Estimating the severity of liver disease is important for predicting survival, assessing risk/benefit of specific treatments, including organ allocation for liver transplantation, and guiding goals-of-care discussions.

Key concepts

• Model for End-Stage Liver Disease (MELD) score is a prognostic scoring system, based on laboratory parameters, used to predict 3-month mortality due to liver disease
• MELD scores range from 6 to 40; the higher the score, the higher the 3-month mortality related to liver disease
• The original MELD calculator uses creatinine, bilirubin, and INR measurements; later, hyponatremia (Na concentration of 125-140 mEq/L) was found to be an independent predictor of mortality in patients with cirrhosis and Na levels were added to the MELD score calculation
• A modified MELD calculator became the standard for organ allocation for liver transplantation in January 2016; the modified MELD calculator, called MELD-Na, takes into account Na values of 125-137
• The MELD score does not accurately predict survival in all patients with cirrhosis; conditions such as liver cancer, hepatopulmonary syndrome, and portopulmonary hypertension, are associated with a higher mortality rate than MELD score would reflect. Therefore, patients with these conditions may receive additional MELD points when listed for liver transplantation

Key recommendations

• Calculate a MELD score every 3-6 months in all patients with cirrhosis to repeatedly assess their score
• Consider referral for liver transplantation in patients with MELD score of 10 or higher
• Consider using MELD score to assess mortality in patients with acute liver failure or acute variceal bleeding
• Calculate MELD scores for patients who have:
  • cirrhosis and are undergoing surgery (abdominal, orthopedic, cardiac, etc.)
  • cirrhosis and are being considered for TIPS
  • alcoholic hepatitis and are being considered for steroids
  • acute liver failure or acute variceal bleeding

Appropriate Use of the MELD

• The original MELD calculator was used to predict mortality in those undergoing placement of a transjugular intrahepatic portosystemic shunt (TIPS)
• The MELD score has been validated to predict short-term survival in patients with cirrhosis waiting for liver transplantation, but it also was found to be useful in predicting liver-related mortality in patients with alcoholic hepatitis, acute liver failure, acute variceal hemorrhage, or postsurgical procedures
• MELD is useful in determining when a patient should be evaluated for transplant; the benefit of liver transplantation outweighs the risk once MELD score is 15 or higher
• Calculate MELD score when considering TIPS for refractory ascites or variceal bleeding; patients with MELD scores of 18 or higher have significant post-TIPS mortality rates
• Include MELD score in the preoperative evaluation of patients with cirrhosis undergoing abdominal, orthopedic, or cardiac surgery
• In patients with alcoholic hepatitis, MELD score of >20 identifies severe disease, when steroid treatment should be considered
• Patients listed for liver transplantation will have their MELD scores updated at regular intervals (from every 7 days if 25 or greater, to every 1-3 months

Understanding the MELD Score Calculation

• When inputting values, laboratory values of less than 1 are rounded to 1
• A score of 40 is set as the upper limit regardless of how high the inputted laboratory values may be
• Original MELD Calculator
• MELD-Na Calculator