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    MELD Score (Model For End-Stage Liver Disease) (12 and older)

    Stratifies severity of end-stage liver disease, for transplant planning.
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    INSTRUCTIONS

    Note: As of January 2016, calculation of the MELD has changed. It now includes serum sodium level. See OPTN's announcement.

    When to Use
    Pearls/Pitfalls
    Why Use
    • Primarily used to stratify patients on liver transplant waiting lists.
    • Predicts mortality in the following scenarios: (a) after transjugular intrahepatic portosystemic shunt (TIPS), (b) cirrhotic patients undergoing non-transplantation surgical procedures, (c) acute alcoholic hepatitis, and (d) acute variceal hemorrhage.
    • The MELD Score predicts three-month survival in patients (age 12+) with liver cirrhosis.
    • Scores range from 6 to 40, with higher scores correlating with increased severity of liver dysfunction and higher three-month mortality.
    • The MELD was updated in January 2016 and now includes serum sodium level.
    • It is preferable to using the calculator to calculate the MELD as there are several caveats relating to minimum and maximum values assigned in the MELD.
    • Values should be no more than 48 hours old.
    • MELD can be used on any patient with end stage liver disease irrespective of cirrhosis etiology.
    • Currently, there is no modification in the score for patients on anticoagulation (given their INR may be elevated).
    • Several conditions are “standard MELD exceptions” and receive a different score (see Next Steps > Critical Actions):  hepatocellular carcinoma, hepatopulmonary syndrome, portopulmonary hypertension, familial amyloid polyneuropathy, primary hyperoxaluria, cystic fibrosis, hilar cholangiocarcinoma and hepatic artery thrombosis.
    • One of the exclusion criteria for the original data set was absence of acute reversible conditions such as spontaneous bacterial peritonitis or prerenal azotemia secondary to dehydration. Therefore, in principle, the score should only be applied after these reversible conditions have been treated, according to the authors (Kamath 2007).
    • In February 2002, MELD was accepted by the United Network for Organ Sharing (UNOS) for prioritization of patients awaiting for liver transplantation in the United States, replacing the Child-Pugh Score.
    • It has been widely studied and validated.
    mg/dL
    mg/dL
    mEq/L
    About the Creator
    Dr. Patrick S. Kamath
    Content Contributors
    • Pranav Patel, MD

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • Consider referral to hepatologist or liver transplant center for patients with MELD Score ≥10.
    • MELD Score should be periodically re-assessed, as it changes with changing lab values.
    • All cirrhosis patients should be periodically screened for hepatocellular carcinoma with serum alpha-fetoprotein (AFP) and by appropriate imaging to see if they can earn “standard MELD exceptions”.

    Critical Actions

    Standard MELD Exceptions

    The following conditions are automatically assigned a MELD Score of 22 (28 in case of hyperoxaluria), with a 10% increase in score every 3 months from diagnosis.

    • Hepatocellular carcinoma (HCC) with one lesion between 2 - 5 cm or two to three lesions <3 cm (Milan criteria), provided no vascular invasion or extrahepatic disease.
    • Hepatopulmonary syndrome with PaO2 <60 mmHg on room air.
    • Portopulmonary hypertension, with mean pulmonary artery pressure (mPAP) >25 mmHg at rest but maintained <35 mmHg with treatment.
    • Hepatic artery thrombosis 7–14 days post-liver transplantation.
    • Familial amyloid polyneuropathy, as diagnosed by identification of the transthyretin (TTR) gene mutation by DNA analysis or mass spectrometry in a biopsy sample and confirmation of amyloid deposition in an involved organ.
    • Primary hyperoxaluria with evidence of alanine glyoxylate aminotransferase deficiency (these patients requires combined liver-kidney transplantation).
    • Cystic fibrosis with FEV1 (forced expiratory volume in 1 second) <40%.
    • Hilar cholangiocarcinoma.

    Formula

    Per OPTN policy, January 2016 (pages 4–5):

    Candidates who are at least 12 years old receive an initial MELD(i) score equal to:

    MELD(i) = 0.957 × ln(Cr) + 0.378 × ln(bilirubin) + 1.120 × ln(INR) + 0.643

    Then, round to the tenth decimal place and multiply by 10. Maximum MELD = 40.

    If MELD(i) > 11, perform additional MELD calculation as follows:

    MELD = MELD(i) + 1.32 × (137 – Na) –  [ 0.033 × MELD(i) × (137 – Na) ]

    Additional rules:

    • All values in US units (Cr and bilirubin in mg/dL, Na in mEq/L, and INR unitless).
    • If bilirubin, Cr, or INR is <1.0, use 1.0.
    • If any of the following is true, use Cr 4.0:
      • Cr >4.0.
      • ≥2 dialysis treatments within the prior 7 days.
      • 24 hours of continuous veno-venous hemodialysis (CVVHD) within the prior 7 days.
    • If Na <125 mmol/L, use 125. If Na >137 mmol/L, use 137.

    Facts & Figures

    Interpretation:

    MELD Score

    Mortality

    <9

    1.9%

    10–19

    6.0%

    20–29

    19.6%

    30–39

    52.6%

    ≥40

    71.3%

    More Info: OPTN/UNOS Documentation on MELD and PELD 

    Evidence Appraisal

    MELD was originally developed in 2001 by researchers at the Mayo Clinic to estimate survival of 231 patients undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) placement and thus coined the “Mayo End Stage Liver Disease (MELD)” score.

    In addition to serum bilirubin, creatinine levels and INR, etiology of liver disease was included, but subsequently removed due to difficulty estimating risk in patients with multiple causes of liver disease. The name was also later changed to Model for End-stage Liver Disease.

