Background: Acute-on-chronic liver failure (ACLF) is associated with high mortality, but transplantation improves survival. Optimizing organ function is time-consuming and can increase infection risk. This study investigated the optimal pretransplant waiting period. Methods: In this retrospective study of patients with ACLF who underwent transplantation between January 2021 and August 2024, perioperative details and morbidity were compared between survival and mortality groups. Receiver operating characteristic (ROC) analysis was used to determine the cutoff for the pretransplant waiting period. Results: Among 112 patients with ACLF under the European Association for the Study of the Liver criteria, 61 (54.5%) underwent living donor liver transplantation (mean age, 41 years; 51 males [83.6%]). The most common etiology was viral infection (44.2%). The median Chronic Liver Failure Consortium (CLIF-C) score was 44 (respiratory failure, 14.7%; renal failure, 16.4%). There were 14 (22.9%) posttransplant deaths. The median waiting period between admission and surgery was longer in the mortality group (8 vs.4 days, P=0.2). The area under the ROC curve for the optimal pretransplant waiting period was 0.723 (P=0.01). A cutoff of 5 days predicted mortality with 71.4% sensitivity and 61.9% specificity. On univariate analysis, survivors and nonsurvivors differed significantly in age, hemoglobin level, warm ischemia time, and postoperative gastrointestinal (GI) bleeding; on multivariate analysis, postoperative GI bleeding independently predicted mortality. During a median follow-up of 17 months, no deaths occurred. Conclusions A pretransplant waiting period of 5 days predicted mortality; furthermore, postoperative GI bleeding was an independent predictor of mortality. Further studies are required to confirm these findings.

The primary goal of living donor liver transplantation (LDLT) is to optimize outcomes for the recipient while ensuring donor safety. However, there is a risk of small-for-size syndrome, particularly in obese patients, where graft weight might be inadequate. In such scenarios, dual-lobe LDLT represents a more viable alternative. Although ethical concerns exist regarding potential risks posed to two healthy donors, this method may be most appropriate when deceased donor grafts are unavailable. Here, we describe a case involving an obese patient classified as Child-Pugh class C with chronic liver disease who underwent dual-lobe LDLT. The criteria for selecting the right lobe graft differed slightly from standard protocols, as did the implantation technique. The patient experienced low-output bile leakage, which resolved spontaneously. Priority in graft selection was given to the number of bile ducts, as the right lobes of both donors had nearly equal volumes. Despite simultaneous implantation, cold and warm ischemia times remained manageable due to effective coordination. Although the literature suggests a higher incidence of vascular and biliary complications in dual-lobe LDLT than in single-lobe procedures, these risks can be mitigated by careful planning and coordination.