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.
Keywords: MELD 3.0; allocation; cirrhosis; equity; gender; mortality.
© 2026 The Author(s). Liver International published by John Wiley & Sons Ltd.