Liver Transplant
Patients awaiting transplant commonly have questions regarding there MELD score, and how this number is determined. As you can imagine, there is great anxiety in patients awaiting transplant. At almost every clinic visit, patients are asking for they’re updated score. In my own practice, at every visit we calculate the new score and discussed this result with them. The MELD score, which we have been using for the past several years, is calculated by taking the patient’s most recent bilirubin, creatinine, and INR, which is then entered into the computer and calculated. Theoretically, the MELD score can arrange in values between 5 and 40. It has generally been accepted that patients with a MELD score less than 15 have a better survival is not transplanted. Those with scores over 15 should be considered for transplant. The higher the MELD score, the more ill the patient is, with a greater likelihood of not surviving. In the greater Houston area, most of the transplant programs, including ours at the Methodist Hospital, are transplanting patients with MELD score is greater than 25.
There are certain exceptions to the MELD score. Many of these are developed regionally. With patients who develop hepatocellular carcinoma, in most cases, they will receive a MELD exception of 22 points, even if they have a lower calculated score as described above. It’s been well established that patients with liver cancer should be transplanted quickly. This MELD exception allows this to take place. If after 3 months the patient is not transplanted, additional points are granted. Other MELD exceptions for pulmonary hypertension, refractory gastrointestinal bleeding, and refractory ascites are also allowed. These are given on a case by case basis after a regional review by other transplant centers. Not every exception is granted, and this could be another source of anxiety for patients and their family.
Looking at the bilirubin, creatinine, and INR, you could see that as the patient becomes more ill, their MELD score will reflect a higher value. It is very difficult to sit with the patient who has a low MELD score, who happens to feel very ill, and tells him that they must continue to get even more debilitated before a transplant is performed. While the current allocations system works for the vast majority of patients, there are always going to be those patients that have a MELD score that does not accurately represent how sick they are. For these patients, this is where most of the anxiety and concern is present. The best that we can do as physicians and other healthcare providers is to reassure them and worked very closely with them. I personally have been involved in liver transplantation for over 20 years, and the same issues we faced 20 years ago, despite a different allocations system, remained today.
To calculate your own MELD score, I have listed a link below. Of course, if you have any questions, feel free to contact me or post your comments on this blog for others to see and learn from. You can always reach me at Liver Specialists of Texas at 713-794-07 00.
Dr. Joseph S. Galati is a native of Long Island, New York. He received his undergraduate degree at Syracuse University and attended St. George's University School of Medicine.
Can a person with stage 4 chirosis Meld score go down? My husband did have a Meld Score of 11 now they said it is a 5. Is that possible?
Thank you,
Lori
It can indeed. Based on the values of the creatinine (kidney function), bilirubin, and INR (clotting time of the blood), all have the potential to change based on how sick (or well) a patient is. I have seen very stable patients waiting for transplant have stable MELD scores in the low to mid teens (15-17), who experience a severe case of peritonitis, or have a massive variceal hemorrhage. Instantly, their MELD score shoots up to the high 20′s or 30′s due to acute kidney failure (rise in creatine), and an increase in the INR. Similarly, these patients can recover, and get back to their baseline values, and continue to do pretty well. Hope this explains your question.
My father 63 years, had heart bypass surgery in 2002, has been diabetic since 20 years, has never consumed alcohol, has tested negative for Hep A and B and C. No Liver Cancer. has been diagnosed with decompensated cirrhosis. +++ is what doctors have written. the cretanine is 0.91, and the billurbin total is 0.5 (jendrassik-Grof) and the Prothrombin time is TEST 14.9 SECONDS, CONTROL 12.0 SECONDS, INR 1.26., Sodium (Na)ISE 127.9, Albumin 2.5 g/dl, Ascitic Fluid-Albumin 1.2 g/dl. THE FIBROSCAN SHOWS stiffness 26.6 (KPa), IQR 4.1 (KPa), CS 27.7 KPa, Sucess Rate 91%. I am based in New Delhi, India. My problem is doctors here just told us Liver Transplant is the only way. He has fluid retention in abdomen, edema, does not feel hungry, is constipated. Doctors here are not telling me in lay mans term what is the problem. whether his condition is so serious that he can not survive for more than a couple of months without transplant, as we can not afford the cost of transplant. I am begging you to please let me know where i stand ? i HAVE ALL REPORTS, ct scan, endoscopy, fibroscan, liver bioposy, his hVPG is 16. can you please help and tell me. If you want any other test done, or reports please let me know. but please help.
