Patrick S. Kamath, MD, is a professor of gastroenterology and hepatology at the Mayo Clinic in Rochester, Minnesota. His research interests include acute-on-chronic liver failure, nonalcoholic fatty liver disease, polycystic liver disease, Budd-Chiari syndrome and hereditary hemorrhagic telangiectasia. Dr. Kamath is internationally renowned as a leading researcher in hepatology and has also won numerous awards as an educator.
Why did you develop the MELD Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?
Following a trans-jugular intrahepatic portosystemic shunt (TIPS) procedure for complications of portal hypertension, some patients do well and others fare poorly. My colleague in statistics, Mike Malinchoc, and I studied laboratory variables prior to the procedure and identified INR, serum creatinine, serum bilirubin and etiology of cirrhosis being predictive of survival. We developed a score based on these variables and demonstrated it predicted survival in a wide variety of patients with cirrhosis not undergoing TIPS. The score was originally called the Mayo End-Stage Liver Disease (MELD) model and was shown to be superior to the Child-Turcotte-Pugh score.
At about the time we published the score, the Institute of Medicine determined that organ allocation for liver transplantation should no longer be based on waiting time but on an objective score that reflected severity of liver disease. The MELD Score fulfilled their criteria and was accepted as the score to prioritize organ allocation for liver transplantation. We changed “MELD” to Model for End-Stage Liver Disease assuming that the score would be more readily accepted by the liver transplantation community if it was not identified with a single institution.
What pearls, pitfalls and/or tips do you have for users of the MELD Score? Are there cases when it has been applied, interpreted, or used inappropriately?
The MELD Score has been validated as a predictor of survival in patients with cirrhosis, alcoholic hepatitis, acute liver failure, and in patients with acute hepatitis. In terminally ill patients with cirrhosis, the number of extra-hepatic organ failures is more predictive of mortality than is the MELD Score.
Along those lines, MELD is sometimes applied to patients with any degree of liver dysfunction, not just potential transplant candidates, as a quick, reliable, and easily-understood way of communicating how sick a patient is. Any thoughts on those uses?
Yes, MELD score is a metric for how sick a patient is. However, patients like to be given a number when we discuss risks. That’s where the MELD calculators at Mayo help.
What recommendations do you have for doctors once they have applied the MELD Score? Are there any adjustments or updates you would make to the score given recent changes in medicine?
Low serum sodium is an independent predictor of mortality in patients with cirrhosis. In 2008, my colleague Ray Kim published the MELD-Na Score which includes serum Na; this score improves slightly the predictive accuracy of the MELD score in predicting mortality.
Are there cases where you would recommend using Dr. Kim’s MELD-Na Score over the newer MELD Score that incorporates sodium (per the update to OPTN policy 1/2016)?
Currently, only for liver transplant.
How do you use the MELD Score in your own clinical practice? Can you give an example of a scenario in which you use it?
I use the MELD score to counsel patients and their families. I go over mortality risk, actual percentages rather than “high” or “low”, that can be expected if they undergo a TIPS procedure or surgery. If they are on the liver transplant waiting list, I can give them some idea when they might receive an organ. If patients have alcoholic hepatitis, I use the MELD score to predict risk of mortality. If the MELD score is >40 and patients with alcoholic hepatitis are not candidates for liver transplantation, I discuss palliative care.
Any other research you’re working on that you’re particularly excited about?
My colleague Vijay Shah leads a research group at Mayo of which I am a part. We are looking at newer treatments for alcoholic hepatitis.