Liver Transplant Options for People with Low MELD Scores

By Larissa Biggers
April 14, 2023
A man clutches his abdomen. An illustrated liver appaers on top of his hands.

Because more people in the U.S. need a liver transplant than there are donors, many in need may have a long wait for a donor liver. Most potential recipients aren’t added to the national waitlist until their MELD score -- which measures the severity of liver disease -- reaches 15. However, waiting for a deceased donor liver isn’t the only option. Lindsay King, MD, a transplant hepatologist at Duke Health, and her colleagues offer multiple alternatives to people who need a liver transplant but don’t want to delay. “We get our patients safely transplanted faster because we work hard to get them healthy organs and we consider many types of donors,” she said. 

When You’re Sicker Than Your MELD Score

MELD scores range from six to 40. The higher the score, the greater your chances are of dying from liver failure in the next three months. That’s why people with higher scores rank higher on the waitlist for a deceased donor organ. However, some people are far sicker than their MELD score indicates. They may have a score of 12 but have fluid in their abdomen, confusion, jaundice, or gastrointestinal bleeding, explained Dr. King. 

Thinking Creatively

MELD scores are intended to be objective and to make deceased donor liver allocation as equitable as possible. But because so many people need liver transplants, the average MELD score in the U.S. at the time of transplant is around 30. Taking the traditional approach of waiting for a deceased donor liver could take months to years. “If your MELD score is in the teens or twenties and you need a liver transplant, we have to think creatively about how we can get you a donor liver,” said Dr. King. 

Beyond the National Waitlist

After someone is added to the national waitlist, the average wait time for a liver transplant in the U.S. is 240 days. Although the median wait time for a liver transplant at Duke is much shorter -- 85 days -- Duke offers a variety of alternatives to help people get transplanted faster, even if they rank low on the national waitlist. These include:

  • Living donor transplant: A portion of a living person’s liver is removed and transplanted into someone whose liver is no longer working properly.
  • Hepatitis B-positive transplant: The procedure is the same as traditional transplant surgery. Afterward recipients take a daily medication to suppress any infection that might develop.
  • Hepatitis C-positive transplant: A healthy hepatitis C-positive liver is transplanted into a recipient. Antiviral medication follows surgery to ensure a cure.
  • Split liver transplant: A liver from a deceased donor is divided between two recipients.
  • HIV-positive transplant: A deceased donor with HIV donates their healthy liver to an HIV-positive recipient.

Because this wide range of options isn’t available at many hospitals, Duke can take advantage of otherwise healthy livers that aren’t being allocated to other patients.

“We also have access to machine perfusion devices that keep donor livers viable much longer than the standard preservation process,” said Dr. King, “so donated organs can travel farther to reach recipients.” These devices significantly reduce risks associated with liver donation after circulatory death (DCD), which occurs after a donor’s heart has stopped beating. These advanced technologies and aggressive organ retrieval efforts make more high-quality organs available to more people, shorten wait list times, and lead to better outcomes.

MELD Scores Continue to Evolve

Since 2002, when the MELD score became the standard benchmark for transplant allocation and prioritization, it has undergone several improvements. In 2016, for example, when sodium levels were found to help predict waitlist mortality, this measurement was added to MELD score criteria. 2023 will see a new version (called MELD 3.0), which will incorporate new variables to enhance accuracy and address gender-based disparities in scores. “We will continue to refine the score and to do a better job of predicting who needs a transplant,” Dr. King said.

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