Hyponatremia and mortality among patients on the liver-transplant waiting list

N Engl J Med. 2008 Sep 4;359(10):1018-26. doi: 10.1056/NEJMoa0801209.


Background: Under the current liver-transplantation policy, donor organs are offered to patients with the highest risk of death.

Methods: Using data derived from all adult candidates for primary liver transplantation who were registered with the Organ Procurement and Transplantation Network in 2005 and 2006, we developed and validated a multivariable survival model to predict mortality at 90 days after registration. The predictor variable was the Model for End-Stage Liver Disease (MELD) score with and without the addition of the serum sodium concentration. The MELD score (on a scale of 6 to 40, with higher values indicating more severe disease) is calculated on the basis of the serum bilirubin and creatinine concentrations and the international normalized ratio for the prothrombin time.

Results: In 2005, there were 6769 registrants, including 1781 who underwent liver transplantation and 422 who died within 90 days after registration on the waiting list. Both the MELD score and the serum sodium concentration were significantly associated with mortality (hazard ratio for death, 1.21 per MELD point and 1.05 per 1-unit decrease in the serum sodium concentration for values between 125 and 140 mmol per liter; P<0.001 for both variables). Furthermore, a significant interaction was found between the MELD score and the serum sodium concentration, indicating that the effect of the serum sodium concentration was greater in patients with a low MELD score. When applied to the data from 2006, when 477 patients died within 3 months after registration on the waiting list, the combination of the MELD score and the serum sodium concentration was considerably higher than the MELD score alone in 32 patients who died (7%). Thus, assignment of priority according to the MELD score combined with the serum sodium concentration might have resulted in transplantation and prevented death.

Conclusions: This population-wide study shows that the MELD score and the serum sodium concentration are important predictors of survival among candidates for liver transplantation.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Validation Study

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Female
  • Humans
  • Hyponatremia* / etiology
  • Liver Cirrhosis / blood
  • Liver Cirrhosis / classification
  • Liver Cirrhosis / mortality
  • Liver Cirrhosis / surgery
  • Liver Failure / blood
  • Liver Failure / classification*
  • Liver Failure / mortality
  • Liver Failure / surgery
  • Liver Transplantation*
  • Male
  • Middle Aged
  • Prognosis
  • Severity of Illness Index
  • Sodium / blood*
  • Tissue and Organ Procurement*
  • Waiting Lists*


  • Sodium