Model for End-Stage Liver Disease (MELD) Score
The MELD score is the primary tool for determining liver transplant priority and predicting short-term mortality risk in patients with end-stage liver disease, calculated using objective laboratory tests including bilirubin, INR, and creatinine. 1
MELD Score Calculation
The MELD score is calculated using the following formula:
MELD Score = 3.78 × log(bilirubin in mg/dL) + 11.2 × log(INR) + 9.6 × log(creatinine mg/dL) + 6.4 1
Important considerations in the calculation:
- Laboratory values less than 1.0 are set to 1.0
- Serum creatinine is capped at a maximum value of 4.0 mg/dL
- For patients on dialysis, creatinine value is set to 4.0 mg/dL
Clinical Significance and Mortality Risk
The MELD score directly correlates with mortality risk in patients with end-stage liver disease:
| MELD Score | 3-Month Mortality Risk |
|---|---|
| 6-9 | 1.9% |
| 10-19 | 6% |
| 20-29 | 19.6% |
| 30-39 | 52.6% |
| 40+ | 71.3% |
Applications in Liver Transplantation
- MELD score ≥15 is recommended for listing patients for liver transplantation, corresponding to a 5-year transplant benefit of 12 months of life gain 1
- Early referral is recommended when MELD >10 or when the first major complication of cirrhosis occurs 1
- Patients with MELD <14 have better 1-year survival without transplantation than with it 1
- The United Network for Organ Sharing uses MELD scores (with bonus points for hepatocellular cancer) to prioritize allocation of deceased donor livers 3
Clinical Utility Beyond Transplantation
The MELD score has proven useful in predicting mortality in various clinical scenarios:
- Variceal bleeding
- Hepatorenal syndrome
- Alcoholic hepatitis
- Acute liver failure
- Risk assessment for non-transplant surgery
- Risk assessment for transjugular intrahepatic portosystemic shunts (TIPS)
Limitations and Considerations
- MELD fails to predict mortality in approximately 15% of patients with end-stage liver disease 3
- The score may be less accurate when INR or creatinine are elevated due to reasons other than liver disease 4
- MELD scores correlate inversely with post-transplant survival, with very high scores (>25) associated with poorer outcomes 1
- Female patients may have worse outcomes than males with the same MELD score, particularly in the creatinine-dominant subtype 1, 5
MELD Subtypes and Prognosis
Recent research has identified that the dominant variable driving the MELD score affects outcomes:
- MELD-Cr (creatinine-dominant): Associated with higher waitlist mortality and lower transplant rates compared to other subtypes 5
- One-year intent-to-treat survival rates differ by subtype: 78% for MELD-Br (bilirubin-dominant), 75% for MELD-INR, and 65% for MELD-Cr 5
Evolution of MELD
The MELD score has evolved over time:
- MELD-Na: Incorporated serum sodium to improve prognostic accuracy
- MELD 3.0: The newest iteration includes patient sex and serum albumin levels, with revised weights for sodium, bilirubin, INR, and creatinine 6
- MELD 3.0 is expected to reduce overall waitlist mortality and improve access for female liver transplant candidates 6
Monitoring Recommendations
Regular monitoring of MELD score is essential as it can change over time:
- Every 3-6 months in stable patients
- More frequent monitoring (every 1-3 months) if there are signs of clinical deterioration 1