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Liver disease scores

MELD 3.0, MELD-Na, original MELD and Child-Pugh from one set of labs, with the transplant-referral trigger; FIB-4 for fibrosis triage; and Maddrey, MELD and the Lille model for the alcohol-associated hepatitis steroid decision.

MELD 3.0 · OPTN 2023Child-Pugh · FIB-4Maddrey · Lille (ACG 2024)Reviewed Oct 2026

1Patient

2Labs

3Clinical

4Fibrosis — FIB-4 optional

Uses age from section 1.

5Alcohol-associated hepatitis optional

How it works

Which score for which question

Transplant priority and referral: MELD 3.0 has been the US allocation score (OPTN) since 13 July 2023. AASLD/AST (2013): consider transplant evaluation once a patient with cirrhosis has an index complication — ascites, hepatic encephalopathy or variceal hemorrhage — or hepatocellular dysfunction gives a MELD ≥15; worsening renal function or other rapid decompensation warrants prompt evaluation. That guideline predates MELD 3.0, so the tool flags referral if either the original MELD or MELD 3.0 is ≥15.

Alcohol-associated hepatitis: ACG 2024 stratifies severity with MELD (>20 severe, ≤20 moderate), noting the supporting studies used the original MELD, not MELD-Na. The Maddrey discriminant function (≥32) is the historical index. Response to steroids is judged by the Lille score at day 7 or day 4; >0.45 is non-response.

Child-Pugh stays useful for bedside staging, drug labelling and surgical risk, but its ascites and encephalopathy grades are subjective — one reason MELD replaced it for allocation.

MELD equations and OPTN rules

MELD 3.0 (Kim 2021; OPTN, candidates ≥18 y)

1.33 [female] + 4.56 ln(bili) + 0.82 (137 − Na) − 0.24 (137 − Na) ln(bili) + 9.09 ln(INR) + 11.14 ln(Cr) + 1.85 (3.5 − alb) − 1.83 (3.5 − alb) ln(Cr) + 6

Bilirubin, INR and creatinine below 1.0 → 1.0. Creatinine above 3.0 → 3.0, and 3.0 if dialysed ≥2 times or ≥24 h CVVHD in the 7 days before the test. Sodium bounded 125–137 mmol/L; albumin bounded 1.5–3.5 g/dL. Rounded to the nearest whole number; minimum 6, maximum 40. Units: mg/dL, mmol/L, g/dL.

MELD-Na (OPTN 2016–2023)

MELD(i) = 0.957 ln(Cr) + 0.378 ln(bili) + 1.120 ln(INR) + 0.643 → rounded to the tenth, × 10
if MELD(i) > 11: MELD = MELD(i) + 1.32 (137 − Na) − 0.033 × MELD(i) × (137 − Na)

Same lower bounds; creatinine cap 4.0 (and 4.0 after dialysis/CVVHD as above); sodium 125–137; maximum 40.

Original MELD (Kamath 2001): 9.57 ln(Cr) + 3.78 ln(bili) + 11.2 ln(INR) + 6.43, same bounds as MELD-Na, rounded. Shown uncapped in the hepatitis panel because steroid-benefit data extend above 40.

Estimated 90-day survival (MELD 3.0): 0.946^exp(0.17698 × MELD 3.0 − 3.56). Derived on the 2016–2018 US waitlist; it describes waitlist mortality without transplant, not an individual prognosis.

Child-Pugh table
Points123
Bilirubin<2 mg/dL (<34 µmol/L)2–3 (34–51)>3 (>51)
Albumin>3.5 g/dL (>35 g/L)2.8–3.5 (28–35)<2.8 (<28)
INR<1.71.7–2.3>2.3
AscitesNoneMild or diuretic-controlledModerate or worse despite treatment
EncephalopathyNoneGrade 1–2Grade 3–4

Class A 5–6 · B 7–9 · C 10–15. Pugh’s original used seconds of PT prolongation (<4, 4–6, >6 s); the INR cut-offs are a later substitute and vary slightly between references (some use 2.2).

