Liver transplant candidates are listed and transplanted based on their MELD score. Understanding your score and how its calculation will give you a better understanding of your wait time and the severity of your illness.
History of the MELD Score
The MELD score (Model for End-Stage Liver Disease) is a scoring system for the chronic liver disease of people 12 and older. As an aside, a similar model is used for pediatric patients called PELD. It was developed by Dr. Patrick Kamath at Mayo as a way to predict the mortality of patients who had received the TIPS procedure. It was later discovered as a more effective way to assess the severity of liver disease over the previously used Child-Pugh score.
Originally called the Mayo End-Stage Liver Disease model, the name was changed from Mayo to Model. This made it a more acceptable term across the liver transplant community as it was not associated with a specific institution.
Once developed, changes came for the allocation of livers for transplantation. The Institute of Medicine determined that it should no longer be based on wait time but on a score that reflected liver disease severity.
MELD is an accurate predictor of the survivability of patients with most types of liver disease. So, in early 2002, UNOS adopted MELD scoring for the prioritization and allocation of liver transplants versus wait time. UNOS uses scores from 6-40 (although it is possible to score higher than that).
How Is MELD Score Calculated?
YAY! MATH! No? I’m the only one who gets excited about this stuff? MELD is based on lab tests of your blood. The lab numbers used for MELD are:
- Creatinine
- Bilirubin
- INR
- Serum Sodium (added as a factor in 2016)
If you want to calculate your own MELD score, there is a formula. As you’ll see, it is a bit complicated. So, if you really want to calculate your MELD, you can just use an online calculator (hooray, internet!!) like this one.
Maybe you are a glutton for punishment, love math, or are bored after weeks of being in the hospital (like I was). To manually calculate your score, start with the old MELD score value. And you may want to grab a calculator.
Old MELD Score
MELD Score = 9.57 x ln[creatinine (mg/dL)]+ 3.78 x ln[bilirubin (mg/dL)] + 11.20 x ln[INR] + 6.431. Labs that are less than 1 should be rounded up to 1 for this calculation. If you’ve had dialysis twice in the last 7 days, your creatine should be calculated at 4.
For instance, when I was sick, these were my numbers about one month before my transplant:
- Creatinine = 2.19
- Bilirubin = 29.6
- INR = 5.2 (at one point it was actually 7.4…my blood was thin y’all!)
- Sodium = 135
(9.57xln[2.19]=20.9583) + (3.78xln[29.6]=111.888) + (11.20xln[5.2]=58.24) + (6.431) = 7.502+12.806+18.465+6.431=45.204 or a MELD of 45. Because I received my transplant in 2013 before the inclusion of sodium, this was my MELD score.
New MELD Score
Now, to include the sodium.
MELD-Na (Na is the symbol for sodium) = MELD + 1.32 x (137-Na) – [0.033 x MELD x (137-Na)]. Sodium levels less than 125 should be set to 125 and more than 137 should be set to 137. There are also adjustments taken into account for glucose levels over 100.
45+1.32x(137-135)-[0.033x45x(137-135)] = 45+2.64-2.97=44.67 or a MELD-Na of 45. Sodium and glucose levels can have a much larger impact. It just so happens my score came out the same in both cases.
Understanding What Your MELD Score Means
Alright, so now you’ve got your MELD score. Now what? You are listed based on the severity of your disease. So, if your MELD score is 16, you could be on the list for years while those with higher scores receive their transplant. If you are, say a 45, you are skyrocketed to the top of the list. Exceptions to this are 1A patients who have a survival rate of hours to a few days, and other, more rare situations.
The higher your MELD, the higher the risk of dying within 90 days if you do not receive a transplant. Keep in mind, that this is not all that goes into your prognosis. It is simply a tool. It won’t take into account your age, gender, health issues, support systems, or drinking.
People with lower MELD scores are often evaluated for live donor transplantation. They are sick enough to warrant a transplant even with a lower MELD. But there is such a shortage of organs available. For that reason, deceased donor transplantation is typically for those who are sicker.
Exceptions
There are some cases where a person’s MELD score may never climb high enough for transplant on their score alone. For these people, there are exceptions. Some common exceptions would be:
- Liver or biliary cancer (Hepatocellular Carcinoma/HCC or Cholangiocarcinoma)
- Lung disease related to liver failure
- Hepatic artery thrombosis post-transplant
- Biliary Atresia, Primary Biliary Cirrhosis, Primary Sclerosing Cholangitis
This is a brief list. Your team will request exception points from UNOS in cases where a score is not increasing but a patient is decompensating.
I should mention here that going home and laying on the sofa waiting for a transplant will not make your score go up. Because it is based on blood work, you do not have any control over your score. This keeps the playing field as fair as possible for everyone who is listed.
In fact, becoming physically weak will only hurt you. Your recovery could be longer, or worse, you could become too weak for your doctors to perform the surgery at all. At that point, you would be inactivated on the list altogether.
MELD Score Survival Rate and Test Frequency
Survival Rate
There are 3-month survival rates associated with different stages of the MELD score. Please keep in mind these are general. Every person is going to be different. And, as one of my doctors said to me once, “80% mortality still leaves 20% survival. You can be one of the 20%.” Do not look at these stats and give up. MELD scores change frequently and you must continue to fight.
MELD less than 9 is 96.3-98.1%
10-19 is 80-94%
20-29 is 54.5-80%
30-39 is 25.5-47.4%
Over 40 is 0-29%
Test Frequency
You will need to get labs drawn to update your MELD score with UNOS. The higher your MELD score, the more frequent the labs. This is a UNOS rule, so if you do not get your MELD labs drawn when requested, your score will not be updated for that period and you’ll be inactivated. In other words, don’t miss your lab draws. It would be awful for an organ to come in that is a good match and not receive it because you didn’t get a blood draw, wouldn’t it?
MELD less than 10 – labs are drawn every year
MELD 11-23 – labs are drawn every 90 days
MELD 19-24 – labs are drawn every 30 days
MELD over 25 – labs are drawn every 7 days
It’s Not ALL About the MELD
When it comes to liver transplants, several factors are taken into consideration in the matching process. MELD is just one of these factors:
- MELD
- Blood Type (not including Rh factor)
- Age
- Body Size (a male donor who is 6’4 and 250 pounds would not likely fit in a female who is 5’2 and 110 pounds)
- Distance between the recipient and the hospital
- Wait time (the person waiting longer will get the organ when patients match in MELD, blood type, and other considerations.)
- Availability of candidate (e.g., temporarily inactivated because of a vacation, inability to be reached, or current infection)
- Geography (livers can remain outside the body for 12-15 hours, so there are more options for long-distance transport)
- Geography (priority is made locally, then regionally, then nationally)
Now you have an oh-so-keen understanding of your MELD score. You know how it relates to your liver disease how it is figured and what it means for your wait. Remember that is just a piece of the bigger picture that is you as a person and as a transplant candidate.
I feel like I know a thing or two when it comes to survival. After all, I was given a 20% chance of living beyond 90 days at diagnosis. Four months later, I had a MELD of 45 and was still fighting. One month after that, I received my transplant at a MELD of 38. I am 3 months away from my 8th liver transplant anniversary.
So keep on fighting my friends. If I can do it, so can you!
