# Excluding Ascites From the GEMA‐Na Score Does Not Impact Outcome Predictions in Liver Transplant Candidates

## TL;DR

Excluding ascites from the GEMA-Na score doesn't hurt its ability to predict outcomes for liver transplant candidates, and it still performs better than other scores like MELD.

## Contribution

The study shows that removing the subjective ascites component from GEMA-Na has minimal impact on outcome prediction accuracy.

## Key findings

- Removing ascites from GEMA-Na only slightly reduced its predictive accuracy (Hc = 0.755 vs. 0.753) but still outperformed MELD scores.
- Over 80% of patients retained the same score when ascites was excluded from GEMA-Na.
- GEMA-Na without ascites outperformed MELD-3.0 and MELD-Na in predicting wait-list outcomes across multiple countries and subgroups.

## Abstract

Although GEMA‐Na outperforms MELD 3.0 for liver allocation, concerns about the subjectivity of its ascites component persist. We compared the performance of a GEMA‐Na iteration that excludes ascites with other allocation scores.

A multinational cohort study was conducted, including adult candidates for elective liver transplantation in the UK (2010–2020), Australia (1998–2020), and Spain (2016–2021). The primary outcome was mortality or delisting for sickness within 90 days. The prognostic impact of ascites was evaluated using multivariable Cox's regression. Discrimination was assessed using Harrell's c‐statistics (Hc). The study included 15 391 patients (28.5% women). The prevalence of the primary outcome was 5.8% in the UK, 5.3% in Australia, and 4.7% in Spain. The presence and severity of ascites was associated with an incremental risk of the primary outcome: 3.3% without ascites, 5.8% with mild ascites, and 7.7% with moderate–severe ascites (p < 0.001). Removal of ascites from the GEMA‐Na score resulted in a one‐point reduction in 18% of patients (52.4% of patients with moderate–severe ascites). GEMA‐Na without ascites showed only a marginal decrease in discrimination (Hc = 0.755 vs. Hc = 0.753; p = 0.007) but still significantly outperformed MELD 3.0 (Hc = 0.734; p < 0.001) and MELD‐Na (Hc = 0.737; p < 0.001). In women, GEMA‐Na with and without ascites demonstrated comparable discrimination (Hc = 0.784 vs. Hc = 0.783; p = 0.61), both outperforming MELD 3.0 (Hc = 0.750; p < 0.001), and MELD‐Na (Hc = 0.749; p < 0.001).

Despite the prognostic impact of ascites among liver transplant candidates, GEMA‐Na without ascites outperformed other scores in predicting wait‐list outcomes and may be used wherever the inclusion of ascites is considered too subjective.

Key Points
Among patients with end‐stage liver disease listed for liver transplantation, the presence and grade of ascites are associated with an incremental risk of 90‐day mortality or delisting for sickness.Including ascites as part of a transplant prioritisation score such as GEMA‐Na raises concerns on subjectivity in some scenarios.An iteration of GEMA‐Na without ascites results in minimal score changes and roughly 80% of patients retain the same score.In more than 15.000 patients from three different countries, GEMA‐Na without ascites consistently outperformed MELD‐Na and MELD 3.0 in predicting wait‐list outcomes, including subgroups of interest such as women and patients with moderate–severe ascites.

Among patients with end‐stage liver disease listed for liver transplantation, the presence and grade of ascites are associated with an incremental risk of 90‐day mortality or delisting for sickness.Including ascites as part of a transplant prioritisation score such as GEMA‐Na raises concerns on subjectivity in some scenarios.An iteration of GEMA‐Na without ascites results in minimal score changes and roughly 80% of patients retain the same score.In more than 15.000 patients from three different countries, GEMA‐Na without ascites consistently outperformed MELD‐Na and MELD 3.0 in predicting wait‐list outcomes, including subgroups of interest such as women and patients with moderate–severe ascites.

Among patients with end‐stage liver disease listed for liver transplantation, the presence and grade of ascites are associated with an incremental risk of 90‐day mortality or delisting for sickness.

Including ascites as part of a transplant prioritisation score such as GEMA‐Na raises concerns on subjectivity in some scenarios.

An iteration of GEMA‐Na without ascites results in minimal score changes and roughly 80% of patients retain the same score.

In more than 15.000 patients from three different countries, GEMA‐Na without ascites consistently outperformed MELD‐Na and MELD 3.0 in predicting wait‐list outcomes, including subgroups of interest such as women and patients with moderate–severe ascites.