    In 2002, the United Network for Organ Sharing (UNOS) began using a modified version of the MELD score to prioritize patients on their orthotopic liver transplantation waiting list. MELD was prospectively validated in 2003 by Wiesner et al in 3,437 patients awaiting transplant.

    Further studies demonstrated that MELD can be used to predict short term mortality risk in cirrhosis patients with complications such as variceal bleeding, spontaneous bacterial peritonitis, acute hepatic failure and alcoholic hepatitis. It can also be used in preoperative assessment of cirrhotics undergoing non-transplant surgery and in HCC patients who are not candidates for transplant.

    In 2006, the MELD Exception Study Group and Conference (MESSAGE) created the MELD Exception Guidelines for transplant list patients whose mortality was not accurately predicted by the standard MELD formula.

    In March 2007, Kamath et al reported that, though MELD has the ability to rank cirrhotic patients according to short term mortality, it is not a perfectly universal score, as survival is not accurately predicted in 15-20% of patients, and users must be aware of limitations of its application.

    Literature

    Other References

    Research PaperKremers WK, van IJperen M, Kim WR, Freeman RB, Harper AM, Kamath PS, Wiesner RH. MELD score as a predictor of pretransplant and posttransplant survival in OPTN/UNOS status 1 patients. Hepatology. 2004 Mar;39(3):764-9.Research PaperKamath PS, Kim WR; Advanced Liver Disease Study Group. The model for end-stage liver disease (MELD).Hepatology. 2007 Mar;45(3):797-805.Research Paper OPTN 2016 MELD Policy ChangesResearch PaperFreeman RB Jr, Gish RG, Harper A, Davis GL, Vierling J, Lieblein L, Klintmalm G, Blazek J, Hunter R, Punch J. Model for end-stage liver disease (MELD) exception guidelines: results and recommendations from the MELD Exception Study Group and Conference (MESSAGE) for the approval of patients who need liver transplantation with diseases not considered by the standard MELD formula.Liver Transpl. 2006;12(12 Suppl 3):S128.
    Dr. Patrick S. Kamath

    From the Creator

    Why did you develop the MELD Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

    Following a trans-jugular intrahepatic portosystemic shunt (TIPS) procedure for complications of portal hypertension, some patients do well and others fare poorly. My colleague in statistics, Mike Malinchoc, and I studied laboratory variables prior to the procedure and identified INR, serum creatinine, serum bilirubin and etiology of cirrhosis being predictive of survival. We developed a score based on these variables and demonstrated it predicted survival in a wide variety of patients with cirrhosis not undergoing TIPS. The score was originally called the Mayo End-Stage Liver Disease (MELD) model and was shown to be superior to the Child-Turcotte-Pugh score.  

    At about the time we published the score, the Institute of Medicine determined that organ allocation for liver transplantation should no longer be based on waiting time but on an objective score that reflected severity of liver disease. The MELD Score fulfilled their criteria and was accepted as the score to prioritize organ allocation for liver transplantation. We changed "MELD" to Model for End-Stage Liver Disease assuming that the score would be more readily accepted by the liver transplantation community if it was not identified with a single institution.

    What pearls, pitfalls and/or tips do you have for users of the MELD Score? Are there cases when it has been applied, interpreted, or used inappropriately?

    The MELD Score has been validated as predictor of survival in patients with cirrhosis, alcoholic hepatitis, acute liver failure, and in patients with acute hepatitis. In terminally ill patients with cirrhosis, the number of extra-hepatic organ failures is more predictive of mortality than is the MELD Score.

    Along those lines, MELD is sometimes applied to patients with any degree of liver dysfunction, not just potential transplant candidates, as a quick, reliable, and easily-understood way of communicating how sick a patient is. Any thoughts on those uses?

    Yes, MELD score is a metric for how sick a patient is. However, patients like to be given a number when we discuss risks. That’s where the MELD calculators at Mayo help.

    What recommendations do you have for doctors once they have applied the MELD Score? Are there any adjustments or updates you would make to the score given recent changes in medicine?

    Low serum sodium is an independent predictor of mortality in patients with cirrhosis. In 2008, my colleague Ray Kim published the MELD-Na Score which includes serum Na; this score improves slightly the predictive accuracy of the MELD score in predicting mortality.

    Are there cases where you would recommend using Dr. Kim’s MELD-Na Score over the newer MELD Score that incorporates sodium (per the update to OPTN policy 1/2016)?

    Currently, only for liver transplant.

    How do you use the MELD Score in your own clinical practice? Can you give an example of a scenario in which you use it?

    I use the MELD score to counsel patients and their families. I go over mortality risk, actual percentages rather than "high" or "low", that can be expected if they undergo a TIPS procedure or surgery. If they are on the liver transplant waiting list, I can give them some idea when they might receive an organ. If patients have alcoholic hepatitis, I use the MELD score to predict risk of mortality. If the MELD score is >40 and patients with alcoholic hepatitis are not candidates for liver transplantation, I discuss palliative care. 

    Any other research you're working on that you're particularly excited about?

    My colleague Vijay Shah leads a research group at Mayo of which I am a part. We are looking at newer treatments for alcoholic hepatitis.

    About the Creator

    Patrick S. Kamath, MD, is a professor of gastroenterology and hepatology at the Mayo Clinic in Rochester, Minnesota. His research interests include acute-on-chronic liver failure, nonalcoholic fatty liver disease, polycystic liver disease, Budd-Chiari syndrome and hereditary hemorrhagic telangiectasia. Dr. Kamath is internationally renowned as a leading researcher in hepatology and has also won numerous awards as an educator.

    To view Dr. Patrick S. Kamath's publications, visit PubMed

    Content Contributors
    • Pranav Patel, MD