It seems that liver transplant is something that needs to be considered. Of course, there are a number of issues that need to be addressed, including his cardiac status. Diabetes for 20 years and prior heart surgery needs to be looked at very carefully.
Are they considering transplant in India? Coming to Houston is always an option, thought there are logistical issues that need to be sorted out.
Unfortunately without transplant, many patients continue to have complications related to their underlying liver disease.
My dad got a call yesterday about his Meld score and it jumped from 18 – 25. I am not very familiar with the meld score system and what it means. They told him that if he starts bleeding from the mouth or nose to go straight to the ER asap. Why?
Dr. Galati
I’m emailing you in reference to my Brother. He contracted Hep C sometime ago and has never received treatment or has have a live biop. I’m interested in the clinical trial GS-585, GS-9451 w/ Peginterferon Alfa 2a (PEG) and Ribavirin. I also have read information about the FibroScan but don’t know where to have one done. He is unemployed and uninsured that is why we are looking for a clinical trial. If you can assist me and maybe direct me to where we can go to have this scan I would GREATLY appreciate it.
Tammi
There are a number of very interesting compounds being developed, as we discuss. Depending on the part of the country your brother lives, opportunities exist. If in Texas, we’d be more than happy to evaluate for a study. You can call our office at 713-794-0700 and speak with Herman Ortiz for details. Good luck. Dr. Galati
Dr. Galati,
Thank you so much. My brother and I are both in Houston. I will call Herman Ortiz now for an appoinment after the holidays. I look forward to meeting you.
Happy Holidays,
Tammi
Dr. Galati,
My father has chirosis of the liver and his MELD score was 12-15 now he has been diagnosed with Peptic Renal Failure and his MELD score is 25. WHat exactly does this mean in refernce to the transplant list as far as when he could get a liver? He is at MUSC which is a smaller hospital.
Thanks again,
Caroline
Going into kidney failure, which is a common complication, elevated ones MELD score, since kidney is one of the three factors used to calculate the score. There is also a special option, if the patient has been on dialysis, that will add to the score as well. While these developments increase the MELD score, and thus the chance for transplant, survival, unfortunately, is also reduce. Hope this helps. Dr. Galati
My boyfriend has a meld score of 6… he had hep. c but has been cured of the hep. with the 6 month treatment. My mother has a meld score of 11. her cirrhosis is due to fatty tissue. My sister had a meld score of 16, it went down to 15, but when it was a 16, she said she had been put on the transplant list in birmingham al. thats where she lives. she has a different doctor than the other two. my mom’s doc. said he worked at uab for 12 yrs. and there is no way my sister could be put on the list with a 16 meld score. he said it has to be 18 or above. My sister takes medicine for the high ammonia. I’m just trying to figure her story out about the transplant list. I know Doctors oppinions vary. I’m just trying to figure out if my sister is being completely truthful. Can you give me some input? My Mom & boyfriend seem to function fine. But my sister is entirely different. Is it because their meld score is so much lower or is it all in the attitude one takes. My sister is on disability due to her cirrhosis(she was a psychologist,but due to the high ammonia level was no longer able to see patients).She doesn’t want to work anyway, so now she doesn’t have to. Also she is overweight. would they even consider putting her on the list with her being overweight? She said she had to undergo many evaluations & do a stress test to be put on the list. Can you give me some input?
Many times the MELD score does not reflect how sick a person is with cirrhosis. Every case is different, and transplant programs do different from city to city regarding who they will lace on the list. The best bet is to make sure everyone understand the plan of care outlined by the doctors, and communicate it to rest of the family.
My husband has alcoholic cirrhosis,since he had bleeding from varices in esophagus,he stopped alcohol completely,it’s been 2 months since the first episode of blood vomiting and he had two more such episodes and his meld score dropped from 14 to 17,why is he not improving inspite of stopping alcohol,is he going to need a liver transplant?
In many cases, after bleeding, the function of the liver continues to get worse, even if they stop bleeding. ANY patient bleeding from varices needs to be evaluated for transplant. If in Texas, I would be pleased to evaluate him for transplant. 713-794-0700.
Dr G,
Is age taken into consideration at all?
I guess because I’m in my 20s with significant liver disease I’m biased.
MELD doesn’t apply to kids with bilary atresia.
Cheers, Alexander.
