What is the significance and management of a high Model for End-Stage Liver Disease (MELD) score in an adult patient with advanced liver disease, such as cirrhosis or hepatitis?

MELD Score: Clinical Significance and Management

What the MELD Score Represents

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

The score is calculated using three objective laboratory parameters that reflect hepatic and renal function 1:

• Serum bilirubin (mg/dL)
• International normalized ratio (INR) of prothrombin time
• Serum creatinine (mg/dL)

The MELD assigns patients a continuous scale from 6 to 40, which correlates with estimated 3-month survival rates ranging from 90% to 7%, respectively 2. Originally developed to assess short-term prognosis in patients undergoing transjugular intrahepatic portosystemic shunts (TIPS), it has become the standard for transplant allocation 2.

Critical Management Thresholds

MELD ≥15: Transplant Evaluation Required

Patients should be referred for liver transplantation evaluation when MELD score reaches ≥15, as this represents the threshold where transplant benefit exceeds risk. 1, 3

Patients with MELD <15 actually have better 1-year survival without transplantation than with it, making transplant listing inappropriate below this threshold 1, 3.

MELD >10 with Hepatic Dysfunction

Patients with cirrhosis should be referred for transplantation when they develop evidence of hepatic dysfunction (Child-Pugh score >7 and MELD >10) or when they experience their first major complication including ascites, variceal bleeding, or hepatic encephalopathy 2.

MELD >20: High-Risk Population Requiring Intensive Management

For MELD scores >20, consider ICU admission, especially with organ failure(s) or other life-threatening complications, as 3-month mortality approaches 20-30% without transplantation. 1, 4

Patients with MELD scores >20 should be actively listed and prioritized for organ allocation 4.

Algorithmic Management Approach

Step 1: Identify and Treat Reversible Factors

Immediately evaluate for precipitating events that may have caused acute decompensation: 4

• Bacterial infection (especially spontaneous bacterial peritonitis)
• Gastrointestinal bleeding
• Hepatotoxic injury
• Acute kidney injury

The 5-year survival rate when complications like spontaneous bacterial peritonitis develop is only 20-50%, with median survival for type I hepatorenal syndrome less than 2 weeks 2.

Step 2: Manage Specific Complications Aggressively

Screen for and treat all cirrhosis complications that contribute to elevated MELD: 1, 4

• Variceal bleeding: Endoscopic management; use TIPS cautiously as 3-month mortality is 35% for MELD 18-24 and 66% for MELD ≥25 1
• Refractory ascites: Medical management first; consider large-volume paracentesis
• Hepatic encephalopathy: Lactulose and rifaximin
• Renal dysfunction: Avoid nephrotoxins; assess for hepatorenal syndrome

Step 3: Transplant Referral and Multidisciplinary Engagement

Engage a multidisciplinary team including transplant hepatologist, transplant surgeon, and other specialists based on comorbidities. 1

Expedited referral is required for type I hepatorenal syndrome. 2

Step 4: Regular Monitoring

Monitor MELD score regularly (every 3-6 months for MELD <15, more frequently for MELD ≥15) to track disease progression and adjust transplant priority. 1, 4

Critical Pitfalls and Caveats

MELD Exceptions: When the Score Doesn't Tell the Full Story

Certain conditions warrant "exception points" because MELD inadequately reflects their mortality risk or transplant benefit: 1, 3

• Hepatocellular carcinoma
• Hepatopulmonary syndrome
• Portopulmonary hypertension
• Refractory ascites
• Recurrent cholangitis

Do not use MELD as the sole criterion for transplant listing in patients with these conditions. 3

Creatinine Reliability Issues

Serum creatinine can be unreliable in cirrhotic patients, potentially overestimating renal dysfunction in patients with sarcopenia (low muscle mass) or underestimating it in those with fluid overload 1, 3, 4. This can artificially inflate or deflate the MELD score 4.

Very High MELD Scores (>30-35)

Patients with MELD scores >30-35 have increased post-transplant mortality and morbidity, requiring careful assessment of transplant candidacy. 1, 3

Absolute contraindications for transplant in this range include 1:

• Lactate >9 mmol/L
• Severe respiratory failure
• Increasing vasopressor support

Clinical Decompensation with Low MELD

Do not ignore clinical decompensation in patients with low MELD scores. 3 MELD does not capture clinical parameters like ascites or encephalopathy, which significantly impact prognosis 4. The score fails to predict mortality in approximately 15% of patients with end-stage liver disease 5.

MELD Not Applicable to Acute Liver Failure

The MELD score cannot be recommended for acute liver failure (ALF), as it was developed for chronic liver disease and performs poorly in this different condition. 2

ICU Admission Criteria for High MELD Patients

Indications for ICU admission include: 1

• Need for organ support
• Massive bleeding
• Grade III-IV hepatic encephalopathy
• Septic shock

Contraindications for ICU admission include: 1

• Severe comorbidities with ACLF-3 (acute-on-chronic liver failure grade 3)
• Advanced neoplasm with life expectancy <6 months
• Severe frailty with sarcopenia or Karnofsky performance status ≤40

Enhanced MELD Variations

Several modifications have been proposed to improve predictive accuracy, including MELD-Na (incorporating serum sodium), Delta MELD (measuring change over time), and MELD 3.0 (incorporating patient sex and albumin levels to reduce gender disparities) 1, 3, 6. MELD-Na is now used for transplant allocation in the United States and better captures mortality risk, especially in patients with hyponatremia 3.