Acute-on chronic liver failure (ACLF) occurs in hospitalised patients with cirrhosis and is characterised by multiorgan failures and high rates of short-term mortality. Without liver transplantation (LT), the 28-day mortality of patients with ACLF ranges between 18-25% in those with ACLF Grade 1 to 68-89% in those with ACLF Grade 3. It has become clear that there is lack of equity of access to LT for patients with ACLF across the world due to the current allocation policies, which are based on prognostic scores that underestimate the risk of death of these patients and lack of appreciation that there is clear evidence of transplant benefit for carefully selected patients as they can have excellent post-LT outcomes. This expert opinion provides evidence supporting the argument that patients with ACLF should be given priority for LT using prognostic models that define the risk of death for these patients, pinpoint risk factors for poor post-LT outcomes, identify unanswered questions and describe the design of a global study, the CHANCE study, which will provide answers to the outstanding issues. It also suggests widespread adoption of pilot programmes across the world as have been initiated in the UK and recommended in Spain to introduce new policies for organ allocation for patients with ACLF