Dear Dr. G,
My husband was hospitalized on 9/10/11 with a M.E.L. score of 18 with the hopes of getting on the transplant list. On 9/21/11 he was listed and then removed frm the list on 9/22/11 because his M.E.L. score was 44. He passed away on 9/24/11. Is it unusual for someones score to jump from 18 to 44 within 11 days? What could cause this?
Sorry for your loss.
The MELD score can change in a matter of days. We are allowed to upgrade on a daily basis because of this. A worsening MELD is reflective of worsening liver function, and survival.
Hi Dr Joe,
My brother has Liver Disease with a meld score of now 29. he is sick and tired and experiencing heavy swelling/ fluid build up. He’s on the list at UCLA, but since his score is increasing, has just been approved for a transfer to Indiana. There he was assured he’d be moved to the top of the transplant list due to his score and condition. Do you feel this is a good move and can you recommend any advice?
Thanks so much.
Steve
My brother was 42 years old. he was diagnosed with Cirrhosis of liver with portal hypertension. he was admitted to hospital (15th May 2012)as recommended by our family doctor as there was fluid accumulation. The hospital told us that the fluid was very minimal and there was no need to drain. He had a dry cough which used to make him restless specially during evening. On informing the doctor they did an X-ray and told us that his lungs was clear and it was a bronchitis and antibiotic was prescribed. He could not sleep whole night but the nurses refused to call the doctor on call.The one week he stayed in hospital his emotional condition was becoming worse. as only thing the hospital was doing was giving medication and doing we asked for a discharge. Hospital had recommended high protein diet. but they were not providing the same at hospital.the nursing care was very bad. I had a discussion with doctor. they explained that he will have to go for a liver transplant and will discuss with my brother when he comes for review after two weeks.
As we were getting ready to leave a friend of ours who also works in the same hospital saw my brother coughing and asked if an echo cardiogram was done for him when I told, no ,he went to meet the doctor. When we got the discharge summary it was mentioned that they wanted to do an echo cardiogram. The patient should do the same when he comes for review after two weeks. They had done an ultra sound, upper GI endoscopy and sigmoidscopy. During his stay in hospital or when discussing about his discharge the doctor mention any thing about his heart being affected due to cirrhosis of liver.
he was discharged on Monday21st May. 22nd night he again had cough like he had during his hospital stay. He could not sleep whole night but he refused to go back to the same hospital. We took appointment with another hospital on Wednesday. He had bath by himself and got ready. to go to hospital. on the way he had a cardiac arrest and passed away.
Just want to know few things:
1. if liver cirrhosis affects heart
2. If an echo was done would the doctors have been able to inform us about the condition better,
I want these information so that when future anybody has similar condition we can be better aware what to check with the doctors.
I Know that no Doctor could have stopped my brother from dying as that is decided by God but if we were informed about the risk factors we would have been better prepared. He could have been provided some support so that he would not have to suffer whole night.
My father has been an alcoholic for twenty years. He has cirrosis and has been to the hospital multiple times this year for the vericose veins on his esophogus rupturing. His doctor refered him to a specialist to help him get on the liver transplant list. Does he even qualify for one? Can alcoholics receive liver transplants? They also mentioned him getting a stint put into his heart.
Alcoholics do qualify for transplant. They must stop all alcohol, and participate in a relapse program such as AA.
I live on the west coast, diagnosed with Autoimmune Hepatitus about 14 years ago due to sulfa antibiotics. For many years I was stable up to 2 years ago when my liver started failing. My MELD was 32 at the hospital for 3 weeks. I was put on TP list in the #1 spot and stayed there for 8 months. During which time, became diabetic, hypothyroidism, cataract surgery in both eyes, 2 tumors (1 brain, 1 jaw), and frequent the ER, have ascites, GI bleed, hepatic encephalopathy and skin cancer. My MELD hovers 8-11 and I am told not high enough to be offered a new liver. My quality of life has diminished, constant procedures performed, ER visits, new problems to add to my list of health problems. At what point do I move back up the list where I might be considered for transplant? Or is my fate that I continue to deteriorate, add so many health issues just to keep my liver working, taking medications with serious side effects, that I work myself into a position that I will never be selected as a good transplant candidate? Can you give me any clarity on this?
This is always a difficult position to be in. Right now, the sickest, with the highest MELD scores, get the donor organs. A MELD such as yours is rather low, but does not fairly reflect the quality of life you describe. Think about dual listing at another program.
