Severe acute pancreatitis in acute-on-chronic liver failure: An absolute contraindication for liver transplantation?

Acute pancreatitis in the context of acute-on-chronic liver failure (ACLF) is a rare but potentially severe complication that can jeopardize eligibility for liver transplantation (LT). We describe two ACLF patients listed for highly prioritized transplantation who developed acute pancreatitis during the late course of ACLF. In the first case, the patient developed necrosis of the pancreatic tail and a large pseudocyst; in the second, necrosis affected > 50% of the pancreatic body and tail. Both patients were delisted and died. While necrotizing pancreatitis was considered an absolute contraindication for LT in these two cases, recent reports suggest that transplantation may be feasible in highly selected patients. A case-by-case multidisciplinary assessment remains essential for appropriate decision-making in this complex scenario. Early LT could contribute to prevent this feared complication.