Early Transplantation in Acute on Chronic Liver Failure: Who and When


Purpose of Review

Acute on chronic liver failure (ACLF) is a unique syndrome that afflicts patients with chronic liver disease and results in high short-term mortality, > 50% at 28 days in patients with severe ACLF (grade 3, ACLF-3). Given this prognosis, there is an urgent need to understand risk factors for this condition, as well as selection criteria for patients who may benefit from liver transplantation (LT).

Recent Findings

Several studies have identified risk factors for developing ACLF, including higher model for end-stage liver disease score, anemia, and morbid obesity, as well ACLF mortality, such as infection, increasing organ failures, and higher white blood cell count. Prognostic tools are now available as online calculators. Regarding LT in ACLF, data suggest that even patients with ACLF-3 may do well after LT, with 1-year survival > 80% in several studies. Improvement in organ failures prior to LT, higher donor quality, and lack of mechanical ventilation further improve outcomes. Importantly, ACLF-3 patients may have higher short-term wait list mortality than patients listed status-1a, suggesting that increased LT prioritization may be warranted.


ACLF is a high-mortality condition that frequently responds well to LT. Ongoing efforts to understand the natural history of ACLF and predictors of improved post-LT survival will facilitate LT criteria for this condition, which may ultimately include increased LT prioritization for selected patients.

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Fig. 1


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Corresponding author

Correspondence to Nadim Mahmud.

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Conflict of Interest

Dr. Sundaram serves on the speakers bureau for Abbvie, Gilead, Intercept, and Salix. Dr. Mahmud, Dr. Hernaez, and Dr. Wu have no disclosures to report.

Human and Animal Rights and Informed Consent

All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).

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This article is part of the Topical Collection on Management of the Cirrhotic Patient

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Mahmud, N., Hernaez, R., Wu, T. et al. Early Transplantation in Acute on Chronic Liver Failure: Who and When. Curr Hepatology Rep (2020). https://doi.org/10.1007/s11901-020-00519-9

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  • End-stage liver disease
  • Portal hypertension
  • MELD score
  • UNOS database