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MAYO CLINIC
How to Calculate a MELD Score: Click on the below url
http://www.mayoclinic.org/gi-rst/mayomodel5.html
Model for End Stage Liver Disease (MELD) and Pediatric End-Stage Liver
Disease (PELD) Calculator
The Model for End-Stage Liver Disease (MELD) and Pediatric End-Stage Liver
Disease (PELD) are numerical scales that are currently used for liver
allocation. The MELD and PELD scores are based on a patient’s risk of
dying while waiting for a liver transplant, and are based on objective and
verifiable medical data.
The MELD score is used for adult liver patients and is based on
bilirubin, INR and creatinine. Liver transplant candidates under the age
of 18 are assigned a PELD score. The PELD score is based on bilirubin, INR,
albumin, growth failure and age when listed for transplant, factors which
better predict mortality in children. These scores do not determine the
likelihood of getting a transplant, which will be based upon organ
availability and the distribution of MELD/PELD scores for patients in a
local area or region.
MELD/PELD Calculator
The MELD/PELD Calculator provided on this site uses the specific
formulas approved by the OPTN/UNOS Board of Directors and used for the
allocation of livers by the OPTN match system.
A full description of the MELD/PELD calculator can be found in the
documentation on the
http://www.mayoclinic.org/gi-rst/mayomodel5.html
The MELD/PELD calculator screen collects data elements used in both the
MELD and PELD score calculations. Please note the following:
The MELD score calculation uses:
- Serum Creatinine (mg/dl) **
- Bilirubin (mg/dl)
- INR
**For adult patients who have had dialysis twice within the last week,
the creatinine value will be automatically set to 4 mg/dl.
The PELD score calculation uses:
- Albumin (g/dl)
- Bilirubin (mg/dl)
- INR
- Growth failure (based on gender, height and weight)
- Age at listing
Questions and Answers
For Patients and Families
About MELD and PELD
The United Network for Organ Sharing (UNOS), a non-profit
charitable organization, operates the Organ Procurement and
Transplantation Network (OPTN) under federal contract. On
an ongoing basis, the OPTN/UNOS continuously evaluates
new advances and research and adapts these into new organ
transplant policies to best serve patients waiting for transplants.
As part of this process, the OPTN/UNOS has
developed a new system for prioritizing patients waiting
for liver transplants. This system is based on statistical
formulas that are very accurate for predicting which
individuals are most likely to die soon from liver
disease. The MELD (Model for End Stage Liver
Disease) is used for adult patients and the PELD
(Pediatric End Stage Liver Disease Model) is used for
pediatric patients.
This document will explain the reasons for adopting
this system and how it will affect patients on the
waiting list.
What is MELD? How will it be used?
The Model for End-Stage Liver Disease (MELD) is a
numerical scale, ranging from 6 (less ill) to 40 (gravely
ill), that will be used for adult liver transplant
candidates. It gives each individual a ‘score’ (number)
based on how urgently he or she needs a liver
transplant within the next three months. The number
is calculated by a formula using three routine lab test
results:
• bilirubin, which measures how effectively the
liver excretes bile;
• INR (prothrombin time), which measures the
liver’s ability to make blood clotting factors; and
• creatinine, which measures kidney function.
(Impaired kidney function is often associated
with severe liver disease.)
The MELD score will replace the previous Status 2A,
2B and 3 categories. The status 1 category (patients
who have acute liver failure and a life expectancy of
less than 7 days without a transplant) will remain in
place as the highest priority for receiving an organ and
will not be affected by the MELD system.
A patient’s score may go up or down over time
depending on the status of his or her liver disease.
Many patients will have their MELD score assessed a
number of times while they are on the waiting list.
This will help ensure that donated livers go to the
patients in greatest need at that moment.
What is PELD? How does it differ from MELD?
Candidates under the age of 18 will be placed in
categories according to the Pediatric End-stage Liver
Disease (PELD) scoring system. PELD will replace
Status 2B and 3 for pediatric patients; Status 1 will
remain in place and will not be affected by PELD.
PELD is similar to MELD but uses some different
criteria to recognize the specific growth and
development needs of children. PELD scores may also
range higher or lower than the range of MELD scores.
