Background : The determination of liver transplantation eligibility for patients with acute-on-chronic liver failure (ACLF) complicated by extrahepatic organ failures, such as respiratory, circulatory, or renal failure, is challenging, and transplant outcomes remain suboptimal. We examined the backgrounds and short-term prognoses of ACLF cases that underwent intensive care before liver transplantation.

Methods : A total of 37 adult ACLF cases from 2001 to December 2024 were included in the study. The diagnosis of ACLF was based on the criteria established by the EASL-CLIF Consortium.

Results : The causes of acute decompensation in ACLF were infection in 18 cases, hepatic encephalopathy in 8 cases, massive ascites in 5 cases, gastrointestinal bleeding in 3 cases, and respiratory failure in 3 cases. Among the 37 cases, 21 (57%) underwent liver transplantation, with a median time from ACLF onset to transplantation of 9 days. Living donor liver transplantation was performed in 20 cases, and deceased donor liver transplantation in 1 case. In the non-transplant group (16 cases, 43%), all patients died, with a median survival time of 15 days after ACLF onset. The 1-year survival rate among transplant cases was 62%, with 7 out of 8 deaths (88%) within the first year attributed to infections. The CLIF organ failure score was significantly higher in the non-transplant group compared to the transplant group (13 vs. 16, p=0.03).

Conclusions : Even in ACLF cases requiring intensive care, 60% of patients were successfully saved through intensive treatment for organ failure and timely liver transplantation.