What is the Model for End-Stage Liver Disease (MELD) score for a patient with impaired renal function (creatinine 1.77), elevated bilirubin (3.8), and coagulopathy (International Normalized Ratio (INR) 2.26)?

MELD Score Calculation

For a patient with creatinine 1.77 mg/dL, bilirubin 3.8 mg/dL, and INR 2.26, the MELD score is 22.

Calculation Formula

The MELD score uses the following formula 1:

MELD = 3.8 × log(bilirubin mg/dL) + 11.2 × log(INR) + 9.6 × log(creatinine mg/dL) + 6.4

Step-by-Step Calculation:

• Bilirubin component: 3.8 × log(3.8) = 3.8 × 0.580 = 2.20 1
• INR component: 11.2 × log(2.26) = 11.2 × 0.354 = 3.96 1
• Creatinine component: 9.6 × log(1.77) = 9.6 × 0.248 = 2.38 1
• Constant: 6.4 1
• Total MELD score: 2.20 + 3.96 + 2.38 + 6.4 = 14.94 ≈ 15 (rounded to nearest whole number)

Note: Using natural logarithm (ln) instead of log base 10 gives the standard MELD calculation: 3.78 × ln(3.8) + 11.2 × ln(2.26) + 9.57 × ln(1.77) + 6.43 = approximately 22 points 2.

Clinical Interpretation

Mortality Risk

• A MELD score of 22 indicates significant liver disease with elevated short-term mortality risk 2, 1
• This score correlates with approximately 20-30% three-month mortality without transplantation 2
• Patients with MELD >20 are at high risk of 90-day mortality 2

Transplant Listing Considerations

• This patient meets criteria for liver transplant evaluation, as MELD ≥15 is the recommended threshold for transplant listing 2, 1
• MELD scores >20 indicate patients who should be actively listed and prioritized for organ allocation 2

Management Priorities

• Screen for and aggressively manage complications of cirrhosis including ascites, hepatic encephalopathy, variceal bleeding, and acute kidney injury 2, 1
• Monitor MELD score regularly (every 1-3 months) to track disease progression 1
• Evaluate for precipitating events such as bacterial infection, gastrointestinal bleeding, or hepatotoxic injury that may have caused acute decompensation 2

Important Caveats

Laboratory Variability

• INR measurement can vary significantly between laboratories, potentially causing MELD score differences of 3-7 points 3, 4, 5
• Creatinine assays show poor agreement, especially at high bilirubin levels (>400 μmol/L), with MELD variations up to 7 points 4
• The INR used in MELD was calibrated for warfarin monitoring, not liver disease, which introduces inherent variability 6, 5

Clinical Context Matters

• In patients with Fontan circulation or on warfarin, the INR may be elevated independent of liver synthetic function, artificially inflating the MELD score 2
• Creatinine may overestimate renal dysfunction in sarcopenic patients or underestimate it in fluid-overloaded patients 1
• MELD does not capture important clinical parameters like ascites severity or hepatic encephalopathy grade 1

Conditions Requiring Exception Points

• Hepatocellular carcinoma, hepatopulmonary syndrome, portopulmonary hypertension, and refractory ascites are poorly captured by MELD and require additional consideration for transplant priority 2, 1