ALT This randomized, double-blind trial tested whether oral midodrine helps patients with ACLF and high MELD scores. One hundred thirty patients were assigned to midodrine 5–7.5 mg tid or placebo for 30 days plus standard care. Midodrine did not improve transplant-free survival (TFS) at 1 month (HR, 0.99 [95% CI: 0.37–2.65]) or 3 months (HR, 0.93 [95% CI: 0.48–1.8]). Ascites control at days 30 and 90 was similar between groups. Midodrine increased mean arterial pressure (MAP) more than placebo but did not significantly change plasma renin activity or reduce cirrhosis- or diuretic-related complications, indicating no clinical benefit beyond MAP rise.