Model for End-Stage Liver Disease (Combined MELD 3.0, MELD-Na & Original)

Introduction

The Model for End-Stage Liver Disease (MELD) score estimates how severe a patient’s chronic liver disease is and their risk of dying within about three months. Its best-known use is ranking adults on the US liver transplant waiting list, so the sickest patients receive organs first. Patrick Kamath, MD, and colleagues at the Mayo Clinic developed the original version in 2001. It has since been updated twice. This calculator shows all three versions from one set of lab values.

The three versions

• Original MELD (2001): Uses bilirubin, INR, and creatinine. It was the basis of US transplant allocation from 2002.

• MELD-Na (2016): Adds sodium. In 2016, the Organ Procurement and Transplantation Network (OPTN) and United Network for Organ Sharing (UNOS) adopted this version, because low sodium is a strong independent sign of higher mortality.

• MELD 3.0 (2023): The current standard. W. Ray Kim, MD, and colleagues introduced it in 2021, and OPTN/UNOS replaced MELD-Na with MELD 3.0 in July 2023 for adult liver transplant prioritization. It adds a serum albumin term, a +1.33 correction for female sex, and interaction terms between albumin and creatinine and between sodium and bilirubin, and it lowers the creatinine cap from 4.0 to 3.0 mg/dL. The sex correction addresses a known disadvantage for women. Creatinine-based formulas tended to underestimate how sick women were.

Who it’s for, and limitations:

The adult MELD 3.0 formula applies to patients 18 and older. For candidates aged at least 12 who were under 18 at registration, the equation is similar but excludes the sex coefficient and uses a different constant. Children under 12 are assessed with a separate score called PELD. MELD isn’t meant for acute liver failure, and patients with liver cancer usually receive priority through separate exception rules. Results can be skewed by blood thinners (which raise the INR), kidney problems unrelated to the liver, and recent IV albumin, which can falsely raise the albumin value.

Scoring & Results

1. MELD 3.0 Score (points)

   1. Candidates who are at least 18 years old at the time of registration receive an initial MELD score equal to: 

      1. MELD 3.0 = 1.33*(Female) + 4.56*ln(Serum bilirubin) + 0.82*(137 - Sodium) – 0.24*(137 - Sodium)*ln(Serum bilirubin) + 9.09*ln(INR) + 11.14*ln(Serum creatinine) + 1.85*(3.5 – Serum albumin) – 1.83*(3.5 – Serum albumin)*ln(Serum creatinine) + 6

   2. Candidates who are currently at least 12 years old and were less than 18 years old at the time of registration receive a MELD score equal to:

      1. MELD 3.0 = 4.56*ln(Serum bilirubin) + 0.82*(137 - Sodium) – 0.24*(137 - Sodium)*ln(Serum bilirubin) + 9.09*ln(INR) + 11.14*ln(Serum creatinine) + 1.85*(3.5 – Serum albumin) – 1.83*(3.5 – Serum albumin)*ln(Serum creatinine) + 7.33

   3. MELD 3.0 Criteria

      1. Serum bilirubin, INR, and serum creatinine values below 1.0 are set to 1.0.

      2. Sodium is limited to a range of 125-137 mEq/L, and if outside of these bounds, is set to the nearest limit.

      3. Serum albumin is limited to a range of 1.5-3.5 g/dL, and if outside of these bounds, is set to the nearest limit.

      4. The following candidates receive a creatinine value of 3.0 mg/dL:

         1. Those with a creatinine value greater than 3.0 mg/dL.

         2. Those who received two or more dialysis treatments within 7 days prior to the serum creatinine test.

         3. Those who received 24 hours of continuous veno-venous hemodialysis (CVVHD) prior to the serum creatinine test.

      5. The MELD 3.0 score is rounded to the nearest integer.

1. MELD-Na (UNOS/OPTN) (points)

   1. Per OPTN policy, January 2016 (pages 4–5), candidates who are at least 12 years old receive an initial MELD(i) score equal to:

      1. MELD(i) = 0.957*ln(Creatinine) + 0.378*ln(Bilirubin) + 1.120*ln(INR) + 0.643

   2. MELD-Na Criteria

      1. Round to the tenth decimal place and multiply by 10. 

      2. If MELD(i) > 11, perform additional MELD calculation as follows: MELD = MELD(i) + 1.32*(137 – Na) – [0.033*MELD(i)*(137 – Na)]

1. MELD (Original, Pre-2016) (points)

   1. MELD (Original, Pre-2016) = (0.957*ln(Serum creatinine) + 0.378*ln(Serum bilirubin) + 1.120*ln(INR) + 0.643)*10

   2. MELD (Original, Pre-2016) Criteria

      1. If hemodialysis, value for Creatinine is automatically set to 4.0

      2. If any score is <1, the MELD assumes the score is equal to 1.

2. MELD 3.0 Estimated 90-day Survival (%)

   1. Estimated 90-day survival = 0.946exp(0.17698*MELD 3.0 – 3.56) * 100

3. MELD (Original, Pre-2016) and MELD Na (UNOS/OPTN) Estimated 90-day Mortality (%)

Management Considerations

Source: OPTN/UNOS Documentation on MELD and PELD 

• OPTN considers a maximum score of 40 when assessing transplant appropriateness. 

• If in the United States, refer to the Organ Procurement and Transplantation Network for the latest policies on liver transplant.

• Kamath PS, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001.

• Kim WR, et al. Hyponatremia and mortality among patients on the liver-transplant waiting list. N Engl J Med. 2008.

• Kim WR, et al. MELD 3.0: The Model for End-Stage Liver Disease Updated for the Modern Era. Gastroenterology. 2021.