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MELD scores and Liver Transplants

Liver disease is any disturbance of liver function that causes illness. Liver disease is a broad term that covers all the potential problems that cause the liver to fail to perform its designated functions. Usually, more than 75% or three quarters of liver tissue needs to be affected before decrease in function occurs. The liver is a prolific organ, and has the unique characteristic of regeneration.

Liver disease manifests itself from a number of different factors. Alcohol and drugs (even herbal remedies (kava kava, ma-huang) can cause Cirrhosis. Hepatitis A (virus from fecal matter), Hepatitis B, C and D (body fluid exposure) and Hepatitis E (food and water) cause liver disease. Other virus and diseases can also cause liver disease, such as Mononucleosis, fatty liver, Hemochromatosis, Wilsons or Gilberts Diseases, and others.

Post Transplant

Vicki in ICU after her Liver Transplant

When the liver is failing, and its decline exceeds its ability to regenerate, a transplant, or death become the only possible outcomes. Liver transplants are performed in a transplant hospital specializing in Liver transplants. There are 139 transplant centers, in 11 regions of the United States.

Two types of Liver Transplant are possible: Living transplant and a deceased transplant. As those names suggest, a living transplant comes from a live donor and a deceased transplant from someone who has passed. A live donor donates a portion of their liver, and it is then placed in the recipient. A deceased transplant places the whole liver from the deceased in the recipient.

In 2013, 6,455 transplants occurred, with 253 live transplants and 6,203 deceased transplants. 16,372 people were on the transplant waitlist. 39% of those on the transplant list received a liver, 4% from a live donor, and 96% from a deceased donor. Since the risk to the donor is so high, few liver transplants come from live donors.

 

 

The criteria for those on the liver transplant waiting list, include:

  1. First off, your Hepatologist has to recommend you for a transplant, and a transplant center has to accept you.
  2. The acceptance is based upon your health condition, and your MELD (Model of End-stage Liver Disease – PELD is the pediatric version) score.
  3. If you are an alcoholic, you will have to be free from any alcohol use for 1 year, be subject to random drug and alcohol tests, and attend some sort of rehabilitation or AA program.
  4. In general, you must be free of cancer or any other life threatening disease.
  5. Your MELD score generally must be 15 or higher.

A MELD, coupled with age and blood type determines priority for a liver transplant (a few other medical conditions can also obtain bonus points in the MELD calculations). The MELD score is determined through an algorithm that takes into account your INR (International Normalized Ration measures blood clotting, higher scores meaning blood is not clotting) score, your Bilirubin (yellow breakdown product of blood, high scores meaning it is not being excreted in the bile) score and your Creatinine (breakdown product of creatine, higher scores meaning kidney failure) score.

The MELD Score formula looks like this:

MELD = (0.957 * ln(Serum Cr) + 0.378 * ln(Serum Bilirubin) + 1.120 * ln(INR) + 0.643 ) * 10
(if the patient is on dialysis, the value for Creatinine is automatically set to 4.0).

A MELD calculator can be found at the MAYO clinic website. The Mayo clinic pioneered liver transplant methodologies, and originally came up with the MELD formula (it was originally named the MAYO end-stage Liver Disease). If you would like a MELD calculator in MS Excel format, send me a note and I will send it to you.

The MELD score ranges from a low of 0 to a high of 40. A MELD score for a healthy person is under 5. Any MELD above 6 is an indication of liver disease. A MELD of 15 indicates that a patient has liver disease, and the risk of transplant is equal to the risk of the liver disease itself. The risk of death due to transplant is 15%. A MELD score of 40 indicates a patient has a 98% mortality rate in the next 12 months. The graphic below illustrates the MELD score and its corresponding mortality rates at both 90 days and 1 year. This mortality is averaged over the transplant population, and can vary with time and location.

MELD Mortality

3 month and 12 month mortality

Ideally, a liver transplant happens with a MELD score somewhere between 15 and 25, although this can be rare. In the Midwest, the average score for a transplant is around 22. However, in high-density cities, such as New York or Los Angeles, the average transplant is more like 32.

Liver transplants tend to be very safe, and because of the MELD scoring system, very objective. The higher the MELD score, the higher the probability of a patient getting a transplant. Of course, the higher the MELD, the sicker a patient tends to be also.

