What Model for End-Stage Liver Disease (MELD) score qualifies a patient for liver transplantation?

MELD Score Qualification for Liver Transplantation

A MELD score ≥15 is the minimum threshold recommended for listing patients for liver transplantation, as this corresponds to a 5-year transplant benefit of 12 months of life gain. 1, 2

Understanding MELD Score and Transplant Qualification

The Model for End-Stage Liver Disease (MELD) score is the primary tool used for determining liver transplant priority. It predicts short-term mortality risk in patients with cirrhosis and guides organ allocation based on objective laboratory tests including:

• Bilirubin
• International Normalized Ratio (INR)
• Creatinine 1

Key MELD Thresholds:

• MELD <14: Patients have better 1-year survival without transplantation than with it 1
• MELD ≥15: Minimum listing criteria for patients with end-stage liver disease 2, 1
• MELD >30: Represents extremely high mortality risk (52.6-71.3%) and requires urgent consideration 1

Clinical Decision Algorithm

1. Early Referral (MELD >10):

   • Consider liver transplantation evaluation when the first major complication of cirrhosis occurs (ascites, variceal bleeding, hepatic encephalopathy) 1

2. Listing Decision (MELD ≥15):

   • This is the threshold at which transplant benefit emerges
   • Corresponds to a 5-year transplant benefit of 12 months of life gain 2
   • Patients below this threshold generally have better survival without transplantation 1

3. Priority Stratification:

   • Higher MELD scores receive greater priority for organ allocation
   • MELD scores correlate with the following mortality risks:
     • 10-19: 6% mortality risk
     • 20-29: 19.6% mortality risk
     • 30-39: 52.6% mortality risk
     • 40+: 71.3% mortality risk 1

Important Considerations and Caveats

Risk Factors Beyond MELD

Even with MELD ≤15, certain factors increase mortality risk and may warrant consideration for transplantation:

• Severe hypoalbuminemia
• Hepatorenal syndrome
• Hepatic hydrothorax 3

Post-Transplant Outcomes

• MELD scores correlate inversely with post-transplant survival
• Very high MELD scores (>25) are associated with poorer post-transplant outcomes, with maximum impact during the first year 1, 4
• This creates a clinical dilemma: patients with the highest MELD scores have the highest waitlist mortality but potentially worse post-transplant outcomes

Monitoring Requirements

• Regular monitoring of MELD score is essential as it can change over time
• Reassessment every 3-6 months in stable patients
• More frequent monitoring (every 1-3 months) if there are signs of clinical deterioration 1

Special Populations

• Status 1A patients (acute liver failure): Typically prioritized over chronic liver disease patients regardless of MELD score 5
• Hepatitis C patients: Those with very high MELD scores (>24) may have poorer outcomes post-transplant 6
• Female patients: May have worse outcomes than males with the same MELD score, particularly in the creatinine-dominant subtype 1

In summary, while a MELD score ≥15 is the standard threshold for liver transplant listing, the decision must consider additional risk factors, expected post-transplant outcomes, and the specific clinical circumstances of each patient.