*Purpose: The Model for End Stage Liver Disease-Sodium (MELD-Na) score is a reliable predictor of 90-day mortality however its long term predictive ability is unclear, especially in patients with lower scores. Studies on this topic often use databases of patients already listed for transplant which can introduce selection bias. We therefore sought to assess the outcomes of these low MELD-Na patients prior to transplant referral.

*Methods: We utilized HealthLNK, a Chicago-wide database, which incorporates the de-identified electronic medical records from six health care institutions. We included adult patients not on warfarin with icd-9 codes of cirrhosis whose MELD-Na scores were never higher than 15 during the period between January 1, 2006, and December 31, 2012. Records were linked with the state death registry and the “immediate cause of death” as listed on the death certificate was reviewed. Patients’ deaths were classified as “liver related”, “non-liver related”, and “non-descript” as adjudicated by a transplant surgeon and two hepatologists. “Non-descript” deaths were further reviewed and classified based on contributing causes listed. T tests and chi-squared tests were performed for statistical inference.

*Results: We identified 9,502 patients with cirrhosis of whom 4,622 patients had MELD-Na scores that were never higher than 15. Overall patient in both high and low MELD-Na groups were similar in distributions of age, race, and insurance status. However, the low MELD-Na group was more likely to be female (44% vs 35%, p<0.001) and less likely to have alcohol related liver disease (32% vs 57%, p<0.001) or hepatocellular carcinoma (HCC; 15% vs 20%, p<0.001). Low MELD-NA patients were less likely to have decompensated disease and there were fewer deaths in the low-MELD Na group (15% vs 45% p<0.001). They were also less likely to receive a transplant (1.9% vs 12.3%, p<0.001). However in both groups, the most common cause of death was liver related (61% in low MELD-Na patients vs 74.3%, p<0.001). Among these liver related deaths, low MELD-Na patients most commonly died from HCC (33.8% vs 19.5% p<0.001) as compared to the higher MELD-Na group which most commonly died of infection (21.9% vs 19.6%, p<0.001).

*Conclusions: Despite low MELD-Na scores, patients are not free from liver related mortality and selected patients may benefit from exploring earlier transplantation options such as living donor or higher risk grafts.

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