Liver transplantation in acute-on-chronic liver failure: a global multisociety consensus 2026 recommendations

Hepatology

Acute-on-chronic liver failure (ACLF) is a life-threatening syndrome characterised by acute deterioration of liver function in patients with underlying chronic liver disease, often accompanied by hepatic or extrahepatic organ failure. Clinical manifestations may include rapidly worsening jaundice, coagulopathy, ascites and hepatic encephalopathy. ACLF is associated with a high risk of short-term mortality, with reported 28-day mortality rates ranging from 23% to 74%, depending on disease severity and the number of organ failures. Liver transplantation (LT) can provide a substantial survival benefit in appropriately selected patients; however, decisions regarding transplant eligibility and timing must account for disease severity, transplant prioritisation, perioperative risks and expected post-transplant outcomes.[1] The 2026 global multisociety consensus provides recommendations on patient selection, transplant prioritisation, risk assessment, donor options and bridging therapies to guide the role of LT in the management of ACLF.[2]Consensus recommendationsNo.Clinical contextRecommendation1Severe ACLF and short-term mortalityGiven their exceedingly high risk of short-term mortality, significant survival benefits may be derived by patients with severe ACLF, warranting expedited multidisciplinary assessment and access to rapid LT.2Mortality risk assessmentIn patients with severe ACLF, the risk of death may be higher than that predicted by the calculated MELD score.3LT allocation and prioritizationThe development of objective policies for prioritizing LT in patients with ACLF is needed as an alternative or addition to MELD score-based allocation to reduce waitlist mortality.4Factors associated with post-LT mortalityIn patients with severe ACLF undergoing LT, an increased risk of 1-year post-liver transplant mortality is associated with respiratory failure, the requirement for moderate- to high-dose vasopressors, lack of improvement in organ failures, presence of diabetes, and frailty.5Eligibility for LTLT should only be offered to patients with ACLF when an expected 1-year survival of greater than 75%–80% can be achieved.6Healthcare resource utilizationAlthough LT in patients with severe ACLF is associated with significantly higher healthcare resource utilization both before and after LT, it remains justified if acceptable post-LT survival continues to be achieved.7Pretransplant infectionsAn increased risk of post-LT complications is associated with MDROs or fungal infections in patients with severe ACLF before LT.8Living donor LTIn experienced centers, living donor LT may be associated with outcomes similar to those of deceased donor LT in patients with ACLF, while potentially offering an advantage through increased access to expedited LT.9LT in older adultsAlthough older adults with ACLF undergoing LT have higher waitlist and post-transplant mortality compared with younger recipients, acceptable 1-year post-transplant survival may still be achieved in carefully selected older candidates.10Bridging therapies while awaiting LTIn patients with ACLF awaiting LT, extracorporeal therapies, including therapeutic plasma exchange, may be used as supportive bridging measures to stabilize organ function and improve short-term survival compared with standard medical therapy alone.ConclusionThe 2026 global multisociety consensus emphasizes the need for expedited transplant assessment and appropriate prioritization of patients with severe ACLF, given their substantial risk of short-term mortality. Careful evaluation of post-transplant risk factors, expected survival, infection status, age, and donor options is essential for patient selection. Extracorporeal therapies may also provide supportive bridging during the waiting period. Overall, LT should be considered within a multidisciplinary framework that balances transplant urgency with the likelihood of acceptable post-transplant outcomes.[2]Reference(s):1. Li X, Zhang L, Pu C, Tang S. Liver transplantation in Acute-on-Chronic liver failure: Timing of transplantation and selection of patient population. Front Med (Lausanne). 2022;9:1030336. Published 2022 Dec 8. doi:10.3389/fmed.2022.1030336. https://pmc.ncbi.nlm.nih.gov/articles/PMC9773247/2. Acute-on-chronic liver failure: a global multisociety consensus on definitions. Hepatology. 2026. doi:10.1097/HEP.0000000000001891. https://www.ovid.com/jnls/hep/fulltext/10.1097/hep.0000000000001891~acute-on-chronic-liver-failure-a-global-multisociety