What does it take to make the list? My dad lives in Alabama, has a MELD count of 15, (he has cirrosis of the liver and diabetes) and while he was doing testing found out he had liver cancer as well. When talking with the drs there, they seemed pretty sure that it was very likely that he would be put on the list and be transplanted quickly. But when getting the paperwork back, he didn’t even make the list and is being asked to do the Ablation procedure. Is this normal to not make the list? If a patient has this Ablation procedure will they then be placed on the list? Sorry, we just aren’t getting any answers and are very worried.
It’s a long process to get listed, and each program, based on their region of the country, has different rules they go by. You can always seek a second opinion. Happy to evaluate. Give us a call. Dr. Galati
My 58 year old sister has end stage cirrhosis. She is being treated with lactulose, but her hallucinations are increasing and she is nauseated and vomiting all day long. She has had fluid drained from her stomach once about 5 months ago. I just read about a drug called xifaxan being used in conjunction with lactulose to reduce the ammonia levels and hallucinations. However, there seems to be a risk of C Diff developing with this drug. The physicians in our small town don’t quite know what to do with her and are just experimenting with drug dosages and trying different drugs. Should she ask dr. to try Xifaxan or some other drug? She is not in the hospital. Should she be?
It seems at age 58, if there are no other medical conditions, she should be evaluated at a liver transplant program. Xifaxan can be used by itself or in combination with lactulose to control hepatic encephalopathy.
My father was diagnosed with liver cancer in March 2012. He took the mediactions and. participated in clinical trials, but nothing has worked. His doctors have told him he has less than 4 months. As of his last scan, his cancer had not spread. Why is he not a candidate for a transplant?
Thanks for the note. Liver transplantation is possible in cases of liver cancer, though size and location matters. Has he been seen at a center that deals with liver transplantation and liver cancer. If not, I would seek out an opinion at such a center. Let me know what city he lives in and I can suggest a few options.
Hi, Dr. Galati
My mom diagnosed with HCC, she is on transplant list for 11 months, right now her meld score is 29. her hep c has genotype 3A , and after 4 weeks of treatment the viral load is not detectable, still she is continue the treatment. right now she is on 30 weeks of treatment. her hepatologist said that she has to continue treatment until the liver transplant. the last scan shows there is no melignancy also no any residual disease.
In case of HCC they said they have trasnplant asap so i would like to know why its take that much time alSo she is O+ve blood group. Her AFP IS 1.5.
Do you think my mom will benifit if i transfer her care to methodist hospital. also i would like to know if there is any multiple listing availble.
THANK YOU SO MUCH FOR YOUR HELP.
It appears that she is receiving appropriate treatment. I assume she is receiving the MELD exception points. The HCV treatment, as long as she is tolerating the treatment, is also a great plan. Would be happy to get her double listed, though with a MELD score of 29, she is very close-depending on where she liver. Happy to assist. Let me know. Dr. Joe Galati
Hi, Dr. Galati
Yes, because My Mom have HCC, she start her MELD score 22, right now her score is 29. she live in Houston, also I would like to know after 28 points, she done the scan in 3 months and she only got 1 more point instead of 3 points so I would like to know how is the MELD Score work after 28 points. And as per last scan report of MRI, There is no malignancy or residuals disease. Mom done chemoembolization IN APRIL 2012 AND she also on NEXAVAR 200 mg BID. I would like to know it is safe to continue the medication. Also her WBC COUNTS always in between 2.3-2.9 so, if is SAFE to give her NUPOGEN shots weekly.
Thank you so much for your time and help, I am so glad that you response us back. Again Thank You So Much For Your Help.
Hello, a close family member had a MELD score of 14 a week ago two days after her first hospital visit from increased ammonia and encepholepathy. She has only experienced ascites for the first time once in the past month. Her ascites went away on Lasix. She has cirrhosis and hep c. The doctor did not offer the Interferon treatment even though according to academic journal research anyone MELD <24 is a candidate for low dose Interferon. Do you treat decompensated Interferon? How do we go about finding a doctor who does that? We are in the Pittsburgh are. Thanks so much for your time. This is a great resource.
Treating HCV in the setting of cirrhosis, complicated by ascites and hepatic encephalopathy is very risky. It is unlikely anyone would be willing to treat in a case like this. Newer drugs may soon be available, and less toxic in patients with decompensated cirrhosis.