Do patients with Hepatocellular Carcinoma (HCC) have varying Model for End-Stage Liver Disease (MELD) scores?

Do HCC Patients Have Different MELD Scores?

Yes, HCC patients typically have lower MELD scores than non-HCC cirrhotic patients awaiting transplantation, but receive standardized MELD exception points to prioritize them for transplantation based on their cancer-related mortality risk rather than their liver dysfunction severity. 1, 2

The Fundamental Discrepancy

MELD Score Reflects Liver Function, Not Cancer Burden

• HCC patients generally present with better preserved liver function and lower calculated MELD scores compared to patients with decompensated cirrhosis without HCC. 3
• The MELD score (ranging from 6-40) is calculated using only three objective laboratory parameters: serum bilirubin, INR, and creatinine—none of which directly measure tumor burden or cancer-related mortality risk. 1, 2
• In a comparative study, HCC patients were older and more likely to be Asian, but had significantly less severe liver impairment than patients with cirrhosis alone, despite their cancer diagnosis. 3

The Exception Points System

• Patients with HCC meeting Milan criteria (single tumor ≤5 cm or 2-3 tumors each ≤3 cm without macrovascular invasion) receive standardized MELD exception points of 22. 1, 4
• This exception system exists precisely because MELD inadequately captures the mortality risk from HCC itself—patients can die from cancer progression despite having relatively preserved liver function. 2, 4
• The current 22-point exception actually overestimates mortality risk compared to laboratory MELD patients: outcome-based analysis shows HCC patients with 22 exception points have comparable adverse event rates to patients with laboratory MELD scores of only 15-19. 5

Clinical Implications of This Discrepancy

Transplant Access and Outcomes

• Despite lower actual MELD scores, HCC patients undergo transplantation at significantly higher rates (78.1% vs 51.4%) compared to cirrhotic patients without HCC. 3
• Intention-to-treat survival at 5 years remains similar between HCC and non-HCC patients (73% vs 78%), suggesting the exception system achieves reasonable equity despite the MELD discrepancy. 3
• Post-transplant survival is comparable (83% vs 90% at 3 years), though HCC patients face higher disease recurrence rates (19% vs 10%). 3

MELD Score Variability in HCC Patients

• Among HCC patients undergoing locoregional therapy, MELD scores change dynamically: mean scores increased from 10.1 pre-treatment to 12.9 early post-treatment, then decreased to 11.7 at late follow-up. 6
• Serial MELD determinations correlate well with Child-Pugh score changes (correlation coefficient 0.605 early, 0.512 late), with approximately 2 MELD points changing per unit of Child-Pugh change. 6
• MELD score >15 independently predicts poor prognosis in HCC patients (relative risk 2.17), along with tumor size >5 cm, multiple tumors, and Child-Pugh class B/C. 6

Performance of MELD-Based Systems in HCC

Comparative Prognostic Value

• MELD-based prognostic systems (MELD-CLIP and MELD-JIS) outperform Child-Pugh-based systems for predicting HCC outcomes. 7
• For 3-month survival, MELD-CLIP and MELD-JIS achieved AUC of 0.69 versus 0.64 for original systems (P=0.004 and P=0.0018 respectively). 7
• For 6-month survival, MELD-CLIP (AUC 0.64) and MELD-JIS (AUC 0.62) remained superior to original systems (AUC 0.54 and 0.59). 7
• MELD-based systems performed best specifically among HCC patients receiving locoregional therapy. 7

Alternative Scoring Systems

• The PALBI (platelet-albumin-bilirubin) grade consistently demonstrates superior discriminatory power compared to MELD across all HCC treatment modalities and BCLC stages. 8
• MELD score had the lowest AUC compared to ALBI, PALBI, and Child-Pugh classification for predicting 1-year, 3-year, and 5-year survival in HCC patients. 8
• Within Child-Pugh class A patients (73% of HCC cohort), PALBI identified three distinct prognostic groups while MELD provided less granular stratification. 8

Critical Pitfalls to Avoid

Do Not Use MELD Alone for HCC Transplant Decisions

• MELD score should never be the sole criterion for transplant listing in HCC patients—the exception points system exists specifically because MELD fails to capture cancer-related mortality. 2, 4
• Patients with HCC meeting Milan criteria require exception points regardless of their calculated MELD score. 2, 4

Recognize MELD Limitations in HCC Context

• MELD does not account for tumor characteristics (size, number, vascular invasion, AFP level) that critically impact HCC prognosis. 1
• Serum creatinine can be unreliable in cirrhotic patients, potentially overestimating renal dysfunction in sarcopenic patients or underestimating it with fluid overload. 1, 2
• Clinical decompensation (ascites, encephalopathy) significantly impacts prognosis but is not captured by MELD. 1, 9

Monitor for Dynamic Changes

• MELD scores in HCC patients fluctuate with treatment and disease progression—serial monitoring every 3-6 months is essential. 4, 6
• Acute increases in MELD may reflect treatment-related hepatotoxicity, infection, or tumor progression requiring immediate evaluation. 6