Early transplantation maximizes survival in severe acute-on-chronic liver failure: Results of a Markov decision process model

•We created a Markov decision process model to maximize overall survival ACLF-3 patients within 7 days of listing.•We examined three variables: earlier transplantation, organ quality, and recovery of organ failures.•Earlier transplantation maximizes overall survival probability, due to high waitlist mortality of patients with ACLF-3.•The impact of a marginal organ on post-LT mortality is less consequential than the mortality from delaying transplantation.•The likelihood of organ failure recovery within 7 days of listing was less than 10%.