Model for End-Stage Liver Disease Score
Estimate 90-day mortality in chronic liver disease. MELD score is used for liver transplant prioritisation and prognosis in cirrhosis and acute-on-chronic liver failure.
What is the MELD Score?
The Model for End-Stage Liver Disease (MELD) score is a validated prognostic scoring system for patients with chronic liver disease, liver cirrhosis, and acute liver failure. Originally developed to predict 90-day mortality following elective TIPS (transjugular intrahepatic portosystemic shunt) procedures, it became the primary tool for organ allocation in liver transplantation in the United States (UNOS/OPTN) from 2002 and is now used by European transplant networks. MELD uses three objective laboratory values — INR, serum bilirubin, and serum creatinine — to generate a score predicting short-term mortality risk. MELD-Na (incorporating serum sodium) has improved predictive accuracy and is now preferred by many centres.
When to use it
Use in adults with known or suspected chronic liver disease, cirrhosis, or acute liver failure to estimate prognosis and prioritise liver transplantation. Also guides intensity of monitoring and ICU admission decisions.
Scoring Criteria
MELD Score — Variables & Points
INR (International Normalised Ratio)
Measure of liver synthetic function
Serum bilirubin (µmol/L or mg/dL)
Measure of hepatic excretory function
Serum creatinine (µmol/L or mg/dL)
Measure of renal function; reflects hepatorenal syndrome risk
(MELD-Na) Serum sodium (mmol/L)
Added in MELD-Na — hyponatraemia independently predicts mortality in cirrhosis
Score Interpretation
Low severity
90-day mortality <5%; outpatient monitoring
Moderate severity
90-day mortality ~6–20%; regular hepatology follow-up
High severity
90-day mortality ~20–30%; transplant evaluation
Very high severity
90-day mortality >50%; urgent transplant listing consideration
Guideline Recommendation
EASL Clinical Practice Guidelines on Cirrhosis (2018): MELD is the recommended prognostic tool for liver transplant prioritisation and for determining intensity of care in decompensated cirrhosis. MELD-Na is preferred over MELD alone in patients being considered for transplantation.
Clinical Pearls
MELD is calculated as: 3.78×ln[bilirubin mg/dL] + 11.2×ln[INR] + 9.57×ln[creatinine mg/dL] + 6.43. Values are capped at specific limits.
MELD-Na adds: MELD + 1.32×(137-Na) − [0.24×MELD×(137-Na)]; sodium <125 or >137 mmol/L is capped.
Creatinine is capped at 4.0 mg/dL; patients on dialysis are assigned a creatinine of 4.0 mg/dL.
A rising MELD score over time is more informative than a single value — monitor trajectory, especially around acute decompensation events.
MELD does not capture hepatocellular carcinoma (HCC) risk — MELD exception points can be added for HCC candidates on transplant waiting lists.
Limitations
Does not include clinical events such as variceal haemorrhage, encephalopathy, or ascites that independently affect prognosis.
Less accurate in patients with cholestatic liver disease where bilirubin is disproportionately elevated.
Creatinine is influenced by muscle mass — MELD may underestimate severity in frail, sarcopenic patients.
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Frequently Asked Questions
What is a high MELD score?
A MELD score ≥20 indicates substantial liver disease severity with 90-day mortality risk of 20–30%. Scores ≥30 carry >50% 90-day mortality and typically require urgent liver transplant evaluation. Scores ≥40 are associated with >70% short-term mortality without transplantation.
What is the difference between MELD and Child-Pugh score?
MELD uses three objective laboratory values (INR, bilirubin, creatinine) and is the current standard for transplant prioritisation. Child-Pugh includes two subjective components (ascites severity and encephalopathy grade), making it less reproducible. MELD has replaced Child-Pugh for transplant allocation but Child-Pugh remains useful for assessing surgical risk and cirrhosis staging.