Management Approach for Patients with High MELD Scores

Understanding MELD Score and Its Significance

The American Association for the Study of Liver Diseases recommends that patients with a high Model for End-Stage Liver Disease (MELD) score should be evaluated for liver transplantation, as the MELD score is an excellent predictor of short-term pre-transplant mortality risk and serves as the primary basis for organ allocation in many countries 1, 2
A MELD score ≥15 is generally recommended as a threshold for listing patients for liver transplantation, as patients with MELD <15 may have lower survival benefit from transplantation 1, 2
The 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 2

The European Association for the Study of the Liver suggests identifying and treating complications of cirrhosis that may be contributing to the high MELD score (variceal bleeding, infection, renal dysfunction) 1, 2
Refer for liver transplantation evaluation when MELD score is ≥15 or when major complications of cirrhosis occur 1, 2
Engage a multidisciplinary team including transplant hepatologist, transplant surgeon, and other specialists based on comorbidities 2, 3

The American College of Gastroenterology recommends monitoring MELD score regularly to track disease progression and adjust transplant priority, and managing specific complications of cirrhosis, such as refractory ascites, variceal bleeding, and hepatic encephalopathy 2, 4, 5, 6
In patients with very high MELD scores (>35), mortality following liver transplantation may be increased, requiring careful patient selection 2
Recognize conditions where MELD score may not accurately reflect mortality risk or transplant benefit, including hepatocellular carcinoma, hepatopulmonary syndrome, portopulmonary hypertension, refractory ascites, and recurrent cholangitis 1, 2, 5, 7

The European Association for the Study of the Liver recommends that patients with acute-on-chronic liver failure (ACLF) have a significantly higher predictive ability for 28-day mortality compared to MELD score, MELD-Na score, and Child-Pugh score, as shown by the CLIF-C ACLF score 8
For MELD score >20, consider intensive care unit (ICU) admission, especially with organ failure(s) or other life-threatening complications, as recommended by the American College of Radiology 8, 9
ICU admission criteria should be the same as for other populations, and denial of critical care solely due to underlying cirrhosis is not justified, according to the European Association for the Study of the Liver 8
Indications for ICU admission include need for organ support, massive bleeding, grade III-IV hepatic encephalopathy, and septic shock, as recommended by the European Association for the Study of the Liver 8

For bleeding gastric varices in patients with high MELD scores (≥20), endoscopic management may be beneficial as it can increase portal perfusion, and balloon-occluded retrograde transvenous obliteration (BRTO) may improve hepatic synthetic function, as recommended by the American College of Radiology 9, 10
Transjugular intrahepatic portosystemic shunt (TIPS) should be used cautiously, as 3-month mortality is 35% for MELD scores 18-24 and 66% for MELD scores ≥25, according to the American College of Radiology 9, 10

Contraindications for ICU admission in high MELD patients include severe comorbidities with ACLF-3, advanced neoplasm with life expectancy <6 months, and severe frailty with sarcopenia or Karnofsky performance status ≤40, as recommended by the European Association for the Study of the Liver 8