By Lynne Eldridge, MD 

 Medically reviewed by Jay N. Yepuri, MD

A MELD score, short for Model for End-Stage Liver Disease, can provide important information about liver failure prognosis and inform decisions about liver transplant. It is based on key lab test results used to measure liver function.

While a good tool, the MELD score is a statistical measure and does not take into account several factors that might affect your individual prognosis. A MELD score interpretation should always be considered within the context of clinical findings and your specific medical history.

This article explains how a MELD score is calculated. It will help you understand what the MELD values mean, as well as what limitations and considerations should be kept in mind when interpreting your score.

Tharakorn / Stock Photo

Purpose of MELD Score

MELD score tests can be used for anyone over the age of 12 with end-stage liver disease, regardless of the cause of the disease.

A modified MELD score (the PELD score) is used for children under the age of 12. With children, age less than 12 months or the failure to grow are also considered.

There are several reasons for why your healthcare provider may recommend calculating your MELD score.

Liver Transplantation Prioritization

The MELD score is used to make decisions about liver transplants among people with end-stage liver disease. Far more livers are needed than there are donor organs, and it's a tool to help make challenging assessments about risks and benefits in specific cases.

This importance is better understood by looking at the success rates of liver transplantation in appropriate situations. At the current time, overall survival rates are over 90% at one year and over 80% at five years after transplant.1

Short-Term Risk of Death

The MELD score is used to predict mortality (the risk of death) over the next 90 days of illness in cases including:

• People with acute alcoholic hepatitis

• People who have liver cirrhosis (extensive scarring) but face other surgeries, such as cardiac care. One study found a 2% rise in surgical mortality risk for each MELD point over 20 and a 1% increase per point below 20.2

• People who have had a transjugular intrahepatic portosystemic shunt (TIPS) placement

• People with hemorrhaging from esophageal varices3

The MELD score may also help predict longer term survival for a wide range of liver diseases, including esophageal varices, spontaneous bacterial peritonitis, and hepatorenal syndrome.2

A 2020 study suggested MELD scores might also inform prognosis after surgery to remove liver cancer, and be used to assess surgical risk in people with liver disease with or without cirrhosis.4

History of the MELD Score

A MELD score was originally used to predict three-month survival in end-stage liver disease, largely replacing the Child-Turcotte-Pugh system. MELD scores were adopted by the United Network for Organ Sharing (UNOS) in 2002 to help prioritize people waiting for a liver transplant. In 2016, serum sodium was added to the MELD score formula, with other changes currently being evaluated.

Calculating Your MELD Score

A MELD score is calculated using the results of key laboratory tests, as well as any recent dialysis data related to renal (kidney) failure.

Values used in the calculation include:

• Creatinine: This kidney function test is done because liver disease can lead to kidney failure (hepatorenal syndrome).

• Bilirubin: This is a measure of how well the liver gets rid of bile. Increased levels are common in liver disease.

• International Normalized Ratio (INR): This is a measure of clotting factors the liver is unable to manufacture as liver disease progresses.

• Serum sodium: This was added to the formula in January of 2016 (MELD-Na) to assess sodium levels.

Blood tests need to be performed within 48 hours of the time the calculation is made to be accurate and to qualify for liver transplant consideration.

Since the formula used to determine the score is complex, a MELD calculator is often to do the number crunching. The Organ Procurement & Transplantation Network, part of the U.S. Department of Health & Human Services, has a MELD Calculator that anyone can use.

Limitations

The MELD score is a statistical test. Apart from a MELD score, prognosis includes several factors not included in the calculation, such as:

• Age

• Sex

• The presence of continued drinking with alcoholic liver disease

• Nutritional status

• Other health conditions

• Family support (family caregiver)

A 2019 study found that sex, age, and family support for high-risk people were all factors not included in the MELD score. In the lower risk group, family support, the liver function test AST, and albumin (a measure of protein in the blood) were important to the prognosis in addition to MELD scores.5

There are other limitations. People on anti-coagulant blood thinners have an artificially elevated INR that is not offset by the MELD score formula. Further, any blood draw or lab variability could also reduce accuracy.6

Liver Function Tests and MELD

Liver function tests do not necessarily correlate with the severity of liver disease. For example, lab tests may be abnormal in some people with mild disease, but relatively normal in people with severe disease.7 There is also a lag time in blood tests that may not reflect current changes in liver disease, such as improvement.

