Peak-MELD scores, a disease trajectory associated with reduced access to liver transplantation

The Model for End-Stage Liver Disease (MELD) score has been the primary allocation tool in the Eurotransplant region. However, certain patient groups remain disadvantaged. As diagnostic and therapeutic means evolve, regular revision of allocation criteria is necessary. Infectious diseases can lead to acute organ dysfunction and transient increases in MELD scores, whereas uncontrolled infections represent a contraindication to transplantation. In this retrospective study, we investigated peak-MELD scores, defined as a transient increase of at least five MELD points within 1 month, and evaluated their association with infections and liver transplantation outcomes. Among 109 patients listed for liver transplantation at LMU University Hospital between 2019 and 2022, 11% experienced a peak-MELD trajectory. It was associated with a significantly lower transplantation rate independent of baseline characteristics (HR = 0.37; 95% CI [0.15, 0.92]; p = 0.03). Patients with peak-MELD scores underwent more frequent waitlist status changes (median 2.50 vs. 0.00; p < 0.001), with infections representing the predominant cause of these changes (median 33.33% vs. 0.00%; p = 0.002). In this small single-center study, our findings suggest that a transient MELD increase associated with infectious complications may reflect a clinically vulnerable disease trajectory linked to reduced access to transplantation. Larger multicenter studies are needed to validate these findings and to further evaluate the implications of MELD fluctuations on waitlist outcome. At present, clinicians may consider dynamic disease courses when assessing liver transplantation urgency in patients with cirrhosis.