![]() ![]() 8 The initial elaboration of the MELD score was based on a cohort of patients undergoing transjugular intrahepatic portosystemic shunt procedures for portal hypertension. 7, 8 Derived from a trio of simple, reproducible, and objective laboratory parameters (serum bilirubin, prothrombin time international normalized ratio, and serum creatinine), MELD provides robust estimates of mortality risk across a broad range of patients. The development of MELD marked an important milestone in our ability to predict the prognosis of patients with chronic liver disease. 4- 6 In this essay, I discuss transplant decision-making approaches for liver transplant candidates, focusing especially on patients at the ends of the risk spectrum. 3 The combination of waiting list mortality risk and posttransplant mortality risk assessed by MELD and other factors can be used to estimate whether candidates are likely to derive a survival benefit from a liver transplant. The model for end-stage liver disease (MELD) scoring system has emerged as an excellent predictor of mortality on the waiting list 1, 2 and also predicts mortality after liver transplantation. ![]() Listing criteria for liver transplantation are currently very broad and delisting criteria have never been promulgated or placed into policy. Liver transplantation is currently offered as a therapeutic option for patients with a wide range of end-stage liver diseases whose outcome is predicted to be fatal, usually at a point when the candidate is still expected to live long enough to survive the uncertain wait for a donor organ. Donor organs are available in small numbers relative to the pool of candidates and our ability to predict the future lifetimes of individual patients is limited. Of course, we are unlikely to inhabit such a world anytime soon. Transplants would not be performed in circumstances in which the nontransplant option was associated with a longer lifetime, and this statement would hold true for patients throughout the disease severity spectrum. In an ideal world, every patient with liver disease whose predicted lifetime with a transplant is longer than his or her lifetime without a transplant would be able to receive an organ transplant at an optimal and timely point in the course of their disease and no waiting list deaths would occur.
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