Development and Internal Validation of the MELD–ERT Score for Mortality Risk Stratification After Liver Transplantation

Background/Objectives: The Model for End-Stage Liver Disease (MELD) score reflects pretransplant disease severity, but does not capture intraoperative factors that may influence post-transplant outcomes. This study aimed to develop and internally validate a composite MELD–erythrocyte transfusion (ERT) score for mortality risk stratification after liver transplantation (LT). Methods: This retrospective, single-center cohort study included 125 adult LT recipients between August 2024 and July 2026. A MELD–ERT score (0–2) was constructed using ROC-derived cut-offs for MELD and intraoperative ERT. Prognostic performance for mortality and overall survival (OS) was evaluated using regression, conventional and time-dependent ROC and survival analyses, with bootstrap internal validation. Results: During a median follow-up of 544 days, 30 patients (24.0%) died. MELD and ERT were independently associated with mortality. Mortality increased stepwise across MELD–ERT scores of 0, 1, and 2 (0%, 36.2%, and 59.1%, respectively). The MELD–ERT score showed good discrimination (AUC 0.836, 95% CI 0.776–0.897), with an optimism-corrected AUC of 0.818 after bootstrap validation. Its discrimination was comparable to MELD alone (p = 0.660) and superior to ERT alone (p = 0.002). Time-dependent AUCs for MELD–ERT were 0.893, 0.930, 0.837, and 0.812 at 3, 6, 12, and 24 months, respectively. OS differed significantly across score categories (log-rank p < 0.001), and high-risk patients had a 9.7-month shorter 24-month RMST (95% CI 5.4–14.3; p < 0.001). Conclusions: The MELD–ERT score provides a simple approach to post-LT mortality risk stratification and demonstrated good discrimination after internal validation. However, it did not significantly outperform MELD alone. External validation is warranted.