A new study published in Clinical Transplantation assessed the impact of overt hepatic encephalopathy (OHE) on waitlist mortality in three cohorts of cirrhotic patients awaiting liver transplantation, with differences in composition of patient population, transplantation policy and transplantation rates. These cohorts were derived from two centers in the Netherlands - reference and validation cohort, n=246 and n=205, respectively, and one in Spain - validation cohort, n=253. The results revealed that OHE was associated with mortality, independently of Model of End-stage Liver Disease (MELD) score, other cirrhosis-related complications and hepatocellular carcinoma (HCC). Meanwhile, the addition of extra MELD points for OHE counteracted its negative impact on survival. These findings were confirmed in the Dutch validation cohort whereas in the Spanish cohort, containing a significantly greater proportion of HCC and with higher transplantation rates, OHE was not associated with mortality. From the findings, it was concluded that OHE is an independent risk factor for one-year waitlist mortality and might be a prioritization rule for organ allocation. However, its impact seems to be attenuated in settings with significantly higher transplantation rates.