Despite the adoption of “sickest first”liver transplantation, pretransplant death remains common, and many early deaths occur despite initially low Model fo r End-stage Liver Disease (MELD) scores. From 1997-2003, we studied 507 cirrho tic United States veterans referred for consideration of liver transplantation t o identify additional predictors of early mortality. Most of the patients were m ale (98%) with cirrhosis caused by hepatitis C and/or alcohol (88%). Data for 296 patients referred prior to February 27, 2002 (training group), were analyzed ; findings were validated in 211 patients referred subsequently (validation grou p). In the training group, 61 patients (21%) died within 180 days without trans plantation; their median initial MELD score was 21. MELD score, persistent ascit es, and low serum sodium (<135 mEq/L) were independent predictors of early morta lity. In patients with a MELD score of less than 21, only low serum sodium and p ersistent ascites were independent predictors of mortality; for MELD scores abov e 21, only MELD was independently predictive. Prognostic significance of persist ent ascites and low serum sodium for low MELD score patients was confirmed in th e validation group. Risk varied continuously with worsening hyponatremia. Modify ing MELD, by including points for persistent ascites and low serum sodium, impro ved prediction of early pretransplant mortality in lowMELDscore patients. In con clusion, persistent ascites and low serum sodium identify patients with cirrhosi s with high mortality risk despite low MELD scores. Ascites, hyponatremia, and o ther findings indicative of hemodynamic decompensation merit further prospective study as prognostic indicators in patients awaiting liver transplantation, and should be considered in setting minimal listing criteria. Despite the adoption of “sickest first” liver transplantation, pretransplant death remains common, and many early death occur with initially low Model fo r End-stage Liver Disease (MELD) scores. From 1997-2003, we studied 507 cirrho tic United States veterans referred for consideration of liver transplantation to identify additional predictors of early mortality. Most of the patients were ale (98%) with cirrhosis caused by hepatitis C and / or alcohol (88%). Data for 296 patients referred prior to February 27, The training group, 61 patients (21%) died within 180 days without trans plantation; their median initial MELD score was 21. MELD score, persistent ascites, and low serum sodium (<135 mEq / L) were independent predictors of early mortal disease. In patients with a MELD score of less than 21, only low serum sodium and p ersistent ascites were independent predictors of mortality; for MELD scores abov e 21, only MELD was independently predictive. Prognostic significance of persist ent ascites and low serum sodium for low MELD score patients was confirmed in validation group. Risk varied continuously with worsening hyponatremia. Modify ing MELD , by including points for persistent ascites and low serum sodium, impro ved prediction of early pretransplant mortality in low MELD score patients. In con clusion, persistent ascites and low serum sodium identify patients with cirrhosi s with high risk risk despite low MELD scores. Ascites, hyponatremia , and o ther findings indicative of hemodynamic decompensation merit further prospective study as prognostic indicators in patients awaiting liver transplantation, and should be considered in setting minimal listing criteria.