What the MELD Score Tells You
The MELD score is a validated, objective scoring system that predicts 3-month mortality in patients with end-stage liver disease and serves as the primary tool for prioritizing liver transplant allocation. 1
Core Function: Mortality Prediction
The MELD score calculates short-term mortality risk using three objective laboratory parameters that reflect hepatic and renal function 1, 2:
- Serum bilirubin (hepatic synthetic function)
- International normalized ratio (INR) (coagulation/hepatic synthetic function)
- Serum creatinine (renal function)
The score generates a continuous numerical scale from 6 to 40, with higher scores correlating with worse prognosis—ranging from approximately 90% 3-month survival at MELD 6 to only 7% survival at MELD 40. 2
Primary Clinical Applications
Liver Transplant Allocation
MELD ≥15 is the established threshold for transplant listing because patients with MELD ≤14 have better 1-year survival without transplantation than with it. 1, 3 The score drives organ allocation in the United States and most European countries by prioritizing patients based on objective mortality risk rather than waiting time. 1
Mortality Prediction Across Multiple Clinical Scenarios
Beyond transplant allocation, MELD accurately predicts short-term mortality in 1, 4:
- Decompensated cirrhosis
- Variceal bleeding
- Hepatorenal syndrome
- Hepatopulmonary syndrome
- Alcoholic hepatitis (MELD ≥18 indicates poor prognosis) 2
- Patients undergoing non-transplant surgery or TIPS procedures 4, 5
Critical Advantages Over Child-Pugh Score
MELD offers several key advantages over the Child-Pugh-Turcotte classification 1, 2:
- Entirely objective laboratory-based criteria (no subjective assessments of ascites or encephalopathy)
- Continuous numerical scale (not categorical classes)
- Includes renal function (serum creatinine), which is an important prognostic marker absent from Child-Pugh 2
Important Limitations and When MELD Fails
MELD Exceptions Requiring Additional Points
MELD fails to predict mortality in approximately 15% of patients with end-stage liver disease and cannot adequately capture severity in nearly 50% of cases. 6, 4 Certain conditions warrant "exception points" because MELD inadequately reflects their mortality risk 6, 1:
- Hepatocellular carcinoma (HCC) with compensated cirrhosis—MELD cannot gauge dropout risk from tumor progression 6
- Hepatopulmonary syndrome
- Portopulmonary hypertension
- Refractory ascites
- Cholestatic liver disease 6
Clinical Pitfalls to Avoid
Serum creatinine can be unreliable in cirrhotic patients, potentially overestimating renal dysfunction in patients with sarcopenia or underestimating it in those with fluid overload. 1
Very high MELD scores (>30-35) are associated with increased post-transplant mortality and morbidity, requiring careful assessment of transplant candidacy rather than automatic prioritization. 1
Do not use MELD as the sole criterion for transplant listing in patients with HCC or other MELD exceptions, as the score fails to capture their true risk. 1
Do not ignore clinical decompensation in patients with low MELD scores—even patients listed with low MELD scores (≤22) face significant risk of death from liver-related causes, with 31% removed from waiting lists for death or clinical deterioration. 7
Enhanced MELD Variations
Several modifications have been proposed to improve predictive accuracy 1, 5:
- MELD-Na (incorporating serum sodium)
- Delta MELD (measuring change in MELD over time)
- Integrated MELD
- MELD 3.0
Management Algorithm Based on MELD Score
MELD ≥15: High-Risk Population Requiring Immediate Action
- Refer immediately for liver transplantation evaluation 1
- Engage multidisciplinary transplant team 1
- Identify and treat acute complications (variceal bleeding, hepatic encephalopathy, hepatorenal syndrome) 1
- Monitor MELD score regularly for progression 1
- Consider living donor liver transplantation to reduce waiting list mortality 3