Table of Contents
Intro
This blog post is part of a series that will review different scoring and calculations that clinicians use to predict patient outcomes and make informed clinical decisions.
We’ll go through some background, the calculator, and example scenarios to apply it in the real world.
For each one we’ll link to a calculator that you can use. There are many options but we recommend MDcalc.com as they provide a great interface for most of the calculators that you’ll use. (Apple App or Android App).
Summary
Patients with end stage liver disease can have a high risk of mortality.
Background
The most common mechanisms of liver injury include: viral infections (such as Hepatitis B), alcoholic liver disease, fatty liver disease, drug toxicity. Each of these insults to the liver eventually lead to a condition referred to as liver cirrhosis, where the liver is scarred by excessive fibroblast activity. Liver cirrhosis is an irreversible condition that permanently damages the liver and its functional capacity.
The liver plays a role in clearing toxins, metabolizing drugs, blood sugar balance, producing coagulation factors, platelet proliferation, etc. Without a functioning liver, several important physiological processes are deficient, which greatly accelerates mortality.
MELD Scoring
For this reason, the MELD (Model for End Stage Liver Disease) was developed to predict the chance of mortality within 3 months based on certain criteria. The actual formula is complex and can be found here. The table below outlines criteria and scoring.
| MELD Score | % Chance of Mortality in 3 Months |
| 40 | 71.3 |
| 30-39 | 52.6 |
| 20-29 | 19.6 |
| 10-19 | 6.0 |
| 9 or less | 1.9 |
Example Case
You are a medical student serving on the internal medicine service today and are responsible for the admission of a 58 year old male brought in by his sister for his “drinking problem”. The patient had a strong musty odor on his breath and upon further questioning he reports a long history of liver cirrhosis secondary to heavy alcohol use after a personal tragedy 8 years ago. Understanding how important the liver is in both producing substances found in blood like coagulation factors as well as clearing metabolic toxins, you decide to obtain a comprehensive set of lab tests including a CBC/CMP/UA/Coag studies/Glucose.
Patient has not had dialysis in the past week
Creatinine: 1.9 mg/dL
Bilirubin: 2.4 mg/dL
INR: 1.6
Sodium: 133 mEq/L
The patient was brought in by his sister who is familiar with liver cirrhosis. She understands that it is common amongst severe alcoholics and asks you: “How sick is my brother?”
MELD Scoring
Here, we meet a 58 year old male suffering from liver cirrhosis. With his lab values his calculated MELD score is 24 points according to MDcalc. This is associated with a 19.6% estimated 3-month mortality.. The MELD score is useful in the clinical setting to not only discuss a patient’s 3 month mortality risk but is also used primarily by the UNOS for liver allocation in patients with end stage liver disease. The MELD score also provides guidelines on how often labs need to be repeated for higher mortality risk patients.
Clinical notes
- If the patient did not self-report liver cirrhosis, how can liver cirrhosis be diagnosed?
- Although the signs of liver cirrhosis can be detected by blood tests, the diagnosis requires radiologic imaging or biopsy
- Cirrhosis can be diagnosed by CT, Ultrasound, MRI, or needle biopsy of the liver. Liver biopsy is the gold standard test used for determining early to intermediate liver cirrhosis. Non-invasive tests are used in the clinical setting when there is no to minimal liver fibrosis or advanced fibrosis. A liver biopsy is however needed for liver fibrosis/cirrhosis staging.
- Although the signs of liver cirrhosis can be detected by blood tests, the diagnosis requires radiologic imaging or biopsy
- Treating and managing liver cirrhosis
- Liver cirrhosis is a progressive disease and, at some point, irreversibly fatal based on the level of progression
- Many “treatments” for liver cirrhosis help prevent or manage the symptoms of liver cirrhosis. These include, but are not limited to lifestyle changes (no alcohol, low-sodium diet), prophylactic antibiotics, medications to help clear toxins (lactulose), or transjugular intrahepatic portosystemic shunt (TIPS).
- The only curative treatment for liver cirrhosis is a liver transplant. MELD score is one of the most important clinical indicators (not the only indicator) used by the Organ Procurement and Transplantation Network to determine liver allocation.
- Here are typical MELD scores and how often they’re recalculated:
- 25 or higher: Every week
- 19-24: Every 30 days
- 11-18: Every three months
- 10 or less: Once a year
- Here are typical MELD scores and how often they’re recalculated:
