Decompensated cirrhosis but low MELD—Should we wait or refer for liver transplantation?

Cirrhosis constitutes a significant global health burden with decompensation characterized by ascites, hepatic encephalopathy, as well as variceal hemorrhage. These decompensation features are independent predictors of mortality. Liver transplantation remains the definitive treatment for patients with cirrhosis. However, given that this is a limited resource, thus its allocation, using the MELD score, has to be judicious despite decompensation features affecting the patient's quality of life. Patients with grade 3 ascites or overt hepatic encephalopathy have significant mortality; therefore, in some instances, these decompensation features should be considered indications for liver transplantation despite low MELD. The majority of patients listed for liver transplantation have low MELD scores (≤15 points); and approximately half will die due to liver-related complications. Current evidence demonstrates a mortality reduction of ~40% with LT in those patients with a low MELD. Furthermore, new scores have been developed, such as the MELD 3.0, which incorporates female sex, albumin, and all the MELD-Na components (bilirubin, creatinine, international normalized ratio, and sodium), and the Gender-Equity Model for Liver Allocation, that includes bilirubin, international normalized ratio, and the Royal Free Hospital glomerular filtration rate, which have demonstrated improved discrimination. Lastly, to address the limited resource, living donor liver transplant has demonstrated a significant survival benefit in patients even at MELD-Na scores as low as 11, suggesting that life-years gained are similar to deceased-donor transplant. In this review, our goal is to present the frequency of patients listed for transplant with low MELD, and the limitation of using MELD in patients for liver transplantation. We will provide practical guidance on the management of common complications of cirrhosis and early consideration for liver transplant referral in patients with clinical decompensation and low MELD.