MELD Score and the Question of When I am Getting My Liver?

Those of us involved in solid organ transplantation are faced with a question daily. That question is “when am I getting my liver?”  The question is posed by patients, their family, or interested friends. In every case, I have to say,  “I just don’t know, it depends on your MELD score”.  And that’s the truth.  Most patients have at best a primitive understanding of the MELD score. The longer they are on the list for transplant, the better they grasp the concept and how the system works.  Below I will give an overview of how the MELD system works, and what this means to the individual patient.

MELD stands for Model for End Stage Liver Disease,  and was put into use in 2002. Before this time, patients needing liver transplants were grouped into four medical urgency categories. The categorieswere based on a scoring system that included some laboratory test results and some symptoms of liver disease. The symptoms of liver disease was difficult to control for and standardize. One concern with using symptoms in scoring was that different doctors might interpret the severity of those symptoms in different ways. In addition, this scoring system could not easily identify which patients had more severe liver disease and were in greater need of a transplant.  Research showed that MELD accurately predict most liver patients’ short-term risk of death without a transplant. The MELD formulas are simple, objective and verifiable, and yield consistent results whenever the score is calculated.

Calculating the MELD score can easily be done from numerous web sites. Click here to calculate a MELD score. Scores can range from 6 (well) t0 40 (critical).

The factors that go into calculating the MELD score include bilirubin, INR, and serum creatinine. Additional points are given if the patient has been receiving dialysis withing the past week. There is discussion that other factors may eventually be used to calculate the score, but for now this is the best we have.

Bilirubin is elevated in chronic liver disease. Bilirubin is what gives the yellow skin color and jaundice seen in liver disease. The higher the bilirubin, the greater the jaundice. Bilirubin is an indirect marker of advanced liver disease. As a patient’s liver status becomes worse, and thus more sick, the bilirubin will tend to rise. The higher the bilirubin, the higher MELD score. You can plug in different bilirubin values to see how this well effect the score. The normal bilirubin is generally less than 1 mg/dL.

The INR (International Normalized Ratio) is a lab test frequently used in liver disease. With advancing liver disease, the vitamin K dependant clotting factors, which happen to be manufactured in the liver, are reduced. This will result in a prolonged INR. A prolonged INR increases the MELD score.

Creatinine is a lab that measures kidney function. The kidney and liver are intimately related, in that as liver function declines, there is a high probability that kidney function will decline as well. Thus, an elevated creatine (worse kidney function) can be associated with advancing liver dysfunction and increased mortality and complication in the liver patient with advanced liver disease. Again, plug in different values for creatinine and you will see how the MELD will rise. A normal creatinine is usually less than 1 mg/dL.

Waiting time for transplant does not generally play much of a role in organ allocation. Patients listed for transplant earlier, when they may not need transplant, would be given an unfair advantage.  Time on the list could be a factor if two identical MELD score patients were offered an organ.

The MELD score does not take into account various symptoms of chronic liver disease such as fatigue, depression, weakness, the presence of ascites, hepatic encephalopathy, or variceal bleeding. There are other symptoms that our patients report, not taken into strict accound in calculating the MELD score. Dealing with the symptoms, and the sense that they are getting more ill, is a very frustrating position for the patient, as well as the transplant team members. While we address and try to treat these symptoms, it is hard to accept their poor and declining quality of life does not come into consideration.  Several medical conditions that had been considered in the prior liver allocation system, such as ascites and encephalopathy, are not included in the MELD system. This is because these factors have been tested in the MELD formula and did not add to the MELD score’s ability to predict death on the waiting list. In addition, the way these conditions are measured can vary from center to center; therefore, leaving them out of the MELD formula helps to make sure that all patients are scored the same way.

On exception is to appeal to the regional review committee, made up of transplant physicians in a similar region where the patient is listed. This is an opportunity for the team to “ask for more points” to increase the chances that someone will be transplanted.

How high your MELD score has to be before transplant varies on where you live. In the greater Houston area, a MELD of 22 and above (in general) will be a point where patients may be called for transplant. In California, a MELD score of over 30 will likely be needed for transplant.

