Mortality Risk Factors Among Patients With Cirrhosis and a Low Model for End-Stage Liver Disease Sodium Score (≤15): An Analysis of Liver Transplant Allocation Policy Using Aggregated Electronic Health Record Data

Although the MELDNa score is now used for liver transplant allocation in the United States, mortality prediction may be underestimated by the score. Using aggregated electronic health record data from 7,834 adult patients with cirrhosis, we determined whether the cause of cirrhosis/cirrhosis complications is associated with an increased risk of death among patients with a MELDNa ≤15 and whether patients with the greatest risk of death could benefit from liver transplantation (LT). Over a median follow-up of 2.3 years, 3,715 patients had a maximum MELDNa score ≤15. 3.4% were wait-listed for LT. Severe hypoalbuminemia, hepatorenal syndrome and hepatic hydrothorax conferred the greatest risk of death independent of MELDNa score with a 1 year predicted mortality >14%. Approximately 10% possessed these risk factors. Of these high risk patients, only 4% were wait-listed for liver transplantation despite no difference in non-liver comorbidities between patients wait-listed and those not listed. Also, risk factors for death among patients wait-listed were the same as those not wait-listed although the effect of malnutrition was significantly greater for wait-listed patients (HR 8.65 CI 2.57-29.11 versus HR 1.47 CI 1.08-1.98). Using the MELDNa score for allocation may continue to limit access to liver transplantation. This article is protected by copyright. All rights reserved.