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.