Abstract: Background and Aims: Although GEMA-Na outperforms MELD 3.0 for liver allocation, concerns about the subjectivity of its ascites component persist. We compared the performance of a GEMA-Na iteration that excludes ascites with other allocation scores. Approach and Results: A multinational cohort study was conducted, including adult candidates for elective liver transplantation in the UK (2010-2020), Australia (1998-2020), and Spain (2016-2021). The primary outcome was mortality or delisting for sickness within 90 days. The prognostic impact of ascites was evaluated using multivariable Cox's regression. Discrimination was assessed using Harrell's c-statistics (Hc). The study included 15-391 patients (28.5% women). The prevalence of the primary outcome was 5.8% in the UK, 5.3% in Australia, and 4.7% in Spain. The presence and severity of ascites was associated with an incremental risk of the primary outcome: 3.3% without ascites, 5.8% with mild ascites, and 7.7% with moderate-severe ascites (p<0.001). Removal of ascites from the GEMA-Na score resulted in a one-point reduction in 18% of patients (52.4% of patients with moderate-severe ascites). GEMA-Na without ascites showed only a marginal decrease in discrimination (Hc=0.755 vs. Hc=0.753; p=0.007) but still significantly outperformed MELD 3.0 (Hc=0.734; p<0.001) and MELD-Na (Hc=0.737; p<0.001). In women, GEMA-Na with and without ascites demonstrated comparable discrimination (Hc=0.784 vs. Hc=0.783; p=0.61), both outperforming MELD 3.0 (Hc=0.750; p<0.001), and MELD-Na (Hc=0.749; p<0.001). Conclusions: Despite the prognostic impact of ascites among liver transplant candidates, GEMA-Na without ascites outperformed other scores in predicting wait-list outcomes and may be used wherever the inclusion of ascites is considered too subjective.

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