This year was notable for changes to exception points determined by the geographic median allocation Model for End‐Stage Liver Disease (MELD) and implementation of the National Liver Review Board, which took place on May 14, 2019. The national acuity circle liver distribution policy was also implemented but reverted to donor service area‐ and region‐based boundaries after 1 week. In 2019, growth continued in the number of new waiting list registrations (12,767) and transplants performed (8,896), including living‐donor transplants (524). Compared with 2018, living‐donor liver transplants increased 31%. Women continued to have a lower deceased­donor transplant rate and a higher pretransplant mortality rate than men. The median waiting time for candidates with a MELD of 15‐34 decreased, while the number of transplants performed for patients with exception points decreased. These changes may have been related to the policy changes that took effect in May 2019, which increased waiting list priority for candidates without exception status. Hepatitis C continued to decline as an indication for liver transplant, as the proportion of liver transplant recipients with alcohol‐related liver disease and clinical profiles consistent with non‐alcoholic steatohepatitis increased. Graft and patient survival have improved despite changing recipient demographics including older age, higher MELD, and higher prevalence of obesity and diabetes.

Background/AimModel for end stage liver disease (MELD), an accurate predictor of survival in patients with end stage liver disease (ESLD), has been used to prioritize livers for transplantation (OLT). Hyponatremia, a common complication of ESLD, is also considered a poor prognostic indicator. However, there are few data on how much prognostic value serum sodium (Na+) adds to MELD in predicting survival among patients with ESLD awaiting OLT. We assess the prognostic value of Na+ in conjunction with MELD in predicting survival among patients awaiting OLT.MethodsThis was a retrospective analysis of a prospective cohort consisting of all adult patients with ESLD registered on the waiting list at our institution from the preMELD era (1990-1999). Acute liver disease and hepatic malignancies were excluded. Laboratory data at the time of listing for OLT were obtained from a computerized laboratory database. The outcome of interest was death on the waiting list within 30, 60, and 90-days of listing. Odds ratios (OR) and receiver operator characteristic curves (ROC) were generated using multivariate logistic regression. Additionally, these same data were also analyzed using Cox regression competing risks.Results861 patients met inclusion criteria with mean age of 50 (SD = 10) of whom 55% were male. Median MELD at listing was 15 (interquartile range, IQR: 11-19). Median Na+ was 137 mEq/L (IQR: 134-140). Using logistic regression, MELD was significantly associated with increased mortality on the waiting list at 30 and 90-days, OR = 1.15 and 1.23, respectively (p<0.001). Adjusting for MELD, decreasing Na+ concentrations conferred increased risk of death at 90-days only, with OR for Na+ = 0.9 (p<0.01). Dichotomizing Na+ as low and high (< 126 and ≥ 126 mEq/L, respectively) revealed that low Na+, adjusting for MELD, was significantly associated with mortality at 90-days only, OR for Na+ = 4.28 (p = 0.02). Finally, adding Na+ to MELD changes little in the ROC curves at 90-days (c-statistic for MELD = 0.88; c-statistic for MELD plus Na+ = 0.89). However, competing risk analysis revealed that low Na+ does provide important prognostic value for patients on the liver transplant waiting list, with a Na+<126 mEq/L being equivalent to ˜ 8-10 additional MELD points.ConclusionIn a simple alive/dead analysis (logistic regression), serum Na+ does not appear to add a measurable gain to the prognostic value of MELD. However, in a more appropriate competing risk analysis, serum Na+ is a significant predictor of death in patients awaiting liver transplantation. Therefore, the addition of sodium to MELD in this group of patients may help optimize allocation.