What Is a MELD Score?

In This Article

The model for end-stage liver disease (MELD) score is a calculation frequently performed for people with liver disease. It can provide important information about prognosis as well as who is in the greatest need of a liver transplant. The MELD score is calculated using the lab tests creatinine, international normalized ratio (INR), bilirubin, and sodium. While a good tool, the MELD score is a statistical measure and does not take into account several factors that might affect your individual prognosis. Therefore the test should always be interpreted along with clinical findings. Learn about the MELD score, limitations, and other considerations for interpreting your MELD score test.

liver disease and the MELD score
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History

The MELD score has undergone some changes since it was first introduced. In its original format, it was used to predict the three-month survival for people with end-stage liver disease, and was adopted by UNOS (the United Network for Organ Sharing) in 2002 to help prioritize people who were waiting for a liver transplant. In 2016, serum sodium was added to the formula, and further modifications are currently being evaluated.

Purpose of Test

The MELD test can be used for anyone over the age of 12 with end-stage liver disease, regardless of the cause of the disease. For children under the age of 12, a different test (the PELD score) is used.

Indications

There are several reasons why your doctor may recommend calculating your MELD score.

Liver Transplantation Prioritization

The MELD test is best known as a method to help prioritize the need for liver transplantation among people with end-stage liver disease regardless of the cause. At the current time, the need for livers far exceeds the availability, and deciding who should receive a liver, and when, has been challenging.

This importance is better understood by looking at the success rates of liver transplantation in appropriate situations. At the current time, overall survival rates are over 90% at one year and over 80% at five years post transplant.

Short-Term Mortality

The MELD score has also been found to predict mortality (the risk of death) over the next 90 days in situations such as:

  • With acute alcoholic hepatitis
  • In people who have cirrhosis and are undergoing surgical procedures aside from liver transplantation: This is very important when procedures such as gallstone surgery, hernia repair, cardiac surgery, and more are being considered. One study found that there was a 2% increased mortality risk with surgery for each MELD point over 20, with a 1% increase in mortality risk per point below 20.
  • After transjugular intrahepatic portosystemic shunt (TIPS) placement
  • When hemorrhage from esophageal varices occurs

The MELD score may also help predict longer term survival (1-year and 5-year survival) for a wide range of liver diseases. In addition to esophageal varices, the score appears to have good predictive value with spontaneous bacterial peritonitis, and with hepatorenal syndrome.

There are additional situations in which the MELD score may be helpful. A 2020 study suggested that the test could have further indications, such as

  • Predicting mortality after liver resection (surgery to remove a liver cancer)
  • To estimate postoperative risk in people with liver disease who both have and do not have cirrhosis.

Cirrhosis/Liver Disease Causes

While often associated with alcoholic liver disease, cirrhosis is a general term that refers to extensive scarring in the liver. It can be caused by a wide variety of conditions that result in liver injury and inflammation. Some of these include:

Calculation

The MELD score is calculated using the results of several laboratory tests, as well as questions as to recent dialysis. Blood tests need to be performed within 48 hours of the time the calculation is made to be accurate and to qualify to be considered for liver transplantation.

Values used in the calculation include:

  • Creatinine, a kidney function test: Liver disease can lead to kidney failure (hepatorenal syndrome)
  • Bilirubin: Bilirubin is a measure of how well the liver gets rid of bile, and increased levels are common in liver disease
  • INR (a measure of clotting): As liver disease progresses, the liver is unable to manufacture clotting factors to the same degree.
  • Sodium: Added to the formula in January of 2016 (MELD-Na)

No matter the results of the calculation, there are several conditions (listed below) that given an automatic score of 22 or more.

Reference Range

MELD scores range from 6 up to 40, with 40 representing the greatest severity of liver disease, and a high risk of death in the ensuing three months without transplantation

Limitations

The MELD score is a statistical test and therefore doesn't necessarily predict what will occur in a specific individual. In addition, there are several factors that may affect the prognosis of liver disease that are not included in the calculation, such as:

  • Age
  • Sex
  • The presence of continued drinking with alcoholic liver disease
  • Nutritional status
  • Other health conditions
  • Family support (family caregiver)

In a 2019 study, factors not included in the MELD score that were significant in people considered high risk included sex, age, and primary caregiver (family member or friend who assists and cares for the patient). In the lower risk group, AST (a liver function test), albumin (a measure of protein in the blood), and primary caregiver were important in determining prognosis in addition to the MELD score.

Liver function tests do not necessarily correlate with the severity of liver disease. For example, laboratory tests may be very abnormal in some people with mild disease, but relatively normal in people with severe disease. There is also a lag time in blood tests that may not reflect current changes. For example, liver function tests may sometimes remain abnormal even when liver disease is improving.

For people on blood thinners (anticoagulants), there is no standard modification of the score despite having an INR that is "artificially" elevated.

Errors in measurement of the labs used to make the calculation could also result in inaccuracy, and these, in turn, could stem from errors in blood draws, to data entry, and more. Lab to lab variability could also reduce accuracy (especially with INR).

Similar tests/Accompanying Tests

A modified MELD score (the PELD score) is used for children under the age of 12. With children, age less than 12 months or the failure to grow are also considered.

Another system, the Child-Turcotte-Pugh system, has been largely replaced by the MELD score.

It's important to note that the MELD score should not be used alone, but rather in combination with symptoms, laboratory and imaging studies, and general health to make decisions regarding treatment.

