Severe acute alcoholic hepatitis (AAH), characterized by high short-term mortality (exceeding 75% at 6 months) in patients failing corticosteroid therapy (Lille score >0.45), represents a paradigm shift in liver transplantation, moving from historical contraindication to a potentially life-saving intervention for highly selected candidates. Landmark studies, notably Mathurin et al. (2011), demonstrated dramatically improved survival (70-85% at 5 years) with early LT compared to medical management alone in rigorously selected steroid-nonresponsive patients experiencing their *first* episode of decompensation. Crucially, strict selection criteria waive the traditional 6-month sobriety rule but mandate a definitive AAH diagnosis, confirmed steroid non-response, absence of severe comorbidities, and, most importantly, an exhaustive multidisciplinary psychosocial evaluation assessing insight, commitment to abstinence, strong social support, and engagement in long-term addiction treatment. While outcomes are excellent and harmful alcohol relapse rates post-LT (10-20% at 5 years) are comparable to patients transplanted for alcohol-related cirrhosis after meeting sobriety rules, significant ethical controversies persist regarding organ allocation fairness and the ability to perfectly predict relapse, necessitating careful protocolized implementation by transplant centers.