Impact of Model for End-stage Liver Disease 3.0 on Waitlist Outcomes of Metabolic Dysfunction-associated Steatohepatitis Cirrhosis Among Liver Transplant Candidates

Background & Aims Metabolic dysfunction-associated steatohepatitis (MASH) cirrhosis is rapidly growing as an indication for liver transplantation (LT). However, the impact of Model for End-stage Liver Disease (MELD) 3.0 on waitlist outcomes in this population is not established. This study assessed the impact of MELD 3.0 on waitlist outcomes of patients with MASH cirrhosis using the Scientific Registry of Transplant Recipients database. Methods This was a retrospective analysis of the Scientific Registry of Transplant Recipients/United Network for Organ Sharing database including LT waitlist registrants from January 1, 2016, to December 31, 2022. Primary outcomes were 90-day waitlist mortality and transplantation probability in patients with MASH vs non-MASH cirrhosis. Results Among 44,037 waitlist registrants, 12,790 had MASH cirrhosis and 31,247 had non-MASH cirrhosis. The median follow-up was 2.63 months. In MASH cirrhosis, 65.4% were up-categorized and 11.2% were down-categorized when transitioning from MELD-Na to MELD 3.0. Up-categorization was associated with higher 90-day waitlist mortality (hazard ratio, 1.14; 95% confidence interval, 1.05–1.24; P = .002) but not higher transplantation probability (hazard ratio, 1.04; 95% confidence interval, 0.98–1.09; P = .18). Among female patients with MASH cirrhosis, up-categorization similarly did not translate into improved transplant probability. Conclusions Although MELD 3.0 reclassifies a substantial proportion of patients with MASH—particularly women—it does not appear to increase transplant access despite higher predicted mortality risk. These findings highlight residual gaps in how MELD 3.0 captures clinical risk in MASH cirrhosis and underscore the need for prospective data following its implementation.