Acute-on-chronic liver failure (ACLF) involves failure of organs outside the liver and carries a high risk of mortality. It represents a sudden decline in liver function in individuals with pre-existing chronic liver disease. Liver transplantation (LT) is the definitive treatment for ACLF. However, patients with ACLF tend to experience greater complications after LT compared to matched individuals with decompensated cirrhosis. Early identification of ACLF patients who would benefit from transplantation within 30 days is essential. Those with advanced ACLF grades or multiple organ failures (OF) are unlikely to benefit from LT, making it crucial to recognize patients for whom LT would be ineffective. Long-term outcomes are excellent for patients who survive the first year following transplantation. Donors with a risk index of 1.7 or higher and those with hepatic macrosteatosis exceeding 15% are generally unsuitable for organ donation.