Does Acute-on-Chronic Liver Failure Still Matter After Liver Transplantation? A Systematic Review and Meta-Analysis of One-Year Survival

Background: Acute-on-chronic liver failure (ACLF) carries high short-term mortality, and liver transplantation remains the only definitive treatment for selected patients. Whether ACLF continues to confer a survival disadvantage after transplantation remains clinically relevant for graft allocation, candidate selection, and prognostic counselling. Methods: This systematic review and meta-analysis evaluated one-year survival after liver transplantation in patients with ACLF compared with non-ACLF transplant recipients. PubMed was searched for eligible studies reporting post-transplant survival outcomes. Data were extracted on study design, population, ACLF definition, comparator group, and one-year survival. Pooled survival proportions were calculated separately for ACLF and non-ACLF groups using random-effects models. Comparative survival was assessed using pooled risk ratios. Heterogeneity and publication bias were evaluated using I2, τ2, funnel plot inspection, and Egger’s test. Results: Ten studies including 59,686 liver transplant recipients were included, of whom 25,016 had ACLF and 34,670 did not. The pooled one-year survival after liver transplantation in ACLF patients was 78.8% (95% CI: 70.1–85.4), with substantial heterogeneity (I2 = 93.1%). In non-ACLF recipients, pooled one-year survival was 86.9% (95% CI: 75.3–93.5), also with high heterogeneity (I2 = 97.8%). Direct comparison showed lower one-year survival in ACLF recipients than in non-ACLF recipients, with a pooled risk ratio of 0.93 (95% CI: 0.92–0.94; p < 0.0001). Egger’s test did not suggest significant publication bias. Conclusions: ACLF does still matter after liver transplantation. Transplanted ACLF patients achieve clinically meaningful one-year survival, supporting transplantation as a valid treatment in selected candidates, but their survival remains lower than that of non-ACLF recipients. The implication is not that ACLF should exclude transplantation, but that ACLF severity, organ failure burden, infection status, and perioperative risk must be integrated more explicitly into selection and allocation decisions.