What MELD score qualifies for a liver transplant?

Why there is no single qualifying MELD score

No MELD score qualifies or disqualifies a patient for a liver transplant, because the Model for End-Stage Liver Disease is a measure of short-term risk of death, not a list of eligibility criteria. Kamath and colleagues validated MELD in 2001 as a predictor of death within 3 months in end-stage liver disease, and the US Organ Procurement and Transplantation Network (OPTN) uses it to put listed candidates in order: the higher the score, the sooner a donor liver is offered. Whether a person is listed at all depends on a full evaluation by a transplant center, covering the liver disease and its complications, other medical conditions, and psychosocial factors. MELD enters that decision in two places: as one trigger for referring a patient to be evaluated, with 15 as the commonly used threshold, and as the number that sets their priority once they are on the list. Some conditions, such as hepatocellular carcinoma, are handled with exception points rather than the calculated score.

The MELD 15 rule for referral

The MELD 15 rule comes from the 2013 practice guideline on evaluation for liver transplantation by the American Association for the Study of Liver Diseases (AASLD) and the American Society of Transplantation (AST), published in Hepatology by Martin and colleagues. It recommends that evaluation for transplant be considered once a patient with cirrhosis has had an index complication, such as ascites, hepatic encephalopathy or variceal hemorrhage, or once liver dysfunction gives a MELD score of 15 or more. That makes MELD 15 a threshold for starting the assessment, not for receiving a liver, and a patient with a decompensating event can be referred at a lower score. The guideline was written when MELD without sodium was in use; OPTN later moved to MELD-Na and then MELD 3.0, which usually give a higher number than MELD for the same patient when sodium is low, so the version you calculate can decide whether a patient crosses 15.

Why 15: the survival benefit by MELD score

MELD 15 marks roughly where a transplant starts to help more than it harms within the first year. Merion and colleagues studied 12,996 adults placed on the US waiting list from 2001 to 2003 and compared the death rate of those who received a deceased donor liver with that of similar candidates still waiting. Overall, recipients had a 79% lower risk of death. But the benefit depended on MELD. At MELD 6 to 11, recipients had a 3.64 times higher risk of death in the first year after transplant than candidates who stayed on the list, and at MELD 12 to 14 a 2.35 times higher risk, because the operation itself carries a risk that low-MELD patients would not otherwise face. At MELD 18 to 20, recipients' risk was 38% lower, and at the maximum score of 40 it was 96% lower. The authors concluded that, with one year of follow-up, patients at lower risk of death before transplant had no demonstrable survival benefit.

How MELD ranks the waiting list

Once a candidate aged 12 or over is listed, OPTN ranks them by their current calculated score, updated as their labs change, so priority follows the risk of dying while waiting. OPTN used MELD-Na, which adds serum sodium to MELD, from January 2016, and replaced it with MELD 3.0 in July 2023. MELD 3.0, published by Kim and colleagues in 2021 from all US wait-list registrations in 2016 to 2018, adds female sex and albumin and caps creatinine at 3.0 mg/dL; in a simulation it led to fewer wait-list deaths than MELD-Na, 7,788 against 7,850. The observed 3-month mortality behind the score is steep: in Wiesner's 2003 cohort of 3,437 listed adults, it was 1.9% at MELD 9 or less, 6.0% at 10 to 19, 19.6% at 20 to 29, 52.6% at 30 to 39 and 71.3% at 40 or more. Children under 12 are ranked by the separate PELD score.

Worked example: which version crosses 15?

The MELD version matters most near the referral threshold of 15. Take a man with cirrhosis and a bilirubin of 2.5 mg/dL, an INR of 1.5, a creatinine of 1.0 mg/dL, a sodium of 134 mmol/L and an albumin of 3.0 g/dL. The original MELD, from bilirubin, INR and creatinine, is 14, just under 15. Adding sodium raises MELD-Na to 17, because his sodium of 134 is below the 137 ceiling the formula uses. MELD 3.0, which also counts his low albumin, is 17 as well. So by the score OPTN uses today he is over the referral threshold, while by the score in place when the guideline was written he is not. In practice the threshold is a prompt rather than a gate: a patient with ascites, encephalopathy or a variceal bleed meets the referral criterion whatever the number, and scores near 15 are worth repeating as the labs change.

Check his numbers, or your own patient's, in the MELD calculator, which shows MELD, MELD-Na and MELD 3.0 together.