Gastrointestinal and Hepatobiliary · Chronic liver disease and transplantation · MELD 3.0

MELD Score (Model for End-Stage Liver Disease)

An objective prognostic score estimating 90-day mortality in advanced liver disease and determining medical urgency for liver transplantation. MELD 3.0 is the current OPTN formulation.

Purpose

To estimate short-term mortality in advanced liver disease and provide an objective measure of medical urgency for liver transplantation; the score also contributes to risk assessment before procedures such as TIPS.

Version	Variables	Calculation	Key points
Original MELD	Bilirubin, INR and creatinine	10 × [0.957 × ln(creatinine) + 0.378 × ln(bilirubin) + 1.120 × ln(INR) + 0.643]	Developed to predict short-term survival after TIPS and subsequently adopted for liver-allocation prioritisation.
MELD-Na	Original MELD variables plus serum sodium	For MELD(i) >11: MELD-Na = MELD(i) + 1.32 × (137 − Na) − [0.033 × MELD(i) × (137 − Na)]	Sodium is bounded at 125–137 mmol/L. It replaced the original MELD in OPTN allocation in 2016 but was superseded by MELD 3.0.
MELD 3.0	Bilirubin, INR, creatinine, sodium, albumin and an adult female-sex term	Round [1.33 if female + 4.56 × ln(bilirubin) + 0.82 × (137 − sodium) − 0.24 × (137 − sodium) × ln(bilirubin) + 9.09 × ln(INR) + 11.14 × ln(creatinine) + 1.85 × (3.5 − albumin) − 1.83 × (3.5 − albumin) × ln(creatinine) + 6]	Current OPTN formulation for adults registered at age ≥18 years. Scores are bounded at 6–40; a higher score indicates greater 90-day wait-list mortality and transplant urgency.
MELD 3.0 laboratory bounds	Bilirubin, INR, creatinine, sodium and albumin	Bilirubin, INR and creatinine: minimum 1.0; creatinine: maximum 3.0 mg/dL; sodium: 125–137 mmol/L; albumin: 1.5–3.5 g/dL	Values outside these limits are replaced by the corresponding boundary before calculation.
Renal replacement rule	Creatinine and recent dialysis history	Use creatinine 3.0 mg/dL after at least two dialysis treatments in the preceding 7 days or 24 hours of continuous veno-venous haemodialysis in that period	This is the MELD 3.0 OPTN rule; the historical MELD/MELD-Na creatinine ceiling was 4.0 mg/dL.

How to use it

MELD is primarily an objective laboratory-based estimate of 90-day mortality rather than a direct measurement of hepatic anatomy or portal pressure.
MELD 3.0 improved calibration by adding albumin and sex, updating coefficients and interaction terms, and lowering the creatinine ceiling to 3.0 mg/dL.
OPTN uses MELD for most liver-transplant candidates aged 12 years or older; candidates younger than 12 years receive a PELD score.
The calculated MELD may underestimate urgency in selected diseases, for which transplant systems may use approved exception pathways.
For TIPS assessment, a high MELD indicates increased procedural risk, but candidacy must integrate indication, bilirubin, haemodynamics, cardiac function, encephalopathy and clinical judgement.

Common mistake

Do not calculate current transplant urgency with the original MELD or MELD-Na formula, and do not enter uncapped laboratory values into MELD 3.0. Exact allocation calculations should use the applicable official transplant-system calculator.

Exam pearl

Original MELD uses bilirubin, INR and creatinine; MELD-Na adds sodium; MELD 3.0 additionally incorporates albumin, an adult female-sex term and interaction terms.

Viva questions

What is the MELD score?: The Model for End-Stage Liver Disease is an objective prognostic score that estimates 90-day mortality in advanced liver disease and helps determine medical urgency for liver transplantation.
Which variables are included in the original MELD score?: The original MELD score uses serum bilirubin, INR and serum creatinine, with natural logarithmic transformation.
How does MELD 3.0 differ from MELD-Na?: MELD 3.0 retains bilirubin, INR, creatinine and sodium, adds albumin and an adult female-sex term, introduces interaction terms and lowers the creatinine ceiling from 4.0 to 3.0 mg/dL.
What laboratory bounds are used for MELD 3.0?: Bilirubin, INR and creatinine have a minimum of 1.0; creatinine is capped at 3.0 mg/dL, sodium at 125–137 mmol/L and albumin at 1.5–3.5 g/dL.
How is creatinine handled in a patient receiving dialysis?: For MELD 3.0, creatinine is set to 3.0 mg/dL after at least two dialysis treatments in the preceding 7 days or 24 hours of continuous veno-venous haemodialysis during that period.
How is the MELD score interpreted?: The score ranges from 6 to 40. A higher score represents greater predicted 90-day wait-list mortality and therefore greater urgency for transplantation.
Which score is used for a child younger than 12 years?: PELD, the Paediatric End-Stage Liver Disease score, is used for candidates younger than 12 years; MELD is used from 12 years onwards in the OPTN system.
What is the relevance of MELD before TIPS?: MELD was originally developed in patients undergoing TIPS, and a higher score indicates increased post-procedural mortality risk. It supports risk stratification but must not replace assessment of bilirubin, cardiac reserve, encephalopathy, haemodynamics and the clinical indication.