Sherona Bau, NP: Navigating MELD Criteria Challenges for Liver Transplant Referral

More than 100,000 people are currently on the national organ transplant waitlist with another person added every 8 minutes, according to data from the Organ Procurement and Transplantation Network.¹

Liver transplants are the second most sought-after organ transplant behind kidney transplants, with the leading diagnoses among both candidates and recipients being alcohol-associated liver disease and metabolic dysfunction-associated steatohepatitis.² The Model for End-Stage Liver Disease (MELD) is a formula used to assign priority to most liver transplant candidates ≥ 12 years of age based on their medical urgency. Scores range from 6-40, with a higher score associated with a greater risk of dying from liver failure in the next 3 months and thus resulting in a higher rank on the waitlist for a deceased donor organ, which comprises the majority of liver transplants.³

Although a patient’s MELD score typically serves as a benchmark for their liver transplant candidacy, many patients are sicker than their score indicates, something Sherona Bau, NP, a hepatology nurse practitioner at the UCLA Pfleger Liver Institute, addressed during her session at the 2024 annual Gastroenterology and Hepatology Advanced Practice Providers (GHAPP) conference in National Harbor, Maryland.

“What I have seen is that in a lot of patients, their symptoms don't really go along with their MELD score. The MELD is 18 or 19, but their symptoms are so profound that they're so fatigued and they're so malnutritioned, they're like skin and bone,” Bau explained to HCPLive. “In those patients, it's very challenging because if you look at just giving them a transplant according to the MELD score, they are probably never going to get the liver transplant.”

For these patients, Bau described instances where it may be necessary to explore transplant options in a different region, citing different MELD score requirements in different states. Additionally, she pointed to the potential of finding a living donor rather than waiting for a deceased one on the waitlist and went on to describe transjugular intrahepatic portosystemic shunt (TIPS) as a “great opportunity” for patients with a low MELD score whose main concern is refractory ascites or bleeding from varices, noting some patients may not require a liver transplant after the procedure.

Bau described the liver transplant evaluation process as being very long and emphasized the importance of patients remaining local if possible to reduce the burden of the trips for appointments as well as the need for a social worker to provide patients with the support they need throughout this process.

“Give them some kind of realistic expectation. Then they know ‘Oh, it's not going to be just like today. We submit the evaluation, I’m going to be listed next month.’ Probably not, it takes a few months for the patient to be listed,” Bau said.

References

1. ^{Health Resources and Services Administration. Organ Donation Statistics. March 2024. Accessed September 30, 2024. https://www.organdonor.gov/learn/organ-donation-statistics}
2. ^{Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR). OPTN/SRTR 2022 Annual Data Report. U.S. Department of Health and Human Services, Health Resources and Services Administration. Accessed September 30, 2024. http://srtr.transplant.hrsa.gov/annual_reports/Default.aspx}
3. ^{Biggers, L. Liver Transplant Options for People with Low MELD Scores. Duke Health. April 14, 2023. Accessed September 30, 2024. https://www.dukehealth.org/blog/liver-transplant-options-people-low-meld-scores}