Formulae
MELD (original)
MELD = 9.57 × ln(Creatinine) + 3.78 × ln(Bilirubin) + 11.2 × ln(INR) + 6.43
Minimum value of 1.0 for Cr, Bil and INR. Creatinine capped at 4.0 mg/dL (use 4.0 if on dialysis ≥2×/week). Score capped at 40.
MELD-Na
MELD-Na = MELD − Na − [0.025 × MELD × (140 − Na)] + 140
Sodium clamped between 125 and 137 mEq/L. Score capped at 40. Adopted by UNOS in January 2016.
MELD 3.0
MELD 3.0 = 4.56×ln(Bil) + 0.82×(137−Na) − 0.24×(137−Na)×ln(Bil)
+ 9.09×ln(INR) + 11.14×ln(Cr) + 1.85×(3.5−Alb)
− 1.83×(3.5−Alb)×ln(Cr) + 1.33 (if female) + 7
Creatinine range 1.0–3.0; Albumin range 1.5–3.5; Sodium clamped 125–137. Developed by Kim et al. (2021).
Interpretation
| MELD Score | Disease Severity | 90-Day Mortality | UNOS Status |
|---|
| < 10 | Low | ~2% | Monitored; transplant unlikely |
| 10–19 | Moderate | ~6% | Listed; monitored closely |
| 20–29 | High | ~20% | Active transplant listing |
| 30–39 | Very high | ~52% | High priority |
| ≥ 40 | Critical | ~71% | Highest priority (1A/1B) |
Mortality estimates from Kamath et al. (2001). Scores updated continuously; organ offers go to highest MELD patient in compatible blood group within region.
Clinical Application
MELD was originally developed to predict 90-day mortality after TIPS placement and was subsequently validated as a general predictor of mortality in end-stage liver disease. It replaced the Child-Pugh score for UNOS organ allocation in February 2002.
- Transplant listing: MELD ≥15 is the threshold above which transplant survival benefit exceeds waitlist mortality in most centres.
- MELD-Na: Incorporates hyponatraemia, which independently predicts waitlist mortality. Adopted by UNOS in 2016; preferred over MELD alone for allocation.
- MELD 3.0: Addresses sex-based disparity in transplant access — women historically receive fewer transplants at equivalent disease severity. Incorporates albumin (a marker of sarcopenia) and corrects for sex. Implemented by OPTN in August 2022.
- Exceptions: Patients with HCC, HRS-AKI and hepatopulmonary syndrome receive MELD exception points to account for conditions not reflected by standard labs.
- Surgical risk: Child-Pugh class is still widely used alongside MELD for perioperative risk stratification in cirrhotic patients.
Evidence & Validation
The original MELD score was validated in a cohort of 231 patients undergoing TIPS and subsequently in over 3,500 patients from multiple centres in a seminal Mayo Clinic study. The c-statistic for 90-day mortality was 0.87.
MELD-Na was validated in the UNOS waiting-list dataset by Biggins et al. (2006), demonstrating a c-statistic of 0.87 vs 0.85 for MELD alone. The 2021 MELD 3.0 paper by Kim et al. used 4 validation cohorts (n > 75,000 patient-years) and showed improvement in c-statistic for 90-day waitlist mortality from 0.838 (MELD-Na) to 0.854 (MELD 3.0) in women.
Limitations
- Does not account for aetiology of liver disease (HCV, ALD, NASH — outcomes differ)
- Creatinine influenced by muscle mass; women and elderly patients may have falsely low creatinine underestimating severity
- Does not capture quality of life, encephalopathy, or refractory ascites
- Serum creatinine varies with lab methodology; harmonisation across centres can differ
- MELD 3.0 requires albumin, which was historically not in the original MELD formula and adds an extra lab requirement
- HCC, HRS and other exception conditions require separate scoring adjustments
Key Guidelines
- AASLD Practice Guidance: Evaluation for liver transplantation (2022)
- EASL Clinical Practice Guidelines: Liver transplantation (2016)
- OPTN Policy: Allocation of Livers and Liver-Intestines (implemented MELD 3.0, August 2022)
- BSG: Guidelines on the management of ascites in cirrhosis (2022)
References
- Kamath PS, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33(2):464–470.
- Biggins SW, et al. Evidence-based incorporation of serum sodium concentration into MELD. Gastroenterology. 2006;130(6):1652–1660.
- Kim WR, et al. MELD 3.0: The Model for End-Stage Liver Disease Updated for the 21st Century. Hepatology. 2021;74(4):1913–1922.
- Wiesner R, et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology. 2003;124(1):91–96.
- OPTN Policy 9: Allocation of Livers and Liver-Intestines. Available at: optn.transplant.hrsa.gov.