So what is the bottom line on the MELD score? Time on the list is of little value, and that this model aims to transplant those that are sickest first. Despite multiple symptoms that patients report, and how bad they feel, it has not been shown that these symptoms lead to an increased chance of death. It is true that you have to get more sick before getting transplanted, but the survival afterwards, and the regaining of quality of life, is what makes the system work. It is far from perfect, but it does work.

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13 Responses to “MELD Score and the Question of When I am Getting My Liver?”

  1. Leslie 04/12/2008 at 12:02 pm #

    I believe i just did the meld score test and it is coming back at 49 and then it asked for the 90 day mortality rate to key in meld and hit the button – it came back 0.97 what does this mean.
    i know i have some the blood results right but i am not sure if PTT and INR are the same thing – i believe they are (clotting time) plt was 97 but 4 days earlier it was 72
    creatinine is 0.88 and bilirubin total is 0.3 – can you explain to me what all this means. currently under no TX program, have cirrohsis compensated of the liver. possible TB CBC levels all low
    Thank youso very much

  2. Leslie 04/12/2008 at 12:20 pm #

    i just sent you a request to information, but just found i believe more current info which chnages the mnumber largely
    bilirubin = 1.3
    cretaitine – still i guess the same at 0.88
    INR = 1.13
    total =8 can you tell me what this means -i so dont understand. and does this number change when hep c is involved.
    currently compensated cirrhosis of the liver and hep c
    thank you for helping me
    leslie

  3. Harmeet Singh 02/28/2009 at 8:54 am #

    I am 59 year old person I have been detected with cirrhosis of liver due to excess intake of alcohol and I am diabetic too.All the other tests are negative.Present details
    bilirubin = 2.4
    cretaitine – 0.6
    INR = 1.73 .
    All the above mentioned figures have come done from the previous details , which were:
    bilirubin = 5.4
    cretaitine = 0.6
    INR = 2.14
    Kindly advise my chances of recovery without going in for transplantation surgery.
    Warm Regards
    Harmeet Singh

  4. Rev Charles Baldwin 05/07/2009 at 9:39 pm #

    Hi Doctor, my name is Rev Charles Baldwin 52 yrs old. I had Hep C since 1994. I had an operation that I believe the disease was transmitted the doctor was diagnosed with Hep C. I had 3 rounds of inerferon, rebatrol, and then Pegasys worked in 2007. Now I have from it end stage cirrhosis. My meld score is 12. I have edema, high blood, high ammonia levels with other symptoms. I also have Lupus. I’ve been able to keep going but with much difficulty. I sleep 10 hours a day. The last few weeks I’ve been getting weaker and sleeping 16+ hours a day. No energy to even leave my chair. I was able to be active 6-8 hours a day now not anything but from a sitting position for a few hours a day. MY QUESTION IS: Does this sound like the natural progression of the disease. Does it sound like I am getting closer to transplant time or ammonia levels causing this? My Liver Specialist is not scheduled for another 2 months away. My ammonia level was elevated to about “38” my last visit. I have been taking lactulose, going 2 times a day on an average. I know it’s impossible for a daignosis but what is your impression. I know that it’s a natural progression. Question 2: Will I be “real sick” even bedfast before I get my liver? My doctor likes bringing transplant candidates with pager at 20 and do the transplant around 25? I will wait for your response. I am making a major decision about my Ministry that I don’t want to make if I am soon to be not able at all? Thank You sir and may God Bless!

  5. V. Copeland 12/30/2009 at 9:51 pm #

    My husband has HCC, diabetes, varicies, and Hep C. He is on the transplant list in Houston. We were told eventually we would have to relocate. I guess like most the waiting is very difficult.I have a teaching position and I worry all the time will they call him this week. I want to be prepared ahead of time. His MELD score is 22 and we live in Oklahoma. Should we already be there? We have to find a place to live. Decisions! Decisions! It is scary!

  6. Sharon Nobles-LaRocca 11/08/2011 at 1:16 pm #

    Hello! I am so glad to have found your website and blog.

    My husband, Thomas 60, is visiting the Houston area very soon – this weekend for a week – and I believe it would benefit him to been seen at your practice.

