Excluding Ascites From the GEMA ‐Na Score Does Not Impact Outcome Predictions in Liver Transplant Candidates
Year: 2026
Type: article
Study design: Observational Study
Abstract: BACKGROUND AND AIMS: 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. APPROACH AND RESULTS: 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). CONCLUSIONS: 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.
Source: Liver International
DOI: 10.1111/liv.70520
Authors: Manuel Luis Rodríguez‐Perálvarez, Antonio Manuel Gómez‐Orellana, Avik Majumdar, Geoffrey W. McCaughan, María Kalafateli, Rhiannon Taylor, Gloria de la Rosa, María Victoria Aguilera, Mikel Gastaca, Carmen Cepeda‐Franco, María Luisa Ortiz, Jordi Colmenero, Alejandra Otero, Rocío González Grande, Alba Cachero, Esther Molina Pérez, Mónica Barreales, Rosa Martín Mateos, María Rodríguez‐Soler, Mario Romero, Cristina Dopazo, Carmen Alonso Martín, Elena Otón, Luisa González Diéguez, María Dolores Espinosa, Ana Arias Milla, Gerardo Blanco Fernández, Sara Lorente, Antonio Cuadrado Lavín, Miguel Sogbe, David Guijo‐Rubio, César Hervás Martínez, Emmanuel Tsochatzis
Institutions: Instituto Maimónides de Investigación Biomédica de Córdoba, Hospital Universitario Reina Sofía, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Córdoba, The University of Melbourne, Austin Hospital, Austin Health, The University of Sydney, Royal Prince Alfred Hospital, General University Hospital of Patras, NHS Blood and Transplant, Organización Nacional de Trasplantes, Hospital Universitari i Politècnic La Fe, Instituto de Investigación Sanitaria La Fe, Hospital de Cruces, Hospital Universitario Virgen del Rocío, Hospital Universitario Virgen de la Arrixaca, Hospital Clínic de Barcelona, Consorci Institut D'Investigacions Biomediques August Pi I Sunyer, Universitat de Barcelona, Complexo Hospitalario Universitario A Coruña, Hospital Regional Universitario de Málaga, Bellvitge University Hospital, Complejo Hospitalario Universitario de Santiago, Hospital Universitario 12 De Octubre, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Hospital Universitario Ramón y Cajal, Hospital General Universitario de Alicante Doctor Balmis, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universitat Autònoma de Barcelona, Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Hospital Universitario Río Hortega, Hospital Universitario Central de Asturias, Hospital Universitario Virgen de las Nieves, Hospital Universitario Puerta de Hierro Majadahonda, Hospital Clínico Universitario Lozano Blesa, Instituto de Investigación Sanitaria Aragón, Marqués de Valdecilla University Hospital, Instituto de Investigación Marqués de Valdecilla, Clinica Universidad de Navarra, The Royal Free Hospital, University College London
Language: English
Subfield: Hepatology
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $4,780
OpenAlex ID: W7126048170