Background/Objectives: Acute-on-chronic liver failure (ACLF) is a severe syndrome in chronic liver disease (CLD) patients, characterized by multi-organ failure and high mortality. Living donor liver transplantation (LDLT) is vital in donor-scarce areas. This study compares baseline characteristics, perioperative complications, and long-term survival between ACLF and non-ACLF patients, emphasizing etiology, ACLF grading, and graft factors. Methods: Data from a prospective registry of 591 adult LDLT recipients (2019–2023) were analyzed. ACLF was defined by EASL-CLIF (multi-organ failure, grades 1–3) and APASL (jaundice/coagulopathy with complications) criteria, evaluated at initial assessment and within 24 h pre-LDLT. Results: ACLF patients (n = 101, 17.1%) showed higher MELD-Na (27 vs. 20, p < 0.001), bilirubin (6.84 vs. 1.75 mg/dL, p < 0.001), creatinine (108 vs. 70.5 μmol/L, p < 0.001), metabolic/genetic etiologies (9.9% vs. 2.8%, p = 0.001), and chronic kidney disease (23.7% vs. 8.1%, p < 0.001), and lower HCC rates (11.8% vs. 29.6%, p < 0.001). GRWR was marginally lower in ACLF patients (0.59 vs. 0.66, p = 0.10). The ACLF group had elevated infection (27.7% vs. 10.4%, p < 0.001), bleeding (14.9% vs. 6.3%, p = 0.004), and biliary complications (15.8% vs. 7.8%, p = 0.010), with longer ICU (5 vs. 3 days, p < 0.001) and hospital stays (33.66 vs. 20.7 days, p = 0.036). Five-year overall survival was reduced in ACLF patients (log-rank p = 0.001), worsening with grade (EASL-CLIF grade 3: 55% vs. 81% for no ACLF, p = 0.002). Graft survival was also lower (75% vs. 85%, p = 0.02). Multivariable analysis identified chronic kidney disease as an independent mortality predictor (HR 2.09, 95% CI 1.11–3.95, p = 0.023). Conclusions: LDLT for ACLF involves higher perioperative risks and poorer long-term survival than non-ACLF patients, with outcomes deteriorating by ACLF grade. Chronic kidney disease independently predicts mortality. Timely LDLT is essential in donor-limited regions.

The Sundaram Acute-on-Chronic Liver Failure-Liver Transplant Mortality (SALT-M) score predicts 1-year posttransplant mortality in patients with severe acute-on-chronic liver failure (ACLF) undergoing deceased donor liver transplantation. Its performance in living donor liver transplantation (LDLT) is unknown. We externally validated SALT-M in 2 independent ACLF-LDLT cohorts: King Faisal Specialist Hospital and Research Centre (KFSHRC), Riyadh (n=121), and a global International LDLT Registry cohort (n=57). Discrimination (AUROC with 95% CI), calibration (observed-to-expected [O:E] ratio, calibration slope, and intercept), and association with observed outcomes were assessed overall and, in the KFSHRC cohort, separately in ACLF grade 1 and severe ACLF (grades 2–3). In the KFSHRC cohort, ACLF grade was 1 in 47.9%, 2 in 43.0%, and 3 in 9.1%; 1-year mortality was 14.9% (global cohort 21.1%). SALT-M predicted ≤30% mortality in 95.9% of the KFSHRC and 98.2% of the global cohort. Discrimination was limited and statistically inconclusive: AUROC 0.56 (95% CI: 0.40–0.72) overall, 0.62 (0.42–0.81) in severe ACLF, and 0.51 (0.25–0.76) in ACLF-1. Calibration-in-the-large was acceptable (O:E 1.18, 95% CI: 0.74–1.87), but the calibration slope was shallow (0.16). None of the 5 SALT-M components was associated with 1-year mortality; white blood cell count (OR: 1.14, p =0.03) and female sex (OR: 3.49, p =0.02) were associated with 1-year mortality. MELD-Na and MELD 3.0 were higher among nonsurvivors in the global cohort ( p =0.03 and p =0.02, respectively). In LDLT-dominant ACLF cohorts—evaluated largely outside the severe-ACLF population for which SALT-M was derived—discrimination could not be confirmed, reflecting profound spectrum restriction and few outcome events rather than demonstrated model failure. SALT-M should be applied cautiously as an adjunctive risk-stratification tool, not as a universal threshold for transplant candidacy.

Introduction: Living liver donation is a major operation performed without direct medical benefit to the donor. Prospective data on longitudinal donor-reported outcomes after minimally invasive donor hepatectomy remain limited, particularly for robotic approaches offered without donor selection. Methods: This prospective observational cohort study included all consecutive living liver donors undergoing robotic donor hepatectomy between April 2024 and March 2025. The robotic approach was offered to all donors without preselection. Donors completed the Short Form-36 (SF-36), Body Image Scale (BIS), and Beck Depression Inventory (BDI) questionnaires preoperatively and at 3, 6, and 12 months post-donation. Longitudinal changes relative to baseline were assessed using Wilcoxon signed-rank tests. Associations with donor demographics, perioperative variables, and recipient disease severity were evaluated using Spearman correlation and nonparametric group comparisons. Results: A total of 214 donors were analyzed (mean age 36.4 y, 54% male). Physical Functioning, Role-Physical, Bodily Pain, and General Health declined at 3 months but recovered and returned to baseline by 12 months. Emotional Well-Being and Energy/Fatigue improved beyond baseline by 6 months and remained elevated at 12 months. Body image disturbance and depressive symptoms remained low throughout follow-up. Older donor age was modestly associated with better psychosocial outcomes. Donor complications and early recipient mortality were associated with transient reductions in selected domains without sustained impact. No consistent associations were observed with graft type, donor-recipient relationship, or recipient disease severity. Conclusions: Robotic living donor hepatectomy is associated with excellent physical and psychosocial recovery during the first postoperative year, supporting its donor-centered benefits.