    He is a Hep C, ESLD/Cirrhosis, alcoholic – reforming, past use of illegal drugs (cocaine) patient. Currently on several medications including 2 diruetics, blood pressure, beta blockers, prozac, Lactulose…..Recent hospitalization in August due to complications from decompensating liver. Banding of variceal bleeding and a bout with hepatic encephalopathy (New Hanover Regional Medical Center, Wilmington NC. Dr William King via Wilmington Gastro).

    Husband does not understand the symptoms and his MELD scoring. He has been placed on driving restrictions which he is fighting tooth and nail….he insists he WILL find a Dr that will say it’s ok for him to drive.

    What evidence can you provide to support the non-driving restrictions?

    How can we help him realize the dangers of ESLD?

    Thank you so much.

    • Dr. Joe Galati 11/09/2011 at 4:14 pm #

      Thanks. We are happy to evaluate him. Have him contact the office at 713-794-0700 and we can see how we can best serve him.

  7. Vicki Diamnd 03/07/2012 at 6:40 am #

    hello doctor, i live in Alaska. I first found out I have Hep c was in 1998. I went through through non-approved studies using Riboviron, interferon and a 3 day injections. am21 bb with TT Titters? I am experimenting the possibility of getting on another studayl Harborview want me to try the pills without interfer andhas put me on their list. If there are studies out there that need subjects, I am more than willing. Logistically it woulld be better to do these trials from Louisiana where I have family support and will help me drive back and forth to Houston. I will give to you all the paperwork they gave Me at the University of Washington on Jan 1, 2012. I tried the interferon/ribaviron twice already The first study included 3 times a week injections. After 6 months I still had virus. Then, they put me on an trial with every dosing with interferon 15 times what a normal body would have in the blood and also taking the ribaviron. I had to quiet that study because I am / was a working mom with two jobs and it started to be impossible for me to continue working. If you could put me on a study down there in the Houston area I will be more than estactic and would ove to participate to the studies going on now there that need subjects for the studies. Can you please help me and direct me to the folks I would need to contact there in Houston that signs up people for studies your help. I know in the cirrhois stage of this discease and it is very scarey.. my emial address is 9075292084 and home phone is 9073381958. Please write me back as I am very anxious to starrt a treatment study the faster the better. I do not want to die but the virus is very determined to kill me. Thankis

  8. kim 08/27/2012 at 7:33 pm #

    those with fatty liver that led to cirrohsis of the liver, with no underlying diseases should be a nation wide law that they automatically get on the list. My dad was always was too good to be on the list. He was in indiana. He started to gain fluid in october 2011, and started to look bad at that time. His scores even until his death were always so good. He had an infection due to parancentisis, kidney failure, but they were able to get them back to normal. went home for one week then creatine levels increased again. In hospital for 3 weeks. when he was released he was skinny, but now he would need dual liver /kidney. I U decided not to pursue my father, but they pursued and alcoholic on the list from california who was 67 and he had dual transplant. My dad had no underlying issues still didn’t pursue him in 2011. he died july 9th. kim

    • Dr. Joe Galati 09/09/2012 at 10:20 pm #

      Very sorry for your loss. As I have posted in other entries, the MELD score does not always reflect the true need a person has for a transplant. In situations where the calculated MELD score is low, based on local availability of organs, there is a chance that low MELD score patients get passed over, until it is too late, and more serious complications develop.

  9. Kiran 04/18/2013 at 9:22 pm #

    Hi, Dr.galati. My mom on active list for liver transplant in houston. She has MELD score 29 and she has more frequent asites. When they done last lab for asitic fluid they found out AFB culture is positive. Now she off for transplant list. And she start medication for TB. But she do not have any symptoms of TB. I would like to know that when they put back on list. What is guid line for that . Can you please let me know. Thank you so much for your help.

  10. kiran 05/22/2013 at 2:39 pm #

    hi, Dr. Galati

    my mom has HCC, SHE IS ON TRANSPLANT LIST FOR ONE AND HALF YEAR. HER SCORE IS 31 ALSO I HAVE A QUESTION THAT DID SHE CONTINUE HER NEXAVER 200 MG DAILY. HER afp is 1.1 also after april 2012 the Dr. done chemo embolization, ass scan until that all are negative for cancer. so i would like to know is it ok to discontinue.because of asities and weight loss aslo weakness. can u please let me know.

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