In our case, Vicki’s Hepatologist referred her in February 2012 for transplant, but only after she survived her ankle surgery. Vicki first interviewed at the University Of Kentucky Medical Center, where they have a Liver Transplant Center in Region 11. She was accepted onto the liver transplant list at UK in May 2012. Later, she also interviewed at the University of Cincinnati Medical Center in Region 10. She was accepted onto the list at UC in February 2013.

During these times, Vicki’s MELD score ranged from a low of 14 to a high of 26. For the first year the range was 14 to 18. Later in 2013, especially after complications from dangerously low Sodium levels, her MELD score fluctuated from 22 to 26; the low Sodium scores provided some bonus points. On January 28, 2014 Vicki finally received her liver transplant.

The Choices We Make determine who we are. We are The Choices We Make.

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  2 comments for “MELD scores and Liver Transplants

  1. Hana
    May 13, 2015 at 13:12

    What is the range for dangerously low sodium level?

    • May 26, 2015 at 12:59

      Hi, and thanks for your question. Understanding Sodium, its relation to body health, and its affects is a complex problem. Also remember, I am not a doctor and nothing presented here should be construed as medical advice. I am only relaying my own experiences resultant from the battle my wife had because of her liver disease.
      Sodium is absolutely necessary for normal body function. A primary function of Sodium is to help balance the fluid levels in the body, inside and outside the cells in equilibrium. Another important role for Sodium is in the working of nerves and muscles.

      Remember first, it is a measure of sodium per volume in your blood. Although total sodium does play a role, it is not as important as the percentage of sodium in the blood.
      Normal Sodium levels are typically measured in the 136 to 145 milliequivalents per liter (mEq/L). For low sodium, especially for those with other health issues (like Liver Disease), the doctors didn’t really worry about low sodium until the levels fell below 125 mEq/L. NOTE: fluctuations in Sodium happen often, especially for people who lead active lifestyles or sweat a lot.
      Sodium levels also rise and fall after eating. It is not necessarily these rapid fluctuations that concern doctors (although they can be concerning and symptoms can appear quickly, but are shorter in duration), but slower changes over time above or below normal levels are much more concerning.

      The kidney is primarily responsible for the sodium levels in the body. The kidney is largely responsible for telling the body either to save sodium, or to let sodium leave the body in urine. If the body is not able to keep sodium, it is a sign that the kidneys are failing.
      A high Sodium level (hypernatremia) is often caused by consuming too much Sodium, or by being dehydrated. Vomiting, diarrhea, Cushing Syndrome and diabetic ketoacidosis are also causes of High Sodium.
      Low Sodium (which is quite rare) can be caused by too much sweating, burns, sever vomiting and diarrhea, and/or poor nutrition. Patients with adrenal gland issues, heart failure, kidney disease, cirrhosis, cystic fibrosis often suffer from low sodium.
      Symptoms of abnormal sodium levels include confusion, lethargy, and even seizures. These symptoms can’t be ignored, they are life threatening and you should consult a doctor quickly. As I also learned on the battle line, a very real potential problem is the balance of fluids inside and outside the cell wall. For if the cell volume is too high, compared to volume outside the cell – the cells in the body could explode.

      In my personal case, my wife suffered from Cirrhosis. A major side effect of cirrhosis is kidney disease. For years my wife’s sodium level hovered around 125. Then, while recovering from one of her many emergency room visits (resultant from her liver disease), and just prior to being released, her sodium levels began to collapse. She became very confused, and this confusion coupled with seizures were part of the reason she had been admitted to begin with. As the Sodium levels continued to fall, she became more and more confused, eventually falling into a near coma. She spent about 3 weeks in the hospital, with Doctors unable to stop the fall. Her Sodium level neared 105 at its worst and she was in ICU for approximately 1 week.

      The battle to improve her sodium levels was one, which really took its toll on me. Doctors were fighting the battle, but not allowing her to drink fluids (kind of counter intuitive – but remember the goal is sodium per volume, and if you increase the volume of fluids, the sodium level falls). She was also on diuretics to help with the buildup of toxins in the blood due to the liver disease. Of course, diuretics stimulate both urine production and bowel movements. The diuretics do decrease the fluid volume in the body, but also reduce sodium.

      I have often referred to the Liver Disease cycle as a catch 22, noting that for every action you take to help a patient improve, there almost always an equal and opposing reaction. Never was this more apparent to me, than with the sodium battle. For every action (whether it was fluid intake or expulsion), my wife almost always experienced a problem in the short term, even if the long term battle was won.
      The Choices We Make

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