The Role of Liver Transplantation in Acute-on-Chronic Liver Failure

Who Should Be Admitted to the ICU and who Should Be Transplanted?

Abstract

Acute-on-chronic liver failure (ACLF) is a syndrome occurring in patients with chronic liver disease, characterized by the acute failure of one or more organs. It represents a critical turning point in the progression of cirrhosis, with a mortality rate reaching up to 70% in intensive care. Liver transplantation, the only curative treatment, radically improves prognosis, offering a one-year survival rate of approximately 85%. However, the shortage of available grafts necessitates a rigorous selection of candidates. Admission to intensive care should follow the same ethical and medical principles as for any critically ill patient, incorporating early assessment of organ failure reversibility. An initial maximal therapeutic commitment is essential to identify eligible patients and, when necessary, apply formal futility criteria to transplantation decisions. Another key challenge is determining the optimal "transplantation window", which requires a delicate balance between patient stabilization, graft availability, and the risk of clinical deterioration. A multidisciplinary approach in close collaboration with an expert transplant center is crucial to ensure an informed and ethical decision-making process, ultimately optimizing transplant access for those most likely to benefit.