Predictors of Mortality in Patients with Cirrhosis and Ascites: A Systematic Review and Meta-Analysis

Background: Cirrhosis complicated by ascites represents a decompensated stage of chronic liver disease associated with substantial morbidity and mortality. Accurate identification of mortality predictors is crucial for risk stratification and timely clinical decision-making.

Objective: To systematically evaluate and synthesize available evidence on predictors of mortality in patients with cirrhosis and ascites.

Methods: A systematic review and meta-analysis were conducted following PRISMA guidelines. A comprehensive search of PubMed, Embase, Scopus, and Cochrane Library databases was performed up to January 2025. Observational studies involving adult patients with cirrhosis and ascites that reported predictors of mortality were included. Data extraction and quality assessment were performed independently by two reviewers. Pooled hazard ratios (HRs) were calculated using a random-effects model, and heterogeneity was assessed using the I² statistic.

Results: A total of 22 studies comprising 6,845 patients were included. Higher MELD score was a strong predictor of mortality, particularly at values ≥20. Hepatorenal syndrome demonstrated the highest mortality risk, followed by spontaneous bacterial peritonitis, hepatic encephalopathy, and hyponatremia. Severe or refractory ascites independently predicted poor outcomes. Subgroup analysis showed improved prognostic accuracy when serum sodium was incorporated into MELD (MELD-Na). Overall, mortality risk was significantly influenced by both hepatic dysfunction and extrahepatic complications.

Conclusion: Mortality in patients with cirrhosis and ascites is multifactorial, with key contributions from hepatic severity, renal dysfunction, infections, and electrolyte imbalance. Integrating clinical and biochemical predictors can enhance risk stratification and guide timely therapeutic interventions.