The MELD Score: Limitations and consequences

-The success of liver transplantation has created unexpected challenges for physicians and surgeons caring for patients with chronic liver disease or acute liver failure. Specifically, with all of these legitimate candidates for liver transplantation, how does one prioritize them given the unfortunate issue of limited donor availability? The answer to that problem has undergone several iterations which have ultimately resulted in the Model for End-stage Liver Disease (MELD) score allocation system. The MELD score, which yields a numeric value based upon serum creatinine, bilirubin and INR has been successful in prognosticating 90 day mortality for these patients, and has proven to be a just method of liver allocation. However, a careful look at the parameters of the MELD score reveals the limitations and resultant caution that should be given to ostensibly objective data. Creatinine and INR are labile especially in the setting of patients with advanced liver disease that are prone to alteration not only by the inherent disease state but also iatrogenic interventions. The implications of these interventions have significant medical and moral consequences as they not only determine immediate treatment but also which patients are allocated the precious life-extending resource of organ transplant. In this review the principles and parameters of the MELD score will be discussed, as well as their ultimate consequences upon both liver and simultaneous liver-kidney transplantation. Key words--liver transplant; liver-kidney transplant; MELD score; transplant priority.