Ascites is the most common complication of portal hypertension associated with cirrhosis. The development of ascites is a harbinger of a poor prognosis and impaired quality of life. The mortality rate is approximately 50% 2 years after the development of ascites. 1 Independent factors associated with ascites-related mortality include hyponatremia, increased serum creatinine levels, low arterial pressure, and low urine sodium levels. 1,2 Among these variables, only the serum creatinine level is part of the formulation of the Model for End-Stage Liver Disease (MELD), which predicts 90-day mortality for patients awaiting liver transplantation. Therefore, the development of a risk prediction model to further improve risk profiling, especially for patients on the transplant waiting list, remains a top priority. Unfortunately, ascites is a subjective clinical marker that is difficult (if not impossible) to incorporate into defined, objective survival models. Heuman et al. 3 previously demonstrated that hyponatremia and persistent ascites are MELD-independent predictors of early mortality and are especially important in patients with MELD scores lower than 21.
In the field of liver transplantation, the greatest challenge continues to be the shortage of donor organs. The landscape has morphed and now includes the risk of using extended criteria donors because this might be the only opportunity or chance for patients. Therefore, developing an accurate, objective survival model that is fair and totally inclusive in association with donor allocation may be as difficult as total health care reform! In this issue of Liver Transplantation, Somsouk et al. 4 address the daunting question of ascites and mortality risk while patients wait for liver transplantation.