When a patient with advanced liver disease is being considered for a transplant, one of the most important questions is: “Who should get the liver first?”
It is not an easy decision. Livers from deceased donors are limited, while the number of patients waiting is much higher. To make this process fair and based on medical urgency, doctors use a tool called the MELD score.
MELD stands for Model for End-Stage Liver Disease. It is not just a number on paper—it is a system that helps doctors decide how sick a patient is, and how urgently they need a transplant. But MELD is also much more than that: it reflects years of medical research, debates, and refinements on how to prioritize patients fairly.
In this blog, we will break down the MELD score in detail—how it is calculated, why it matters, its strengths and its limits, and how doctors actually use it when making real-life transplant decisions.
Why MELD Score Was Needed in the First Place
Before the early 2000s, liver transplants were often allocated based on something called “time on the waiting list.” The longer a patient had been waiting, the higher their chance of receiving a donor liver.
But this approach had two serious flaws:
- Not all patients deteriorate at the same pace. A patient who has been waiting for one year might be much healthier than someone added to the list just two months ago, but with very advanced liver failure.
- Inefficiency. Some livers went to patients who could have survived longer without a transplant, while others who were critically ill died waiting.
The medical community realized that fairness should not mean “first come, first served,” but instead “sickest first.”
That led to the development of the MELD score—an objective, laboratory-based system to measure how severely the liver disease is affecting the body.
The Science Behind MELD: What Numbers Go In
The MELD score is calculated using three routine blood tests:
- Serum Bilirubin – measures how well the liver is clearing waste from the blood. High bilirubin means poor liver function.
- Serum Creatinine – reflects kidney function. Since advanced liver disease often affects the kidneys, this is important.
- INR (International Normalized Ratio) – measures how well the blood clots. A high INR means the liver is struggling to produce clotting factors.
The formula looks mathematical, but in practice, the lab values are simply fed into a calculator that gives a number between 6 and 40.
- 6 means the patient is quite stable.
- 40 means a very high risk of death in the next 3 months without a transplant.
This number becomes the patient’s MELD score.
MELD-Na: A Refinement That Added Sodium
Doctors later realized that one important factor was missing—serum sodium levels.
Low sodium (hyponatremia) is common in advanced cirrhosis, and it strongly predicts survival. Patients with very low sodium levels were dying on the waiting list despite having “average” MELD scores.
This led to an updated version: MELD-Na, which includes sodium in the calculation. Today, most transplant centers use MELD-Na as the standard measure.
What the MELD Score Really Predicts
It is important to note: MELD is not just about the liver. It predicts the chance of dying in the next 90 days without a transplant.
- MELD 10–15: Patient is stable, may not need immediate transplant.
- MELD 20+: Patient is at higher risk, needs close monitoring.
- MELD 30–40: Patient is very sick, top priority for transplant.
So, the higher the score, the higher the urgency.
How Doctors Use MELD in Real Life
For every person on the liver transplant list, the MELD score is calculated regularly—weekly or monthly, depending on how sick they are.
When a donor liver becomes available, it is first offered to the person with the highest MELD score in that region.
This system ensures:
- Urgency is respected. The sickest patients get priority.
- Objectivity is maintained. No doctor can “push” a patient ahead without clear medical evidence.
- Fairness is balanced with outcomes. Livers are not wasted on patients who may not benefit.
At leading transplant centres, including under the guidance of experts like Dr. A.S. Soin, MELD scoring is not just a number—it is integrated into a carefully designed evaluation system to make sure each patient gets the right organ at the right time.
Beyond the Number: What MELD Cannot Capture
While MELD has made the transplant system far more objective, doctors know that MELD is not perfect.
Some examples of what MELD does not fully reflect:
- Certain complications of cirrhosis. Recurrent bleeding from varices, repeated fluid accumulation (ascites), or episodes of hepatic encephalopathy may not dramatically change MELD, but they severely affect quality of life.
- Liver cancers (Hepatocellular Carcinoma). Patients with liver cancer may have good MELD scores but still need urgent transplantation, as waiting too long risks tumor spread. That is why they are often given special “exception points.”
- Sudden deterioration. A stable MELD score may not predict an acute crisis such as massive bleeding or sepsis.
This is where the experience of transplant surgeons like Dr. A.S. Soin matters most—interpreting MELD in light of real clinical complications, and ensuring that patients who might be overlooked by the formula are not left behind.
The Human Side of MELD Decisions
When families hear that their loved one’s MELD score is, say, 18, they often ask, “What does that really mean? Are we close to getting a liver?”
Here lies the difficulty: the MELD score is relative. A score of 18 might mean moderate risk in one region, but if most other patients in that region have scores above 25, then that patient will wait longer.
This is why doctors explain that MELD is both a personal score (how sick one patient is) and a comparative score (how they rank against others waiting).
Why MELD is Not Static: The Constant Updates
The MELD score is recalculated at regular intervals because liver disease is dynamic.
- If the disease worsens, the score rises, pushing the patient up the priority list.
- If the patient stabilizes, the score remains lower, giving others with a higher risk a chance first.
This constant updating ensures the list reflects real-time urgency.
MELD and Ethical Fairness
One of the strengths of MELD is that it removes bias. It does not matter if a patient is rich or poor, young or old—the priority is determined by measurable illness severity.
This makes the system ethically sound and transparent. Families can track the numbers and know why a certain patient got the organ first.
For patients and families, it helps to know that doctors like Dr. A.S. Soin have been instrumental in establishing fair and transparent systems, where organ allocation is guided by medical science, not personal influence.
Limitations and Criticisms of MELD
Despite its value, MELD is not without criticism:
- Does not measure nutrition or frailty. A weak, malnourished patient may have the same MELD score as a physically stronger one, yet their real survival chances differ.
- Regional disparities. Because donor availability differs across areas, two patients with the same MELD score may wait very different times.
These limitations are why research is ongoing into whether MELD should be further refined, perhaps by adding markers of frailty, sarcopenia (muscle loss), or even advanced imaging data.
MELD in Special Groups
MELD score doesn’t apply in the same way to every patient group. Certain situations need their own scoring systems or exceptions.
- Children: For pediatric patients, MELD is replaced by the PELD score (Pediatric End-Stage Liver Disease), which includes growth failure as an additional factor.
- Acute liver failure: MELD is not designed for sudden liver failure cases, where patients can die within days. Such patients are given priority regardless of score.
- Living donor liver transplantation: In living donor cases, MELD helps in assessing urgency, but timing is often guided by the availability of a suitable family donor.
The Future: Beyond MELD Alone
As medicine advances, doctors are exploring additional models:
- MELD 3.0: A newer version that includes albumin levels and gives better accuracy for certain groups, especially women.
- Frailty indices: Physical strength tests, grip strength, and body composition scans to measure real vulnerability.
- AI models: Using data and machine learning to predict survival more accurately.
While MELD will stay as the base, the future will combine it with other tools for even better decisions.
Conclusion
The MELD score is a very important tool in liver transplants today. It helps doctors figure out who needs a liver the most, so that the sickest patients get treated first. But at the end of the day, it’s not just about numbers. Final decisions are always taken by a senior transplant team after looking at the full medical condition of the patient.
For families going through this tough time, having the right doctor to guide you makes a big difference. Being under the care of someone like Dr. A.S. Soin, who is one of the most experienced liver transplant surgeons in the world, can really give you peace of mind.
If you or your loved one is facing serious liver issues, Dr. Soin’s team can help you understand your MELD score, explain all your options in simple terms, and support you step by step towards a safe and successful transplant.
