MELD Score Explained — Liver Transplant Priority in India 2025

By Dr. Srinivas Bojanapu, Liver Transplant & HPB Surgeon, Dhaara Speciality Hospital, Bangalore | Updated June 2025

If your doctor has told you that you or a family member has a MELD score of 18, or 24, or 32 — and hasn’t explained what that means — this article is for you. The Model for End-Stage Liver Disease (MELD) score is the single most important number in liver transplantation in India. It determines when you get listed, how urgently you receive a deceased donor organ, and whether a transplant is even recommended over medical therapy.

As a liver transplant surgeon who performs both living-donor and deceased-donor transplants at Dhaara Speciality Hospital, Yelahanka, Bangalore, I explain the MELD score to every patient family during our first consultation. Here is that explanation, in full.

What Is the MELD Score?

The MELD score is a mathematical formula that predicts the 90-day mortality risk of a patient with chronic liver disease without a transplant. It uses three blood tests:

The formula: MELD = 3.78 × ln[bilirubin] + 11.2 × ln[INR] + 9.57 × ln[creatinine] + 6.43

Scores range from 6 (stable) to 40 (critical). Patients on dialysis are automatically capped at creatinine 4.0 mg/dL.

MELD-Na (sodium-adjusted MELD) is now used in most centres, including ours, as it better predicts mortality in patients with low sodium (hyponatraemia), which is common in advanced cirrhosis. A patient with MELD 18 and sodium of 126 mEq/L has a much higher true risk than their raw score suggests.

MELD Score Ranges — What They Mean

How MELD Determines NOTTO Organ Allocation in India

India’s National Organ & Tissue Transplant Organisation (NOTTO) allocates deceased-donor livers based on MELD score within each state’s waiting list. Here is how it works for Karnataka, managed by the Zonal Coordination Committee Karnataka (ZCCK):

1. Super Urgent (Status 1A): Acute liver failure (no prior cirrhosis) with < 7 days to live — highest priority regardless of MELD
2. MELD ≥ 35: First priority among cirrhosis patients on the state list
3. MELD 25–34: Second tier — organs offered if no MELD ≥ 35 recipient available
4. MELD 15–24: Third tier — typically waiting 6–24+ months for a deceased-donor organ
5. MELD < 15: Listed but rarely receive deceased-donor organs unless the list clears

MELD Score Exceptions — When the Formula Understates Urgency

Some conditions are life-threatening even when the MELD score appears moderate. Transplant centres apply MELD exception points in these cases:

• Hepatocellular Carcinoma (HCC) within Milan Criteria: MELD exception of 22 points granted, increasing by 3 points every 3 months on waiting list
• Hepatopulmonary Syndrome: Arterial PaO₂ < 60 mmHg — MELD exception granted
• Portopulmonary Hypertension: When controlled on vasodilators with mPAP 25–35 mmHg
• Primary Sclerosing Cholangitis with recurrent bacterial cholangitis
• Familial Amyloid Polyneuropathy (FAP)

PELD Score — For Paediatric Patients Under 12

Children under 12 years use the Paediatric End-Stage Liver Disease (PELD) score, which includes:

• Albumin (nutrition/synthetic function)
• Bilirubin
• INR
• Growth failure (height/weight for age)
• Age < 1 year (high risk bonus)

Biliary atresia — the most common paediatric liver disease requiring transplant — typically leads to PELD scores of 15–30 by age 2 if hepatoportoenterostomy (Kasai procedure) fails or provides partial relief.

How to Improve (or Stabilise) Your MELD Score Before Transplant

The MELD score fluctuates with your condition. Steps that can temporarily lower it:

• Treat infection aggressively: Spontaneous bacterial peritonitis (SBP), urinary tract infections, and pneumonia drive creatinine up — often spiking MELD by 5–10 points rapidly
• Paracentesis + albumin infusion: Draining ascites and giving IV albumin (6–8 g per litre removed) prevents hepatorenal syndrome and can reduce creatinine
• Stop all nephrotoxic drugs: NSAIDs, aminoglycosides, contrast agents — all worsen kidney function and inflate creatinine
• Maintain sodium > 130 mEq/L: MELD-Na adjusts upward for hyponatraemia; restricting free water intake (1–1.5 L/day) and optimising diuretics helps
• Rifaximin for hepatic encephalopathy: Reduces ammonia load; though HE doesn’t directly change MELD, hospitalisation for HE often worsens creatinine/bilirubin

Note: Do not try to artificially lower your MELD score if you genuinely need a transplant soon. These measures are about preventing MELD spikes from reversible causes, not gaming the system.

When MELD Alone Is Not Enough — Living Donor Transplant

The MELD system was designed for deceased-donor organ allocation in settings with higher donor rates than India. With India’s current cadaveric donation rate, waiting for your MELD to reach 35 to get a deceased-donor organ often means deteriorating to the point where you are too sick for surgery.

This is why at Dhaara, we recommend starting living donor evaluation when MELD reaches 12–15 — even before listing for a cadaveric organ. This gives 4–8 weeks for donor assessment while the recipient is still in good condition for surgery. Transplanting at MELD 15–20 gives the best outcomes; transplanting at MELD 35 carries significantly higher risk.

Frequently Asked Questions