When is the Model for End-Stage Liver Disease (MELD) score used in patient management?

From the Guidelines

The MELD score should be used in patient management to prioritize liver transplantation candidates, predict short-term mortality, and guide treatment decisions, particularly when the score exceeds 15, indicating a higher urgency for transplantation. When evaluating patients with cirrhosis, the MELD score is a valuable tool to determine transplant priority, assess disease severity, and predict survival. The score incorporates serum bilirubin, serum creatinine, and INR (International Normalized Ratio) values to calculate a number ranging from 6 to 40, with higher scores indicating more severe disease and greater urgency for transplantation 1. Some key points to consider when using the MELD score in patient management include:

• MELD scores above 15 generally warrant consideration for transplantation, as the benefits of liver transplantation only emerge once the MELD exceeds 14 1
• A MELD score > 14 is typically the minimal listing threshold for transplantation, and a score > 15 may be used as a surrogate endpoint in clinical trials to establish a link to "need for transplant" and "mortality" 1
• The MELD score has several limitations, and patients with liver diseases requiring liver transplantation (LT) whose severity is not described by the MELD should be recognized and given a different priority by experts 1
• Hepatocellular carcinoma (HCC) is a particular MELD exception that requires extra points to get access to the transplant, which should be standardized in each country and take into account size, number of nodules, AFP levels, and recurrence after downstaging therapy 1. In clinical practice, the MELD score is used to guide clinical decisions regarding the timing of interventions, hospitalization needs, and the management of complications like ascites, hepatic encephalopathy, and variceal bleeding, providing an objective measure of liver dysfunction severity and allowing for standardized assessment across different clinical settings 1.

From the Research

MELD Score Usage in Patient Management

The Model for End-stage Liver Disease (MELD) score is used in various aspects of patient management, including:

• Prioritization of candidates for liver transplantation, with higher scores indicating a higher priority for transplantation 2, 3, 4
• Prediction of pre-transplant mortality, with increasing MELD scores associated with higher mortality rates 2, 5
• Estimation of survival probabilities without a liver transplant, with MELD scores used to calculate 3-day, 7-day, 14-day, 30-day, and 90-day survival probabilities 3
• Identification of futility predictors, such as patient age, obesity, and multiple comorbidities, to determine which patients may not benefit from liver transplantation 2
• Selection of patients for surgery other than liver transplantation, such as those with cirrhosis who have infections or variceal bleeding 5
• Determination of optimal treatment for patients with hepatocellular carcinoma who are not candidates for liver transplantation 5

Limitations and Refinements of the MELD Score

While the MELD score is a useful tool in patient management, it has several limitations, including:

• Inter-laboratory variability of the parameters included in the score 4
• Inability to predict mortality accurately in specific settings, such as hepatocellular carcinoma 4
• Need for refinement and validation to improve predictive accuracy, such as the addition of variables that are better determinants of liver and renal function 5
• Alternative scores, such as the MELD-LDH score, which may provide better prognostic value in certain patient populations, such as those with acute liver failure 6

Clinical Applications of the MELD Score

The MELD score has several clinical applications, including:

• Liver transplantation, where it is used to prioritize candidates and predict pre-transplant mortality 2, 3, 4
• Management of patients with cirrhosis, where it is used to predict survival and determine optimal treatment 5
• Management of patients with hepatocellular carcinoma, where it is used to determine optimal treatment and predict survival 5
• Management of patients with acute liver failure, where alternative scores such as the MELD-LDH score may provide better prognostic value 6