Management of Patients with Elevated SCORE2/SCORE-OP Risk
Patients with elevated MELD (Model for End-Stage Liver Disease) scores should be promptly referred to a transplant center for evaluation, as they are at significantly increased risk of mortality and require specialized multidisciplinary care. 1
Understanding MELD Score and Its Significance
The MELD score is a validated prognostic tool that accurately predicts short-term mortality in patients with advanced liver disease. It uses objective variables (bilirubin, creatinine, INR) to calculate a score that correlates with survival probability. Recent research confirms that MELD score is a strong predictor of both 30-day mortality and long-term survival in patients with decompensated liver cirrhosis 2.
Risk Stratification by MELD Score:
- MELD ≤8: Lower risk - can generally undergo both minor and major procedures with minimal perioperative mortality 3
- MELD ≥9: Higher risk - associated with 29% perioperative mortality during procedures 3
- MELD >30: Very high risk - requires intensive care management 1
Management Algorithm for Elevated MELD Scores
1. Immediate Management (All Elevated MELD Patients)
- Identify and treat precipitating factors of decompensation 1
- Monitor for complications of portal hypertension
- Assess for signs of hepatic encephalopathy
- Evaluate for infection, which can worsen prognosis
2. Management Based on MELD Severity
For Patients with MELD Score 9-20:
- Regular monitoring of liver function tests and renal parameters
- Surveillance for hepatocellular carcinoma with ultrasound every 6 months 1
- Management of complications (ascites, varices, encephalopathy)
- Referral to hepatologist for specialized care
For Patients with MELD Score >20:
- Consider admission for close monitoring
- More frequent laboratory monitoring
- Early referral to a transplant center for evaluation 1
- Consider ICU admission for MELD score >30 or if encephalopathy grade 3-4 is present 1
For Patients with MELD Score >30 or Acute Decompensation:
- Immediate admission to ICU or high dependency unit
- Aggressive management of complications
- Urgent transplant evaluation 1
3. Specific Management of Complications
Hepatic Encephalopathy:
- Grade 1-2: Outpatient management with lactulose
- Grade 3-4: ICU admission to protect airways 1
- Add rifaximin for recurrent episodes 1
Portal Hypertension:
- Screening for varices in all cirrhotic patients
- Primary prophylaxis with non-selective beta-blockers or band ligation for high-risk varices
- Secondary prophylaxis after variceal bleeding
Ascites:
- Sodium restriction and diuretics for mild to moderate ascites
- Large volume paracentesis for refractory ascites
- Evaluation for transjugular intrahepatic portosystemic shunt (TIPS) in selected cases
Transplant Evaluation
Patients with recurrent or persistent hepatic encephalopathy should be considered for liver transplantation, and a first episode of overt hepatic encephalopathy should prompt referral to a transplant center for evaluation 1. The presence of clinically significant portal hypertension (CSPH) is a strong predictor of first decompensation and should trigger consideration for transplant evaluation 1.
Pitfalls and Caveats
Don't delay transplant referral: A nationwide study showed that the COVID-19 pandemic delayed admission of cirrhotic patients, resulting in higher MELD scores at admission 1. Early referral is crucial for optimal outcomes.
Beware of MELD limitations: Despite its utility, MELD cannot accurately predict survival in approximately 15-20% of patients 4. Consider additional factors such as nutritional status, sarcopenia, and comorbidities.
Avoid unnecessary procedures: In patients with MELD ≥9, consider alternatives to surgical interventions due to high perioperative mortality 3.
Don't underestimate infection risk: Infection can precipitate decompensation and worsen prognosis. Aggressive screening and treatment are essential.
Consider MELDNa: The sodium-adjusted MELD score may provide better prognostic accuracy in some patients 5.
By following this structured approach to management based on MELD score severity, clinicians can optimize outcomes for patients with advanced liver disease and ensure timely referral for liver transplantation when appropriate.