Before the Test

Your healthcare provider will talk to you about the reasons for calculating your MELD score, as well as any potential limitations that may pertain to you as an individual. If you will be having your blood drawn at a different location, your healthcare provider will likely wish for you to bring the results with you to your appointment.

When the MELD calculation is complete, healthcare providers can sometimes estimate the chance that liver disease is or is not related to alcohol use. It's very important to openly talk to your healthcare provider, even if you are embarrassed about things in your past. It's also important to bring a caregiver with whom you are comfortable in being honest.

The MELD score test can be done rapidly, and your healthcare provider may do the calculation before your visit or while in the exam room with you. Since the lab values must be 48 hours old or less, some healthcare providers recommend blood draws early in the week.

MELD Score Interpretation

MELD scores range from 6 to 40, depending on the severity of liver disease. It is best to receive your results in person (rather than by phone) so you can discuss any concerns you have. You can also can ask for clarification about anything you do not understand.

Standard MELD Exceptions

A MELD score is modified in certain situations. An automatic MELD score of 22 is given with the following medical conditions:

• Liver cancer (hepatocellular carcinoma) with one "spot" between 2 centimeters (cm) and 5 cm, or two to three lesions less than 3 cm in diameter when no extension beyond the liver is evident

• Hepatopulmonary syndrome, a related lung disease with a room-air PaO2 less than 60 mmHg

• Portopulmonary hypertension, with mean pulmonary artery pressure (mPAP) greater than 25 mmHg at rest but maintained less than 35 mmHg with treatment

• Hepatic artery thrombosis between seven and 14 days after a liver transplant

• Familial amyloid polyneuropathy

• Cystic fibrosis with FEV1 (forced expiratory volume in one second) of less than 40%

• Hilar cholangiocarcinoma, a type of bile duct cancer

With primary hyperoxaluria, for which a combination kidney and liver transplantation is needed, an automatic MELD score of 28 is assessed.

MELD Score References

The "normal MELD score" is based on the individual, but with a MELD score of greater than or equal to 10, you may be referred to a hepatologist, or liver specialist.

Keep in mind that MELD scores are meant to assess the risk of death within three months, which may support a decision to recommend a liver transplant in order to avoid this high risk.

Here, a 2017 study outlined the average MELD score and three-month mortality as follows:8

What MELD Score Is Needed For a Liver Transplant?

Liver transplant candidates based on MELD scores are prioritized as follows (with higher priority given to children under the age of 18):

• Status 1A and 1B in the same region as the donor

• MELD score 35 and higher within the donor's region (priority made first locally, then regionally, then nationally)

• Local candidates with a MELD score greater than 15

• Regional candidates with a MELD score greater than 15

• National candidates who are status 1A or 1B

• National candidates with a MELD score greater than 15

• Candidates with a MELD score less than 15, first locally, then regionally, then nationally

That said, there are priority situations in which transplantation may be considered regardless of score. These include:

• Priority exemption 1A: When a person has acute liver failure (sudden and severe) and would be expected to survive only hours to a few days without a transplant

• Priority exemption 1B: When very ill, chronically ill children are less than 18 years of age

Follow-Up MELD Scores

Follow-up and repeat measurements of the MELD score will depend on the value of the score as well as your general condition. For example, one medical center uses the following general guidelines:9

• MELD score of 25 or greater: Every 7 days

• MELD score of 19 to 24: Every 30 days

• MELD score of 11 to 23: Every 90 days

• MELD score less than 10: Every year

Can a MELD Score Improve?

