Liver transplantation (LT) is the ultimate therapeutic option for patients with life-limiting liver disease in the setting of advanced decompensated cirrhosis. While rapid strides have been made in LT surgery, adequate pre-operative optimization is one of the cornerstones for successful post-operative outcomes. Adequate pre-operative optimization entails managing conventional decompensation, nutritional rehabilitation, prevention of infections, and cardiopulmonary adequacy optimization. The optimization must be detailed and simultaneously spread across multiple axes, with a special focus on active surveillance for infection and risk stratification in the subgroup with acute on chronic liver failure (ACLF). In selected subgroups, transjugular intrahepatic portosystemic shunt (TIPSS) needs to be carefully considered in patients with recurrent portal hypertensive bleeding and refractory ascites. Renal failure has grave underpinnings in outcomes, and close attention to nephrotoxic stewardship needs to be paid. Evaluation and pragmatic strategies for transplant-listed patients’ immunization need to be translated better into practice.