More completely specified models of posttransplant mortality are being constructed using the values of variables known at the time of transplantation. While unadjusted waiting list mortality rates cover a 300-fold range from low to high MELD scores, the range of corresponding posttransplant mortality rates is about 2-fold (Table 1). 14 More recently, the other components of the MELD score have also been shown to be predictive of posttransplant mortality. 13, 14 In particular, pretransplant renal dysfunction has long been recognized as an important risk factor for posttransplant death. Some of the components of MELD were found to predict posttransplant mortality almost 20 years ago. In contrast, patients with high MELD scores tend, on average, to have declining scores.īox plots of mortality risk on the waiting list, by MELD score. Figure 1 shows that for patients with low MELD scores, progression tends to be modestly upward, but not at a particularly rapid pace. Change in the MELD score at time of next reported score (delta MELD) was calculated by category of MELD, and by the time between the 2 MELD scores. We studied 18,361 candidates waitlisted between Apand March 31, 2004, and analyzed 60,391 MELD scores while active on the waitlist through March 31, 2004. Once a patient has been placed on the waiting list, it is of interest to know the likely direction and magnitude of subsequent changes in MELD score (and the associated risk). 8, 9 In addition to the value of MELD per se as a predictor of mortality, the rate of change in MELD has also been shown to be independently associated with mortality risk in waitlisted candidates. 2, 8 A modification of MELD was developed to account for the needs of pediatric liver transplant candidates (the pediatric end-stage liver disease scoring system), incorporating information on serum albumin and growth failure. 7 Later reports showed that MELD was also predictive of liver patients generally, as well as those selected as potential liver transplant candidates. 8 The initial elaboration of the MELD score was based on a cohort of patients undergoing transjugular intrahepatic portosystemic shunt procedures for portal hypertension. 7, 8 Derived from a trio of simple, reproducible, and objective laboratory parameters (serum bilirubin, prothrombin time international normalized ratio, and serum creatinine), MELD provides robust estimates of mortality risk across a broad range of patients. The development of MELD marked an important milestone in our ability to predict the prognosis of patients with chronic liver disease. 4- 6 In this essay, I discuss transplant decision-making approaches for liver transplant candidates, focusing especially on patients at the ends of the risk spectrum. 3 The combination of waiting list mortality risk and posttransplant mortality risk assessed by MELD and other factors can be used to estimate whether candidates are likely to derive a survival benefit from a liver transplant. The model for end-stage liver disease (MELD) scoring system has emerged as an excellent predictor of mortality on the waiting list 1, 2 and also predicts mortality after liver transplantation. Listing criteria for liver transplantation are currently very broad and delisting criteria have never been promulgated or placed into policy. Liver transplantation is currently offered as a therapeutic option for patients with a wide range of end-stage liver diseases whose outcome is predicted to be fatal, usually at a point when the candidate is still expected to live long enough to survive the uncertain wait for a donor organ. Donor organs are available in small numbers relative to the pool of candidates and our ability to predict the future lifetimes of individual patients is limited. Of course, we are unlikely to inhabit such a world anytime soon.

Transplants would not be performed in circumstances in which the nontransplant option was associated with a longer lifetime, and this statement would hold true for patients throughout the disease severity spectrum. In an ideal world, every patient with liver disease whose predicted lifetime with a transplant is longer than his or her lifetime without a transplant would be able to receive an organ transplant at an optimal and timely point in the course of their disease and no waiting list deaths would occur.

Meld score 24 prognosis