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

Management Strategy for Patients with High MELD Scores

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

Understanding MELD Score and Its Clinical Significance

• MELD score incorporates three objective laboratory parameters: serum bilirubin, serum creatinine, 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 superior prognostic accuracy compared to other models like Child-Pugh score in predicting mortality in patients with cirrhosis 2, 3
• The CLIF-C ACLF score shows significantly higher predictive ability for 28-day mortality compared to MELD score, MELD-Na score, and Child-Pugh score in patients with acute-on-chronic liver failure (ACLF) 4

Initial Management Based on MELD Score

• For MELD score ≥15: Refer for liver transplantation evaluation, as this threshold indicates patients who may benefit from transplantation 1
• For MELD score >20: Consider intensive care unit (ICU) admission, especially with organ failure(s) or other life-threatening complications 4
• For very high MELD scores (>30): Consider urgent liver transplantation, particularly in patients with HBV-related ACLF despite early antiviral treatment 4

Critical Care Management for High MELD Patients

• ICU admission criteria should be the same as for other populations, and denial of critical care solely due to underlying cirrhosis is not justified 4
• Indications for ICU admission include:
  • Need for organ support (vasopressors, mechanical ventilation, or renal replacement therapy) 4
  • Massive bleeding 4
  • Grade III-IV hepatic encephalopathy (for airway protection) 4
  • Septic shock 4
• ICU admission should occur within the first 6 hours after diagnosis 4

Specific Management Based on Etiology

• For HBV-related ACLF: Immediately start nucleos(t)ide analogues (NAs), preferring those with high resistance barriers like entecavir or tenofovir 4
• For patients with renal dysfunction: Consider tenofovir alafenamide instead of tenofovir disoproxil fumarate to avoid worsening renal damage 4
• For alcoholic hepatitis with high MELD (>20): Consider corticosteroid therapy (methylprednisolone 32 mg daily) if no contraindications exist 5

Management of Complications in High MELD Patients

• For bleeding gastric varices in patients with high MELD scores (≥20):
  • Endoscopic management may be beneficial as it can increase portal perfusion 4
  • Balloon-occluded retrograde transvenous obliteration (BRTO) may improve hepatic synthetic function 4
  • Transjugular intrahepatic portosystemic shunt (TIPS) should be used cautiously, as 3-month mortality is 35% for MELD scores 18-24 and 66% for MELD scores ≥25 4

Monitoring and Prognostic Assessment

• Regularly monitor MELD score to track disease progression and adjust transplant priority 1
• For patients with ACLF, assess prognosis after 3-7 days of full critical care support, especially in severe forms (ACLF-3) 4
• Consider using MELD subtypes for more refined risk assessment, as patients with creatinine-dominant MELD scores (MELD-Cr) have lower intention-to-treat survival compared to those with bilirubin-dominant (MELD-Br) or INR-dominant (MELD-INR) scores 6

Special Considerations

• Recognize conditions where MELD score may not accurately reflect mortality risk, including hepatocellular carcinoma, hepatopulmonary syndrome, and portopulmonary hypertension 1
• Women with creatinine-dominant MELD scores have lower one-year intention-to-treat survival compared to men with similar scores 6
• Contraindications for ICU admission in high MELD patients include:
  • Severe comorbidities (advanced pulmonary, cardiac, or neurological disease) with ACLF-3 4
  • Advanced neoplasm with life expectancy <6 months 4
  • Severe frailty with sarcopenia or Karnofsky performance status ≤40 4

Liver Transplantation Considerations

• MELD score ≥15 is generally recommended as a threshold for listing patients for liver transplantation 1
• Patients with HCC may receive MELD exception points to prioritize them on transplant waiting lists 7
• For patients with very high MELD scores (>35), mortality following liver transplantation may be increased, requiring careful patient selection 1