What is the management of Model for End-Stage Liver Disease (MELD) scores?

From the Guidelines

MELD scores should be used to prioritize patients for liver transplantation, with a score of 15 or higher recommended for listing patients with end-stage liver disease. The MELD score is a useful tool for predicting 3-month mortality risk in patients with end-stage liver disease, and it takes into account objective measures such as creatinine, bilirubin, and international normalized ratio 1. When interpreting MELD scores, it is essential to consider the following ranges: scores below 10 indicate low short-term mortality risk, 10-19 suggests moderate risk, 20-29 indicates high risk, and scores above 30 represent very high mortality risk.

Key Considerations for MELD Scores

• Patients with MELD scores above 15 should be referred for transplant evaluation, as 1-year survival is lower without transplantation for patients with MELD scores 6-14 1.
• Patients with very high MELD scores (above 35) have a higher risk of mortality and morbidity after transplantation, and their cases should be carefully evaluated by experts 1.
• The MELD score has limitations, and patients with liver diseases requiring transplantation whose severity is not accurately described by the MELD score should be recognized and given a different priority by experts 1.
• Certain conditions, such as hepatocellular carcinoma (HCC), require special consideration and may need extra points to access transplantation, which should be standardized in each country 1.

Clinical Application of MELD Scores

• Regular recalculation of MELD scores is crucial to ensure that patients receive appropriate priority on transplant waiting lists.
• The MELD score combines laboratory values to objectively assess liver function, coagulation status, and renal function, which deteriorate as liver disease progresses 1.

From the FDA Drug Label

At baseline, 40% had alcoholic hepatitis and 19% had ACLF Grade 3; the mean serum creatinine was 3. 5 mg/dL, and the mean MELD score was 33. 5.2 Ineligibility for Liver Transplant TERLIVAZ-related adverse reactions (respiratory failure, ischemia) may make a patient ineligible for liver transplantation, if listed. For patients with high prioritization for liver transplantation (e.g., MELD ≥ 35), the benefits of TERLIVAZ may not outweigh its risks

The MELD score is used to assess the severity of liver disease and prioritize patients for liver transplantation. A higher MELD score indicates more severe liver disease. In the context of TERLIVAZ treatment, a MELD score ≥ 35 may indicate that the benefits of treatment do not outweigh the risks, particularly with regards to the potential for TERLIVAZ-related adverse reactions to make a patient ineligible for liver transplantation. Key points to consider when evaluating MELD scores in this context include:

• Baseline MELD score: The mean MELD score at baseline was 33 in the studied population 2.
• High prioritization for liver transplantation: Patients with a MELD score ≥ 35 may be at higher risk for adverse reactions and may not benefit from TERLIVAZ treatment 2.
• TERLIVAZ-related adverse reactions: Patients should be monitored for adverse reactions, such as respiratory failure and ischemia, which may impact eligibility for liver transplantation 2.

From the Research

Understanding MELD Scores

• MELD scores are a measure of chronic liver disease severity, used to assess patients awaiting liver transplantation 3.
• The score is calculated based on laboratory values and is used to predict short-term survival in patients with end-stage liver disease.

Predictors of Mortality

• Studies have identified several predictors of mortality in patients with high MELD scores, including:
  • Refractory ascites 3, 4
  • Alcoholic cirrhosis 3
  • Hepatic encephalopathy 3, 5
  • High MELD score itself 3, 6
• These predictors can help identify patients at high risk of mortality and prioritize them for liver transplantation.

Outcomes of Liver Transplantation

• Patients with high MELD scores (> 35) have been shown to have poorer outcomes after liver transplantation, including:
  • Lower patient and graft survival rates 4, 6
  • Higher rates of postoperative complications, such as acute kidney injury and dialysis 4
• However, some studies have reported favorable outcomes in selected patients with very high MELD scores, particularly when transplantation is performed in a situation of stabilization or improvement of organ failures 7.

Management of Patients with High MELD Scores

• Patients with very high MELD scores require close monitoring and sequential assessment of scores or classification based on organ failures to stratify the risk of mortality 7.
• Consideration of a patient's comorbidities and frailty is an important predictive approach in this population 7.
• The absence of "definitive" contraindications and the control of "dynamic" contraindications can help identify a "transplantation window" for these patients 7.