What is the management approach for a patient with a high Model for End-Stage Liver Disease (MELD) score?

Management Approach for Patients with High MELD Scores

Patients with a high Model for End-Stage Liver Disease (MELD) score should be evaluated for liver transplantation, as the MELD score is an excellent predictor of short-term pre-transplant mortality risk and serves as the primary basis for organ allocation in many countries. 1

Understanding MELD Score and Its Significance

• The MELD score is calculated using objective laboratory parameters: serum creatinine, serum bilirubin, and international normalized ratio (INR), making it a reliable tool for predicting 90-day mortality in patients with end-stage liver disease 1, 2
• A MELD score ≥15 is generally recommended as a threshold for listing patients for liver transplantation, as patients with MELD <15 may have lower survival benefit from transplantation 1
• In very sick patients with MELD >30, the risk of mortality and morbidity after transplantation should be carefully assessed, though these patients typically have the greatest need for transplantation 1, 3

Management Algorithm for High MELD Score Patients

Step 1: Immediate Assessment and Stabilization

• Identify and treat complications of cirrhosis that may be contributing to the high MELD score (variceal bleeding, infection, renal dysfunction) 1
• Calculate and document the MELD score to establish baseline and track progression 1, 2

Step 2: Transplant Evaluation

• Refer for liver transplantation evaluation when MELD score is ≥15 or when major complications of cirrhosis occur 1
• Engage a multidisciplinary team including transplant hepatologist, transplant surgeon, and other specialists based on comorbidities 1

Step 3: Management While Awaiting Transplantation

• Monitor MELD score regularly to track disease progression and adjust transplant priority 1, 4
• Manage specific complications of cirrhosis:
  • Refractory ascites: Consider TIPS procedure in selected patients, though MELD score should be evaluated as a predictor of post-TIPS survival 1
  • Variceal bleeding: Implement standard prophylaxis and treatment protocols 1, 5
  • Hepatic encephalopathy: Treat and prevent recurrence 1
  • Alcoholic hepatitis: In patients with alcoholic hepatitis and high MELD scores, consider specific treatments like corticosteroids when appropriate 1, 2

Step 4: Consider MELD Exceptions

• Recognize conditions where MELD score may not accurately reflect mortality risk or transplant benefit, including: 1
  • Hepatocellular carcinoma (HCC) 6
  • Hepatopulmonary syndrome
  • Portopulmonary hypertension
  • Refractory ascites
  • Recurrent cholangitis
  • Other conditions listed in established exception criteria 1

Special Considerations

• Delta MELD (change in MELD over time) may be a better predictor of mortality in some patients and should be monitored 1, 3
• In patients with very high MELD scores (>35), mortality following liver transplantation may be increased, requiring careful patient selection 1, 3
• The MELD score has limitations in approximately 15-20% of patients whose survival cannot be accurately predicted by this model alone 7, 3
• Some centers are exploring modifications to improve MELD accuracy, such as incorporating serum sodium (MELD-Na) or other variables 4, 3

Pitfalls to Avoid

• Do not delay transplant evaluation in patients with rapidly rising MELD scores, even if the absolute value is not yet at listing threshold 1, 4
• Avoid relying solely on MELD score for clinical decision-making; consider the overall clinical picture and presence of complications 1
• Be aware that MELD score may be artificially elevated in situations where INR or creatinine is increased for reasons unrelated to liver disease 4, 3
• Do not overlook MELD exceptions that may qualify patients for additional priority points on transplant waiting lists 1, 6