There is a debate regarding the high mortality risk after liver transplantation in patients with a high MELD score [
8]. Some authors consider that transplantation in these patients can be futile. On the one hand, the survival benefit for these patients is extremely high as shown in patients with severe acute alcoholic hepatitis or with acute-on-chronic liver failure [
9,
10]; on the other, the high mortality rates after liver transplantation can be considered a waste of organs [
8]. The MELD score is highly predictive of the risk of mortality on the waiting list [
4,
11]. Patients on the waiting list with a MELD score of over 30 or 40 have an expected mortality rate of more than 50 and 70%, respectively, within 3 months [
4]. Therefore, there is justification to prioritise these patients. In patients with very high MELD scores (> 35), there is a risk of high post-transplant mortality and of over indication for liver transplantation. There is a consensus that for scores up to MELD 35, post-transplant survival remains unmodified. In patients with a MELD score above 35, there is currently no consensus on the potentially higher risk of post-transplant morbidity and mortality [
12]; however, the postoperative morbidity and ICU length of stay are significantly higher [
12,
13]. Interestingly, the percentage of patients with chronic liver disease transplanted while in the ICU or soon after recovery remains low (< 10%) [
14]. There are several reasons for this. First, patients in the ICU are frequently not evaluated for liver transplantation either because they are not in a liver ICU or because liver transplantation is considered too risky and futile. Several authors have tried to determine, through scores such as the Frailty scoring system [
15] or other scores [
16], the limits at which transplantation is futile. Our personal opinion is that this line of futility is permanently evolving.
Considering the dramatic improvement of the results of liver transplantation over the past years, we need to be more reactive regarding the indication of liver transplantation in the most severe patients, i.e. those in the ICU. When a patient is referred in a critical condition, the very first question to address is: is this patient a potential candidate for liver transplantation? For alcoholic cirrhotic patients, or for patients with acute alcoholic hepatitis refractory to medical treatment, this will require an urgent workup, advice from a specialist in alcohol addiction, and a consensus decision from the team [
9]. When the decision for liver transplantation is taken, patient prognosis should be assessed using ICU scores rather than the MELD score [
17,
18]. An urgent workup to assess comorbidities is also required. The difficult issue is the definition of the optimal window for transplantation in such severe cases. The risk is to perform transplantation in patients without an adequate workup at the worse moment. Therefore, coordination with the ICU specialists in order to determine the appropriate timing for liver transplantation is essential. The optimal transplantation window between several complications is difficult to determine, but essential for its success. This transplantation window may be open during the ICU stay or soon after recovery prior to the advent of the next deteriorating event [
19].