What are the management guidelines for patients with liver disease according to MELD (Model for End-Stage Liver Disease) guidelines?

Management Guidelines for Patients with Liver Disease According to MELD

The Model for End-Stage Liver Disease (MELD) score is an essential tool for prioritizing patients for liver transplantation, with a MELD score ≥15 generally recommended as the threshold for listing patients for transplantation due to its excellent prediction of short-term pre-transplant mortality risk. 1

Understanding MELD Score

• 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
• MELD score has been shown to accurately predict survival in patients with cirrhosis and is the primary basis for organ allocation in many countries 1, 3
• MELD score is superior to the Child-Pugh classification for predicting short-term mortality in patients with cirrhosis 2

Management Algorithm Based on MELD Score

MELD Score ≥15 (High Risk)

• Immediate referral for liver transplantation evaluation 1
• Identify and treat complications of cirrhosis that may be contributing to the high MELD score (variceal bleeding, infection, renal dysfunction) 1
• Engage a multidisciplinary team including transplant hepatologist, transplant surgeon, and other specialists based on comorbidities 1
• Regular monitoring of MELD score to track disease progression and adjust transplant priority 1

MELD Score <15 (Lower Risk)

• Focus on management of specific complications of cirrhosis 1
• Regular follow-up to monitor for disease progression 1
• Consider transplantation when major complications of cirrhosis occur despite optimal medical management 1, 4

Special Considerations in Transplantation Decisions

Hepatocellular Carcinoma (HCC)

• Patients with HCC receive MELD exception points to prioritize them on transplant waiting lists 5, 4
• Standard Milan criteria (single tumor ≤5 cm or up to 3 nodules each ≤3 cm, without macrovascular invasion) are associated with 5-year survival rates of 65-78% 5
• Various extended criteria have been proposed to expand transplantation eligibility beyond Milan criteria while maintaining acceptable outcomes 5
• For patients with HCC and cirrhosis considering hepatic resection, MELD score is a strong predictor of perioperative mortality 6
• Hepatic resection (minor or major) for HCC is recommended only if the MELD score is ≤8; for patients with MELD score ≥9, other treatment modalities should be considered 6

Refractory Ascites

• Transjugular intrahepatic portosystemic shunt (TIPSS) should be considered in patients with refractory ascites 7
• Caution is required if considering TIPSS in patients with MELD score ≥18, current hepatic encephalopathy, active infection, or hepatorenal syndrome 7
• Albumin (as 20% or 25% solution) should be infused after large volume paracentesis of >5L at a dose of 8g albumin/L of ascites removed 7

Hepatic Encephalopathy (HE)

• Non-absorbable disaccharides should be used as secondary prophylaxis after an episode of overt HE 7
• Rifaximin should be added if a second episode occurs within 6 months (recurrent overt HE) 7
• The AASLD suggests not performing surveillance of patients with Child-Pugh class C cirrhosis unless they are on the transplant waiting list, given the low anticipated survival for these patients 7

Limitations of MELD Score

• MELD score may not accurately reflect mortality risk or transplant benefit in certain conditions, including hepatocellular carcinoma, hepatopulmonary syndrome, portopulmonary hypertension, refractory ascites, and recurrent cholangitis 1, 3
• In patients with very high MELD scores (>35), mortality following liver transplantation may be increased, requiring careful patient selection 1
• MELD score is inaccurate in predicting survival in 15-20% of cases 2

Management of Patients on the Waiting List

• Regular follow-up and management are essential to maintain the patient alive on the waiting list and to achieve good post-transplant survival 4
• For patients with HCC, bridge therapy is frequently required to avoid progression and maintain patients within the criteria of liver transplantation 4
• The management of patients on the waiting list is an essential component of the success of liver transplantation 4