A MELD score can improve with treatment for some conditions, such as hepatitis B-related cirrhosis.10 The MELD score also should be recalculated sooner than normal if there are signs that liver failure is getting worse.

Other Considerations

Along with MELD scores, anyone with cirrhosis should discuss regular screening for liver cancer with their healthcare provider. A person diagnosed with liver cancer who does not otherwise qualify for a transplant may meet the criteria based on the standard exemptions.

Sources

Samuel D, Coilly A. Management of patients with liver diseases on the waiting list for transplantation: a major impact to the success of liver transplantation. BMC Medicine. 2018. 16(1):113. doi:10.1186/s12916-018-1110-y

Kim HJ, Lee HW. Important predictor of mortality in patients with end-stage liver disease. Clinical Molecular Hepatology. 2013;19(2):105-15. doi:10.3350/cmh.2013.19.2.105

Allegretti AS, Frenk NE, Li DK, et al. Evaluation of model performance to predict survival after transjugular intrahepatic portosystemic shunt placement. PLoS One. 2019;14(5):e0217442. doi:10.1371/journal.pone.0217442

Zaydfudim VM, Turrentine FE, Smolkin ME, et al. The impact of cirrhosis and MELD score on postoperative morbidity and mortality among patients selected for liver resection. American Journal of Surgery. 2020. doi:10.1016/j.amjsurg.2020.01.022

Kim Y, Kim K, Jang I. Analysis of mortality prognostic factors using model for end-stage liver disease with incorporation of serum-sodium classification for liver cirrhosis complications: A retrospective cohort study. Medicine (Baltimore). 2019. 98(45):e17862. doi:10.1097/MD.0000000000017862

Johnson SA, Vazquez SR, Fleming R, Lanspa MJ. Correction factor to improve agreement between point-of-care and laboratory International Normalized Ratio values. Am J Health Syst Pharm. 2017;74(1):e24-e31. doi:10.2146/ajhp150813

Ahmed Z, Ahmed U, Walayat S, et al. Liver function tests in identifying patients with liver disease. Clin Exp Gastroenterol. 2018;11:301–307. doi:10.2147/CEG.S160537

Aiello FI, Bajo M, Marti F, Gadano A, Musso CG. Model for End-stage Liver Disease (MELD) score and liver transplant: benefits and concerns. AME Medical Journal. 2017; 2:168. doi:10.21037/amj.2017.10.10

University of Wisconsin School of Medicine and Public Health. MELD scores and PELD scores.

Yip TC, Chan HL, Tse YK, Lam KL, Lui GC, Wong VW, et al. On-Treatment Improvement of MELD Score Reduces Death and Hepatic Events in Patients With Hepatitis B-Related Cirrhosis. Am J Gastroenterol. 2018 Nov;113(11):1629-1638. doi:10.1038/s41395-018-0247-9.

Additional Reading

Kartoun Y, Corey KE, Simon TG, et al. The MELD-Plus: A generalizable prediction risk score in cirrhosis. PLoS One. 2017. 12(10):e0186301. doi:10.1371/journal.pone.0186301

Koola JD, Ho S, Chen G, et al. Development of a national Department of Veterans Affairs mortality risk prediction model among patients with cirrhosis. BMJ Open Gastroenterology. 2019;6(1):e000342. doi:10.1136/bmjgast-2019-000342

Samuel D, Coilly A. Management of patients with liver diseases on the waiting list for transplantation: a major impact to the success of liver transplantation. BMC Medicine. 2018. 16(1):113. doi:10.1186/s12916-018-1110-y

Singal AK, Bataller R, Ahn J, Kamath PS, Shah VH. ACG clinical guideline: alcoholic liver disease. American Journal of Gastroenterology. 2018;113(2):175-194. doi:10.1038/ajg.2017.469

U.S. Department of Health and Human Services. Organ Procurement and Transplantation Network. MELD calculator.

By Lynne Eldridge, MD
 Lynne Eldrige, MD, is a lung cancer physician, patient advocate, and award-winning author of "Avoiding Cancer One Day at a Time."