The measures used are as follows:
• bilirubin, which measures how effectively the
liver excretes bile;
• INR (prothrombin time), which measures the
liver’s ability to make blood clotting factors;
• albumin, which measures the liver’s ability to
maintain nutrition;
• growth failure; and
• whether the child is less than one year old.
What Led To the New System?
For the last few years, patients needing liver transplants
have been grouped into four medical urgency
categories. The categories were based on a scoring
system that included some laboratory test results (such
as bilirubin, INR and albumin) and some symptoms of
liver disease (such as ascites and encephalopathy).
One concern with using symptoms in scoring is that
different doctors might interpret the severity of those
symptoms in different ways. In addition, this scoring
system could not easily identify which patients had
more severe liver disease and were in greater need of a
transplant.
Research showed that the MELD formula very
accurately predicts most liver patients’ short-term risk
of death without a transplant. The accuracy of the
formula did not improve when other factors were
added, such as the cause of liver failure or observed
symptoms, such as ascites, encephalopathy, or other
complications of liver diseases. The MELD and PELD
formulas are simple, objective and verifiable, and yield
consistent results whenever the score is calculated.
OPTN/UNOS committees developed the new liver
policy based on MELD and PELD. The policy
proposal was twice published for public comment. It
was approved by the OPTN/UNOS Board of
Directors in November 2001. The OPTN/UNOS
Patient Affairs Committee and patient/family
representatives on the OPTN/UNOS Board of
Directors offered key support for the new system.
How will waiting time be counted in the system?
Under the previous system, waiting time was often
used to break ties among patients of the same medical
status. Various studies, including one done by the
Institute of Medicine, report that waiting time is a poor
indicator of how urgently a patient needs a liver
transplant. This is because some patients are listed for
a transplant very early in their disease, while others are
listed only when they become much sicker.
Under the new plan, with a greater range of
MELD/PELD scores, waiting time will not have to be
used as often to break ties. Waiting time will only
determine who comes first when there are two or more
patients with the same blood type with the same
MELD or PELD score.
If a patient’s MELD or PELD score increases over
time, only the waiting time at the higher level will
count. (For example, someone who has waited 40 days
with a score of 12, and 5 days with a score of 15, would
only get credit for 5 days of waiting time at the score of
15.) Patients initially listed as a Status 1 would also
retain their waiting time if their condition improves and
they later receive a MELD/PELD score. However, if
the patient’s MELD or PELD score decreases again, he
or she would keep the waiting time gained at the higher
score. (Using the earlier example, if the patient’s score
goes from 12 to 15 and back to 12, he or she would
have 45 days of waiting time at the score of 12.)
Patients with higher MELD/PELD scores will always
be considered before those with lower scores, even if
some patients with lower scores have waited longer.
(For example, a patient waiting for one day with a score
of 30 will come ahead of a patient with a score of 29,
even if the patient with a 29 has waited longer because
the patient with a score of 30 has a higher chance of
dying on the list.)
What if I am on the waiting list when the system
changes?
A transition plan will allow you to maintain the priority
gained under the previous system. If you are an adult
Status 2A patient, you will be given priority ahead of
new adult patients listed under the MELD system for
the first 30 days after the new system is in effect. If
you do not receive a transplant within 30 days, your
MELD score will be calculated at that time, and you
will receive 30 days of waiting time at that score.
If you are a Status 2B or 3 patient, your MELD or
PELD score will be calculated at the time the new
system goes into effect. If your score stays the same or
decreases within the first year, you will keep the waiting
time gained under the previous system. If your MELD
or PELD score increases within a year, only the waiting
time in the higher status will apply (see the previous
section, “How will waiting time be counted in the
system?”).
Patients who are listed after the new system is put in
place will receive a MELD or PELD score, based on
their current lab results.
Do MELD and PELD account for all conditions?
MELD/PELD scores reflect the medical need of most
liver transplant candidates. However, there may be
special exceptions for patients with medical conditions
not covered by MELD and PELD. If your transplant
team believes your score does not reflect your need for
a transplant, they can seek a higher MELD/PELD
score than the one determined by lab tests alone.
Is this system likely to change?
