Management Guidelines for Patients with Liver Disease According to MELD

Understanding MELD Score

The Model for End-Stage Liver Disease (MELD) score is an essential tool for prioritizing patients for liver transplantation, with a MELD score ≥15 generally recommended as the threshold for listing patients for transplantation due to its excellent prediction of short-term pre-transplant mortality risk 1
MELD score is calculated using objective laboratory parameters: serum creatinine, serum bilirubin, and international normalized ratio (INR), making it a reliable tool for predicting 90-day mortality in patients with end-stage liver disease 1
MELD score has been shown to accurately predict survival in patients with cirrhosis and is the primary basis for organ allocation in many countries 1

Immediate referral for liver transplantation evaluation is recommended for patients with a MELD score ≥15 1
Identify and treat complications of cirrhosis that may be contributing to the high MELD score (variceal bleeding, infection, renal dysfunction) 1
Engage a multidisciplinary team including transplant hepatologist, transplant surgeon, and other specialists based on comorbidities 1
Regular monitoring of MELD score to track disease progression and adjust transplant priority 1

Focus on management of specific complications of cirrhosis 1
Regular follow-up to monitor for disease progression 1
Consider transplantation when major complications of cirrhosis occur despite optimal medical management 1

Patients with HCC receive MELD exception points to prioritize them on transplant waiting lists 2
Standard Milan criteria (single tumor ≤5 cm or up to 3 nodules each ≤3 cm, without macrovascular invasion) are associated with 5-year survival rates of 65-78% 2
Various extended criteria have been proposed to expand transplantation eligibility beyond Milan criteria while maintaining acceptable outcomes 2

Transjugular intrahepatic portosystemic shunt (TIPSS) should be considered in patients with refractory ascites 3, 4
Caution is required if considering TIPSS in patients with MELD score ≥18, current hepatic encephalopathy, active infection, or hepatorenal syndrome 3, 4
Albumin (as 20% or 25% solution) should be infused after large volume paracentesis of >5L at a dose of 8g albumin/L of ascites removed 3, 4

Non-absorbable disaccharides should be used as secondary prophylaxis after an episode of overt HE 5
Rifaximin should be added if a second episode occurs within 6 months (recurrent overt HE) 5
The AASLD suggests not performing surveillance of patients with Child-Pugh class C cirrhosis unless they are on the transplant waiting list, given the low anticipated survival for these patients 6

MELD score may not accurately reflect mortality risk or transplant benefit in certain conditions, including hepatocellular carcinoma, hepatopulmonary syndrome, portopulmonary hypertension, refractory ascites, and recurrent cholangitis 1
In patients with very high MELD scores (>35), mortality following liver transplantation may be increased, requiring careful patient selection 1