Table 4.

Unresolved Issues in LT for ACLF.

Issues	What do we know	Comments
Selection criteria for LT	Urgent transplantation is suggested if MELD ≥ 30 ACLF grade 2–3 at day 3–7 in absence of contraindications for LT should be taken to LT	MELD < 30, ACLF-C < 30, showing improvement in first week-monitor No ACLF or ACLF grade 1 at day 3–7 (10% and 21% mortality at 28 days, and 38% and 47% mortality at 180 days, keep option of LT on) ≥4 OFs and CLIF-C ACLF > 64 are unlikely to survive, medical care
How long to wait for spontaneous improvement	If no improvement and OF at first week then LT should be considered	Development of SIRS is a poor prognostic sign
How to prioritize these patients for LT as	Scores including multiple OFs are better to predict prognosis	MELD is used for organ allocation, not good for prognosis in ACLF
How to access prognosis very early in course	No good model	Trend of OFs is important
Role of bridge in presence of organ failure	May help	Cost and availability
When not to consider for LT	No defined delisting criteria	Multiple OFs (worsening trend), pulmonary failure, high ionotropes, active infection

MELD: model-for end stage liver disease; OF: organ failure; SIRS: systemic inflammatory response syndrome.