As transplant professionals apply and learn from the
new system, some changes will likely be required to
better meet patients’ needs. In fact, this system is
designed to be flexible and allow improvements. In
transplantation, as in all scientific fields, new studies are
taking place all the time to learn how to save more lives
and help people live longer and better.
What if I have more questions?
If you have any further questions or concerns, you
should contact your transplant team for further
information. Additional details about the OPTN,
UNOS, allocation policy and patient informational
resources are available on the following websites:
http://www.optn.org
http://www.unos.org
http://www.patients.unos.org
The liver has an amazing ability to function even in an advanced state of
hepatitis C (HCV) infection. However, ongoing infection may eventually
damage the liver so severely that it slowly loses the ability to provide
the functions necessary for life.
In previous articles, we have reviewed how the hepatitis C virus infects
the cells of the liver, causing
inflammation. This inflammatory process
causes specialized cells in the liver to begin forming scar tissue, a
condition called
fibrosis.
Eventually, scar tissue distorts the structure and function of the
liver, resulting in
cirrhosis. Although cirrhosis is a
serious health issue, many people with cirrhosis live long lives and may
have few symptoms of liver disease. As long as the patient's health
status is stable, their cirrhosis is said to be "compensated."
Unfortunately, cirrhosis can cause very serious symptoms in some
patients, such as jaundice, ascites and edema, bleeding and mental
confusion. When these conditions develop, the patient is said to have "decompensated"
cirrhosis.1
The development of decompensated cirrhosis signals the onset of
end-stage liver disease, which is also called chronic liver failure.
End-Stage Liver Disease / Liver Failure
There are two forms of liver failure.
Acute Liver Failure. Also called Fulminant Hepatic
Failure, this condition can develop very rapidly, in days or weeks. It is
usually caused by exposure to toxic chemicals; poisonous mushrooms
(Amanita Phalloides); drugs, such as an overdose of acetaminophen; or an
interruption of blood flow to the liver.
Acetaminophen does not appear to damage the liver when ingested as
prescribed, even when cirrhosis is present. However, when taken in large
amounts, or with alcohol, it can cause massive liver damage and lead to
acute liver failure.
In viral hepatitis infection, fulminant hepatic failure may result from
simultaneous infection (coinfection) by hepatitis A and C viruses, or
hepatitis B and D viruses.
Chronic Liver Failure. Also known as end-stage liver
disease (ESLD), this condition usually develops slowly, over years to
decades. Not everyone with hepatitis C infection will develop end-stage
liver disease.2
Diagnosing End Stage Liver Disease
Physicians can determine that a patient has ESLD months or years in
advance. The diagnosis is based on symptoms, in addition to laboratory
studies. The signs are very similar to advanced cirrhosis, and may
include:
- Jaundice (yellowing of the skin)
- Ascites (swelling of the abdomen due to fluid accumulation)
- Edema (swelling of the extremities)
- Changes in laboratory values (ALT, AST, Bilirubin, and other
common liver tests)
- Encephalopathy (confusion, stupor or coma)
- Bleeding abnormalities
- Malnutrition2,3
Not everyone who becomes infected with hepatitis C will develop these
advanced complications. According to the Centers for Disease Control and
Prevention, of every 100 persons infected with HCV:
- 75 to 85 persons may develop long-term infection
- 70 persons may develop chronic liver disease
- 15 persons may develop cirrhosis over a period of 20 to 30 years
- Less than 3 percent of persons may die from liver cancer or
cirrhosis.4
Sources
1. Herrera J. Hepatitis Open Forum, March 2, 2004. The
Hepatitis Neighborhood.
http://www.hepatitisneighborhood.com/
2. Canio J. Understanding Acute Liver Failure.
http://www.ucdmc.ucdavis.edu/transplant/
3. Liver Failure. Merck Manual, Section 10, Chapter 135.
http://www.merck.com/
4. Viral Hepatitis C - Frequently Asked Questions.
Centers for Disease Control and Prevention. http://www.cdc.gov/ncidod/diseases/hepatitis/c/faq.htm#1e
V.J. Smith is a Registered Nurse with a Bachelor's
degree in Nursing and a Master's degree in Clinical Psychology, and has
experience in oncology, critical care and hospice, nursing management,
counseling and clinical administration.
