Comparative performance of ReMELD-Na, MELD 3.0 and established scores after TIPS for refractory ascites: A multicenter study

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BACKGROUND & AIMS: ReMELD-Na and MELD 3.0 are newly introduced prognostic scores for liver graft allocation, but their ability to predict outcomes after transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites in Western populations remains uncertain. This study compared the prognostic performance of ReMELD-Na and MELD 3.0 with FIPS, MELD-Na, and MELD. METHODS: In this multicenter retrospective study, 1,621 patients with cirrhosis undergoing TIPS for refractory ascites at eight German centers (January 2004-June 2024) were analyzed. Outcomes were the composite of death or liver transplantation (LTx) within 90 days (primary endpoint) and one year (secondary endpoint) after TIPS. Prognostic performance was evaluated using the area under the receiver-operating characteristic curve (AUROC), including sex-stratified analyses, and compared using DeLong's test. High-risk groups (above the 85th percentile for the 90-day endpoint and the 75th percentile for the 1-year endpoint) were compared with non-high-risk groups using Kaplan-Meier analysis, scatter plots, and descriptive score-vs.-score spline smoothing. RESULTS: All scores showed limited predictive performance, with AUROC values ranging from 0.635 to 0.675 for the 90-day outcome and from 0.644 to 0.672 for the 1-year outcome. Female patients demonstrated higher AUROC values, reaching 0.714 for FIPS at 90 days. ReMELD-Na showed significantly lower AUROC values than FIPS, MELD 3.0, and MELD-Na. In contrast, MELD 3.0 demonstrated AUROC values comparable to those of the other scores. All models identified high-risk groups with increased rates of death and LTx. CONCLUSIONS: After TIPS for refractory ascites, all scores exhibited limited prognostic performance, but adequately distinguished high- and low-risk patients. MELD 3.0 performed comparably to established models, while ReMELD-Na was inferior to FIPS, MELD 3.0, and MELD-Na. Higher AUROC values in women suggest sex-specific differences and highlight the need for sex-sensitive prognostic tools. IMPACT AND IMPLICATIONS: Accurate prediction of post-TIPS outcomes is essential to optimize management strategies for patients with cirrhosis and refractory ascites. In this large multicenter study, MELD 3.0 demonstrated prognostic performance comparable to established models, whereas ReMELD-Na - recently implemented for liver allocation in the Eurotransplant region - showed inferior predictive performance, raising concerns about its applicability in this setting. These results are particularly relevant as existing models may inadequately capture post-TIPS risk, especially in male patients. Collectively, the findings advocate for a cautious application of ReMELD-Na in clinical decision-making and emphasize the need to develop sex-sensitive, multidimensional prognostic tools to improve patient selection and surveillance.

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