage Liver Disease (NACSELD). Liver transplantation (LT) remains the only curative therapy for ACLF, offering substantial survival benefit. Posttransplant outcomes are strongly influenced by disease severity and timing of intervention, with ACLF grade 3 patients representing challenging population. Dynamic prognostic models, including the CLIF-C ACLF, and AARC scores, enable sequential assessment during the critical first week of illness, identifying patients likely to benefit from urgent transplantation versus those who may recover with medical management. The concept of a "golden window" for transplantation refers to the optimal timeframe within the first week when intervention offers maximal benefit. Living-donor liver transplantation (LDLT) predominates in Asia, whereas deceased donor liver transplantation (DDLT) remains the standard in Western countries. Emerging futility models, such as the TAM score, help identify patients too critically ill to benefit from LT. The ongoing CHANCE study, a global prospective registry, aims to clarify transplant benefit, waitlist attrition, and futility thresholds across diverse populations. Given the heterogeneity of diagnostic criteria, determining transplant candidacy in ACLF is inherently complex and requires individualized patient-specific (n = 1) assessment that integrates multiple frameworks including APASL and EASL-CLIF criteria.