More women are now being included in liver transplant waitlist and undergoing the procedure following the adoption of the updated Model for End-Stage Liver Disease (MELD)?MELD 3.0?with mortality and transplant rates nearly matching those observed in men, according to a retrospective study conducted in the US.

Analysis of the federal Organ Procurement and Transplant Network (OPTN) data showed that since updating the MELD score to MELD 3.0 in July 2023, the percentage of women among new waitlist registrants had increased from 40.4 percent to 43.7 percent (p<0.001), while the percentage of those who received a transplant had risen from 37.3 percent to 42.1 percent (p<0.001). The percentage of women dropping out of the waitlist within 90 days decreased from 13.5 percent to 9.1 percent (p<0.0001). [AASLD 2024, abstract 5002]

Lead study author Dr Allison Kwong from the Stanford University Medical Center in Redwood City, California, US, pointed out that the waitlist dropout rate also decreased among men, from 9.8 percent to 7.4 percent, given the improvements in technology, such as machine perfusion, which have led to an increased number of available livers.

“MELD 3.0 improved access to transplantation for women, and now waitlist mortality and transplant rates between men and women are the same,” Kwong said.

Ranging from 6 to 40, MELD scores predict a patient’s mortality in the short term, and those with higher scores are given higher priority for transplantation. Kwong noted that while the median allocation MELD score at transplant decreased after the adoption of MELD 3.0, the median score for women was still higher than that for men (29 vs 27).  

“The sex disparity in access to liver transplant may not be fully solved by MELD 3.0. There are still body size di?erences that can a?ect one’s probability of transplant, and this would not be addressed by MELD 3.0,” she said.

For the study, Kwong and colleagues looked at more than 20,300 newly registered liver transplant, of which around 18,700 received a transplant. Waiting list outcomes were evaluated in the 12 months before and 12 months after the adoption of MELD 3.0.

Better mortality prediction

MELD 3.0 addresses the shortcomings of the original MELD and MELD-Na models to provide a more accurate prediction of mortality risk in patients. [Gastroenterology 2021;161:1887-1895.e4]

The original MELD model did not fully account for the impact of hyponatremia, a significant risk factor for mortality in patients with cirrhosis. Consequently, MELD-Na, which incorporates serum sodium as a key variable, was developed. Nevertheless, MELD-Na has been criticized for its potential bias against female patients due to its overestimation of renal function in womenbased on serum creatinine levels. [Gastroenterology 2006;130:1652-1660; N Engl J Med 2008;359:1018-1026; JAMA Surg 2020;155:e201129; https://tinyurl.com/mvub2k29]

MELD 3.0 reduces the weight of serum creatinine by lowering its ceiling from 4.0 to 3.0 mg/dL and incorporates the patient’s sex into the model. Other features of the latest MELD update include the addition of serum albumin, as well as interaction terms between creatinine and albumin and between sodium and bilirubin. [Gastroenterology 2021;161:1887-1895.e4]