Question 1

What is the MELD score used for?

Accepted Answer

The MELD (Model for End-Stage Liver Disease) score predicts short-term (90-day) mortality in patients with chronic liver disease and is the primary tool used to prioritise adult liver transplant allocation. The version in use by UNOS in the United States is MELD 3.0 (since July 2023), which replaced MELD-Na (used from 2016).

Question 2

What is the difference between MELD and MELD-Na?

Accepted Answer

MELD-Na incorporates serum sodium into the original MELD formula. Hyponatraemia is an independent predictor of mortality in liver disease, so MELD-Na provides better prognostic accuracy. MELD-Na was used for US liver transplant allocation from 2016 until it was superseded by MELD 3.0 in July 2023.

Question 3

What MELD score qualifies for liver transplant?

Accepted Answer

Generally, a MELD score of 15 or higher indicates that transplant provides a survival benefit over continued medical management. Higher scores receive priority on the waitlist. The maximum assignable score is 40.

Question 4

What is MELD 3.0 and what changed in 2023?

Accepted Answer

MELD 3.0 was adopted by UNOS in July 2023, replacing MELD-Na for adult liver transplant allocation in the United States. It adds female sex and serum albumin as new variables, introduces interaction terms (bilirubin–sodium and albumin–creatinine), and lowers the creatinine ceiling from 4.0 to 3.0 mg/dL. In the Kim 2021 validation cohort, MELD 3.0 reclassified roughly 8.8% of patients to a higher priority tier, disproportionately benefiting women — who had been systematically under-prioritised by MELD-Na owing to lower baseline creatinine for the same degree of renal dysfunction.

Question 5

When does MELD not apply?

Accepted Answer

MELD was derived in adults with chronic liver disease and should not be used to assess acute liver failure (ALF) — the King's College Criteria are the standard for ALF transplant urgency. For patients under age 12 the Paediatric End-Stage Liver Disease (PELD) score is used instead. MELD may also under-predict risk in specific conditions such as hepatopulmonary syndrome, refractory ascites, recurrent cholangitis, and hepatocellular carcinoma within Milan criteria, which is why UNOS allocates MELD exception points for these scenarios.

Question 6

What are MELD exception points?

Accepted Answer

MELD exception points raise a patient's allocation priority above their calculated score when the underlying condition carries mortality risk not captured by the formula. The most common indication is hepatocellular carcinoma within Milan criteria, with a standardised exception schedule. Other accepted exceptions include hepatopulmonary syndrome, portopulmonary hypertension, primary hyperoxaluria, and certain metabolic and cholestatic diseases. In the United States, exceptions are reviewed by the National Liver Review Board (NLRB).

MELD Score	3-Month Mortality	Clinical action
< 10	~1.9%	Continue medical management; transplant not yet indicated
10 – 19	~6%	Transplant evaluation indicated at MELD ≥15 (survival-benefit threshold)
20 – 29	~19.6%	Active transplant listing typical; inpatient observation if decompensated
30 – 39	~52.6%	High waitlist priority; ICU-level care often needed
≥ 40	~71.3%	Maximum allocation priority; score capped at 40

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