Background & Aim We aimed to develop a risk score for LT recipients and donor selection among patients with ACLF‐3. Methods and Results A total of 7166 adult LT recipients (mean age 53 years, 63% males, 56% Caucasians, 42% obese, median MELD score 36.5) using deceased donor grafts in the UNOS database (01/2002–06/2018) who were in ACLF‐3 at LT as per EASL‐CLIF criteria were analysed. Cox regression model on the derivation dataset (N = 3583) showed recipient age, non‐alcohol aetiology, pulmonary failure, brain failure and cardiovascular failure to be associated with 1‐year patient survival. Observed and expected post‐transplant 1‐year survival showed excellent correlation (R = .920). Risk score from cox model on derivation dataset stratified 3583 recipients in validation cohort using cut‐off scores 7.55 and 11.57 to low (N = 1211), medium (N = 1168) and high risk (N = 1199), with 1‐year patient survival of 89%, 82% and 80% respectively. Based on poor versus good quality graft (donor risk index cut‐off at 1.50), 1‐year patient survival for low, medium and high‐risk categories were 90 versus 89% (p = .490), 83 versus 82% (p = .390) and 83 versus 78% (p = .038) respectively. Among recipients with a high‐risk score, donor factors of age ≥60 years, grafts obtained from national sharing and macro‐steatosis >15% were associated with 1‐year patient survival below 66%. Conclusion Among ACLF‐3 liver transplant recipients, those with high risk at the time of transplant receiving better quality graft will improve post‐transplant outcomes. Prospective studies using additional characteristics are needed to derive an accurate risk score model in predicting post‐transplant outcomes among recipients with ACLF‐3.