What is the management plan for a patient with a Model for End-Stage Liver Disease (MELD) score of 18?

Management of a Patient with MELD Score of 18

For patients with a MELD score of 18, the management plan should focus on liver transplantation evaluation, with consideration for antiviral treatment if the patient has hepatitis C, as this represents a critical threshold for treatment decisions. 1

Liver Transplantation Considerations

Transplant Evaluation

• MELD score of 18 represents a pivotal threshold in management decisions:
  • At MELD 18, patients are at the borderline where treatment approaches differ significantly
  • This score indicates advanced liver disease with significant mortality risk

Antiviral Treatment Decisions

For patients with hepatitis C and decompensated cirrhosis:

• MELD <18-20:

  • Treat HCV infection prior to liver transplantation
  • Initiate treatment as soon as possible to complete a full course before transplantation
  • Treatment may improve liver function and potentially lead to delisting in selected cases 1

• MELD ≥18-20:

  • Transplant first, without antiviral treatment
  • Treat HCV infection after liver transplantation 1
  • Exception: If waiting time exceeds 6 months, consider pre-transplant treatment 1

Treatment Regimens for HCV (if applicable)

For patients with MELD <18-20 and HCV:

• Recommended regimens based on genotype:

  • Genotype 1,4,5, or 6: Sofosbuvir + ledipasvir, sofosbuvir + velpatasvir, or sofosbuvir + daclatasvir for 12 weeks with ribavirin 1
  • Genotype 2: Sofosbuvir + velpatasvir or sofosbuvir + daclatasvir for 12 weeks with ribavirin 1
  • Genotype 3: Sofosbuvir + velpatasvir or sofosbuvir + daclatasvir for 24 weeks with ribavirin 1

• Ribavirin dosing:

  • Weight-based dosing: 1000 mg (<75 kg) or 1200 mg (≥75 kg)
  • Start at 600 mg daily and adjust based on tolerance 1
  • For patients with contraindications to ribavirin: Extend treatment to 24 weeks without ribavirin 1

Important Contraindications and Precautions

• Protease inhibitors: Avoid in Child-Pugh B or C decompensated cirrhosis 1
• Monitoring: Frequent clinical and laboratory assessment due to limited safety data in decompensated cirrhosis 1

Management of Portal Hypertension Complications

For patients with refractory ascites:

• MELD <18: Consider transjugular intrahepatic portosystemic shunt (TIPS) 1
• MELD ≥18: TIPS is relatively contraindicated due to higher mortality risk 1
• For large volume paracentesis (>5L): Administer albumin at 8g/L of ascites removed 1

Prognostic Considerations

• MELD score of 18 is associated with approximately 13-20% 90-day mortality risk post-TIPS 1
• Different MELD subtypes carry different prognoses - patients with creatinine-dominant MELD scores have worse outcomes than those with bilirubin or INR-dominant scores 2

Clinical Monitoring

• Regular assessment of liver function tests
• Monitor for signs of hepatic encephalopathy
• Surveillance for hepatocellular carcinoma
• Regular assessment of portal hypertension complications

The management of patients with a MELD score of 18 requires careful consideration of transplantation timing and antiviral treatment strategies, with the goal of optimizing survival and quality of life outcomes.