How to use it
Enter same-day labs in SI units, or switch bilirubin, creatinine and albumin to conventional units (bilirubin µmol/L ÷ 17.1 = mg/dL; creatinine µmol/L ÷ 88.4 = mg/dL; albumin g/L ÷ 10 = g/dL). The two tabs share their lab values, so on the Child-Pugh tab you only add the clinical items.
Dialysis means two or more dialysis treatments, or 24 hours of continuous renal replacement therapy, in the 7 days before the creatinine. It sets creatinine to 4.0 mg/dL for MELD and MELD-Na and to 3.0 mg/dL (265.2 µmol/L) for MELD 3.0. Sex is biological sex, as in Ontario’s allocation policy.
Which score?
| Score | Variables | Where it is used |
|---|---|---|
| MELD 3.0 (Kim 2021) | Bilirubin, INR, creatinine, sodium, albumin, sex | Ontario referral, listing and allocation; current US (OPTN) policy |
| MELD-Na (OPTN form) | MELD plus sodium | Some programs outside Ontario; many older studies |
| MELD (original) | Bilirubin, INR, creatinine | Alcohol-associated hepatitis studies; older literature |
| Child-Pugh | Bilirubin, albumin, INR, ascites, encephalopathy | Bedside severity, drug labels, surgical risk |
All three MELD versions are shown capped at 40, as in allocation, with the uncapped value when it is higher. MELD 3.0 adds points for female sex and low albumin and caps creatinine at 3.0 mg/dL.
Reading the result
90-day survival comes from the MELD 3.0 survival function (Kim 2021), derived in US waitlist patients from 2016 to 2018 who did not have a transplant. For example, MELD 3.0 of 15 → about 98%; 20 → 95%; 25 → 88%; 30 → 73%; 35 → 46%; 40 → 15%.
Transplant referral in Ontario
| MELD 3.0 | What to do |
|---|---|
| Any score | Refer after any decompensation (ascites, spontaneous bacterial peritonitis, jaundice, encephalopathy, portal hypertensive bleeding), or for HCC, hepatopulmonary syndrome or portopulmonary hypertension |
| 11 or more | Ontario’s referral criteria: decompensated patients “typically” have a MELD 3.0 of 11 or more |
| 15 or more | Ontario lists decompensated cirrhosis at MELD 3.0 of 15 or more. AASLD/AST 2025 calls 15 a reasonable referral threshold even without decompensation |
MELD alone should not be a barrier to referral (AASLD/AST 2025). Ontario’s two adult liver transplant programs are in London and Toronto. Referral criteria differ between provinces.
Child-Pugh classes are A (5–6), B (7–9) and C (10–15). In SI units, bilirubin scores 1 below 34 µmol/L, 2 from 34 to 51 and 3 above 51; albumin scores 1 above 35 g/L, 2 from 28 to 35 and 3 below 28; INR scores 1 below 1.7, 2 from 1.7 to 2.3 and 3 above 2.3. Points are taken in the unit you entered, using that unit’s published thresholds. For PBC and PSC, bilirubin thresholds are higher: below 68, 68–170 and above 170 µmol/L (4 and 10 mg/dL). Ontario’s transplant criteria use MELD 3.0, not Child-Pugh.
Pitfalls
- Anticoagulants. On warfarin, the INR does not reflect liver function, so MELD and Child-Pugh are not valid. Direct oral anticoagulants raised MELD by a median of 3 to 10 points in one study (Lisman 2023). Use an INR from before anticoagulation and tell the transplant centre.
- Creatinine in sarcopenia and in women. Low muscle mass lowers creatinine, so MELD underestimates risk. MELD 3.0 adjusts for sex, not for sarcopenia; assess frailty and nutrition separately.
- Hyponatremia. Sodium below 125 counts as 125, and above 137 as 137. Low sodium from diuretics or hypotonic fluids raises MELD-Na and MELD 3.0. Correct chronic hyponatremia slowly (no more than 8 mmol/L a day, EASL 2018) to avoid osmotic demyelination.
- Lab bounds. Bilirubin, INR and creatinine below 1.0 mg/dL count as 1.0, so normal labs give a score of 6.
- Alcohol-associated hepatitis. The steroid decision uses the original, uncapped MELD: use the alcohol-associated hepatitis tool.
- Survival estimates are population averages from US waitlist data. They do not capture HCC, frailty or acute-on-chronic liver failure.