Risks and Contraindications

Since it is a calculation made with existing blood test results, there are few risks associated with calculating a MELD score. Certainly, the MELD score can both overestimate and underestimate risk at times due to other variables.

Before the Test

Your doctor will talk to you about the reasons for calculating your MELD score, as well as any potential limitations that may pertain to you as an individual. Since lab values (to qualify relative to liver transplantation) much be less than 48 hours old, timing is important with regard to your blood draw. If you will be having your blood drawn at a different location, your doctor will likely wish for you to bring the results with you to your appointment.

Timing and Location

The test can be performed rapidly, and your doctor may do the calculation before your visit or while in the exam room with you. Since the lab values must be 48 hours old or less, some physicians recommend having blood drawn early in the week, and to avoid Fridays.

Other Considerations

When the MELD calculation is done, doctors can sometimes estimate the chance that liver disease is or is not related to alcohol use. It's very important to openly talk to your doctor, even if you are embarrassed about things in your past. It's also important to bring a caregiver with whom you are comfortable in being honest.

Interpreting Results

Physicians often calculate the MELD score with a MELD Calculator either before your visit or during your visit. It is best to receive your results in person (rather than by phone) so you can discuss any concerns you have and so you can ask for clarification about anything you do not understand.

Range

MELD scores range from 6 to 40, depending on the severity of liver disease.

Standard MELD Exceptions

With certain situations, exceptions to the MELD score are made. With the following medical conditions, an automatic MELD score of 22 is given (except with hyperoxaluria in which the automatic score is 28).

  • Liver cancer (hepatocellular carcinoma) with one "spot" between 2 centimeters (cm) and 5 cm or two to three lesions less than 3 cm in diameter (as long as there is no evidence of extension beyond the liver)
  • Lung disease related to liver failure: Hepatopulmonary syndrome, with a PaO2 less than 60 mmHg on room air)
  • Portopulmonary hypertension, with mean pulmonary artery pressure (mPAP) greater than 25 mmHg at rest but maintained less than 35 mmHg with treatment
  • Hepatic artery thrombosis 7–14 days post-liver transplantation
  • Familial amyloid polyneuropathy
  • Primary hyperoxaluria (combination kidney and liver transplantation is needed)
  • Cystic fibrosis with FEV1 (forced expiratory volume in 1 second) <40%
  • Hilar cholangiocarcinoma

Scores/Significance

With a MELD score of greater than or equal to 10, referral to a liver specialist (hepatologist) is often recommended.

Given that MELD scores are often performed when considering liver transplantation, and the high success rate of these surgeries, the mortality data doesn't necessarily represent what will happen to you; in other words, it is the high risk of death in three months that often prompts the decision to perform liver transplantation in order to avoid this high risk of death.

A 2017 study outlined that average MELD score and three-month mortality as follows:

3 Month Survival Based on MELD Scores
MELD Score 3-Month Mortality (%)
Less than 9 1.9 to 3.7%
10 to 19 6 to 20%
20 to 29 19.6 to 45.5%
30 to 39 52.6 to 74.5%
Over 40 71 to 100%

Liver Transplantation

MELD scores are viewed carefully when considering priorities for transplant. That said, there are priority situations in which transplantation may be considered regardless of score. These include:

  • Priority exemption 1A: When a person has acute liver failure (sudden and severe) and would be expected to survive only hours to a few days without a transplant
  • Priority exemption 1B: This includes very ill, chronically ill children less than 18 years of age.

Candidates for liver transplantation based on MELD scores are priortized as follows (with higher priority given to children under the age of 18):

  • Status 1A and 1B in the same region as the donor
  • MELD score 35 and higher within the donor's region (priority made first locally, then regionally, then nationally)
  • Local candidates with a MELD score greater than 15
  • Regional candidates with a MELD score greater than 15
  • National candidates who are status 1A or 1B
  • National candidates with a MELD score greater than 15
  • Candidates with a MELD score less than 15, first locally, then regionally, then nationally

Follow-Up

Follow-up and repeat measurements of the MELD score will depend on the value of the score as well as your general condition. One medical center uses the following general guidelines:

  • MELD score of 25 or greater: Every 7 days
  • MELD score of 19 to 24: Every 30 days
  • MELD score of 11 to 23: Every 90 days
  • MELD score less than 10: Every year

Certainly, the MELD score should be recalculated sooner with any worsening of the disease or other concerns.

Other Considerations

Along with following MELD scores, it's recommended that everyone who has cirrhosis be regularly screened for liver cancer (testing includes the blood test alpha-fetoprotein or AFP as well as imaging studies). When found, a person who does not otherwise qualify for liver transplantation may instead meet the criteria via the standard exemptions.

A Word From Verywell

If you are a loved one are having a MELD score calculated, you're likely feeling anxious. What does the result mean and what does that mean for your future? It's important to ask a lot of questions, and to continue asking if you don't understand. Having a good understanding of your condition can help you take an active role in designing a plan that best meets your needs. It's also important to make sure you are seeing a specialist in liver disease if needed. Some researchers have recommended consultation with a liver specialist (hepatologist) or evaluation at a liver transplant center for anyone with a MELD score greater than 10, but this can vary. Getting a second opinion does not mean that you need to transfer your care to another doctor, especially if you like your physician, but does provide the opportunity to have another set of eyes look over your situation.

The importance of your support system cannot be understated. As one of the variables that affected prognosis, the presence of a caring and involved family caregiver (or friend) was associated with a better prognosis whether liver disease was mild or severe. Seek out people in your life who can best support you, but make sure you allow them to help you as well.

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