From TIPS to Transplant Allocation

The MELD score was originally developed to predict 3-month mortality after TIPS procedures. Its objectivity — using only laboratory values — made it far superior to the subjective Child-Pugh score for organ allocation. UNOS adopted MELD in 2002, and MELD-Na in 2016.

The MELD Formula

MELD = 9.57 × ln(Creatinine) + 3.78 × ln(Bilirubin) + 11.20 × ln(INR) + 6.43

Creatinine is capped at 4.0 mg/dL. Patients on dialysis twice in the preceding week are automatically assigned creatinine = 4.0.

Why MELD-Na?

Hyponatraemia (serum sodium < 135 mEq/L) is independently associated with 2–3× increased 90-day waitlist mortality in cirrhosis. The MELD-Na formula:

MELD-Na = MELD + 1.32 × (137 − Na) − [0.033 × MELD × (137 − Na)]

Sodium is capped at 125–137 mEq/L to prevent gaming by aggressive sodium correction.

Score Interpretation

Practical Pearls

Do not aggressively correct hyponatraemia before listing — rapid sodium correction risks osmotic demyelination syndrome. Maximum correction: 8–10 mEq/L per 24 hours. MELD ≥ 15: Transplant listing benefits outweigh operative risk — this is the UNOS threshold for listing consideration. MELD does not capture portal hypertension complications (ascites, encephalopathy, variceal haemorrhage). Always use alongside clinical assessment. Hepatocellular carcinoma exception points: Patients with HCC within Milan criteria receive MELD exception points to account for tumour progression risk not captured by MELD.

Child-Pugh vs. MELD

Child-Pugh remains useful for:

• •Surgical risk assessment
• •Drug dosing in liver disease
• •BCLC staging for HCC
• •Communication with patients (Class A/B/C is intuitive)

MELD-Na is preferred for:

• •Transplant waitlist prioritisation
• •Predicting 90-day mortality
• •Objective serial monitoring