End Stage Liver Disease
What Happens when we reach End Stage Liver Disease ?
The fluid build-up in the abdomen is called
ASCITES.
A healthy liver produces a protein called Albumin, and puts it into the
bloodstream.
Albumin is a colloid.... it sort of "waterproofs" the veins, and keeps
fluids where they should be.
When a person has advanced liver disease, their liver doesn''t produce
enough Albumin.
Veins aren''t "waterproof".... fluid leaks into body tissue, and (because
of gravity) usually collects in the feet or legs (as edema), or in the
abdomen (as ascites)
1. Patients should be on a LOW sodium diet. Salt makes ascites WORSE.
Usually a doctor will tell a patient with ascites to stay under 2000 mg.
of sodium per day, but sometimes they will give you an even lower amount.
Talk to your doctor about how much sodium you are allowed per day.
Read food labels, sodium is in many foods (and drinks). Make sure he stays
under 2000 mg. per day (or even lower, if the doctor advises)
2. The doctor may prescribe diuretics (water pills) to help shed some of
the fluid.
If you take diuretics, it is very important for the doctor to monitor your
electrolytes and kidney function (through blood tests)
3. Patients should weigh yourself everyday.....and any weight gain of 5
pounds or more DURING A WEEK means call the doctor.
(because the doctor may want to adjust the dosage of diuretics)
4. If the patient has ascites which are large, you should avoid doing
anything too strenuous (lifting, pushing, pulling)---- because people with
ascites are prone to umbilical hernias.
5. Any pain in the abdomen, or any sign of fever, means get help quickly.
*********************************
You should ask your doctor for a copy of all blood test results, each time
you have blood work done.
Your blood test numbers will give you a much better idea of exactly
what''s going on.
*********************************
Sleeping a lot can be a sign of ENCEPHALOPATHY.
A healthy liver filters toxins out of the bloodstream.
A damaged liver doesn't filter toxins properly.....
toxins (especially ammonia) build up in the bloodstream, and have an
effect on the brain ("encephalopathy").
Doctors usually prescribe LACTULOSE to help with encephalopathy. Lactulose
is a prescription liquid laxative that binds with ammonia and removes it
from the body.
ASK your doctor about Lactulose.
It's important to keep encephalopathy under control.
Early signs of encephalopathy can be subtle (sleepiness, lots of naps
during the day, changes in mood, forgetfulness, etc.)....
but if not kept under control, it can worsen to asterixis, tremors,
confusion, agitation, disorientation, etc..... and eventually coma (and
even death)
1. If the patient is not already taking Lactulose, ask the doctor about
it. Lactulose will help.
2. If you are already taking Lactulose....and you notice any symptoms
getting worse, CALL the doctor. (Your opinion matters. People with
encephalopathy often don''t realize they are acting odd)
*********************************
DD, the 3 main things ("complications") that you need to be aware of right
now are:
1. Ascites
2. Encephalopathy
3. Varices
*********************************
Varices are internal varicose veins (usually in the esophagus, stomach,
duodenum, or intestine) that are under an extreme amount of pressure.
Varices can burst and bleed (can be life-threatening)
Doctors use endoscopy (scope down the throat) to look for any signs of
Varices.
(If a doctor does see any varices...they can sometimes be "banded" to
prevent future bleeds)
1. If you have not had an endoscopy yet, ask your doctor about it,
you might need done.
2. Any sign of bleeding (coughing blood, or vomiting blood, or vomiting
what looks like coffee grounds, or passing blood, or passing black stools)
means go to the Emergency Room.
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If you have all these symptoms ask your doctor about referring you to a
transplant center for an "evaluation"?
(An "evaluation" is a series of tests and interviews, to see if a person
is a good candidate for transplant.)
If you want information about a liver transplant, you should discuss this
with your doctor (and ask for a referral for an evaluation)
*********************************
More advice---
-make sure he avoids alcohol,
-make sure he gets his doctor's approval before taking any
over-the-counter medications, herbs, supplements, etc.
-make sure he eats a healthy diet (if you have trouble eating 3 full
meals--- try 5 small meals)
Please visit Imkindlys support group online at
End Stage Liver
Disease Support
Written by : IM Kindly
Edited by Janis and Friends
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