Maddrey and Lille
Maddrey DF = 4.6 × (PT − control PT, s) + bilirubin (mg/dL) [= µmol/L ÷ 17.1] R = 3.19 − 0.101 × age + 0.147 × albumin day 0 (g/L) + 0.0165 × (bilirubin day 0 − bilirubin day 7, µmol/L) − 0.206 × renal insufficiency − 0.0065 × bilirubin day 0 (µmol/L) − 0.0096 × PT day 0 (s)
Lille = e−R ÷ (1 + e−R)

Renal insufficiency = creatinine >1.3 mg/dL (≈115 µmol/L). Lille above 0.45 identified non-responders, with 6-month survival of 25% vs 85% (Louvet 2007); ACG 2024 uses the same >0.45 cut-off. ACG 2024 accepts day 4 as equivalent to day 7.

FIB-4
FIB-4 = age (y) × AST (U/L) ÷ [platelets (10⁹/L) × √ALT (U/L)]

Derived by Sterling (2006) in HIV/HCV coinfection; AASLD 2023 uses it as the first-line test for advanced fibrosis in fatty liver disease: <1.3 low risk (manage in primary care, repeat every 1–2 years if metabolic risk factors), 1.3 to <2.67 intermediate (secondary assessment such as vibration-controlled elastography), ≥2.67 high (consider hepatology referral). Convention used here: high at ≥2.67 (AASLD Table 5; the AASLD text says >2.67), and from age 65 the lower cut-off is 2.0 (McPherson 2017, ≥65; AASLD’s Figure 2 says “older than 65”). FIB-4 is inaccurate under 35 and should not be used in acutely ill patients. It triages fibrosis risk — it does not grade an acute hepatitis or established cirrhosis.

Pitfalls
  • MELD needs INR from liver synthetic failure: a vitamin K antagonist raises INR and inflates every MELD version and the Child-Pugh INR points.
  • Creatinine underestimates kidney dysfunction in sarcopenia and in women — the reason for the MELD 3.0 female term and the lower 3.0 creatinine cap.
  • Albumin infusion raises serum albumin and lowers MELD 3.0 slightly; at creatinine ≥2.7 mg/dL the albumin term reverses direction (Kim 2021).
  • Haemolysis or Gilbert syndrome raise unconjugated bilirubin without liver failure.
  • The Maddrey PT must be paired with the same laboratory’s control PT — never substitute INR.

Sources

  1. Kim WR, Mannalithara A, Heimbach JK, et al. MELD 3.0: the Model for End-Stage Liver Disease updated for the modern era. Gastroenterology 2021;161:1887–95.e4. doi:10.1053/j.gastro.2021.08.050 — equation, bounds (Results), original MELD and MELD-Na formulas (Methods), worked cases and predicted mortality (Table 4).
  2. OPTN. Notice of OPTN policy and guidance changes: Improving liver allocation — MELD, PELD, Status 1A, Status 1B (MELD 3.0 policy text: lower bounds, creatinine 3.0 cap and dialysis/CVVHD rule, sodium and albumin bounds, female term for candidates ≥18, minimum 6 / maximum 40; struck-through MELD-Na text). Implemented 13 July 2023 (UNOS announcement).
  3. 90-day survival = 0.946exp(0.17698 × MELD 3.0 − 3.56): Kim 2021 survival function (Supplementary Table 3b) as implemented by the University of Washington Hepatitis C Online and MSD Manual MELD 3.0 calculators; reproduces Kim 2021 Table 4 within 1 percentage point.
  4. Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001;33:464–70. doi:10.1053/jhep.2001.22172
  5. Pugh RN, Murray-Lyon IM, Dawson JL, et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973;60:646–9. Point table with SI units and INR alternative as given in the MSD Manual Professional, Child-Turcotte-Pugh scoring system table.
  6. Martin P, DiMartini A, Feng S, Brown R Jr, Fallon M. Evaluation for liver transplantation in adults: 2013 practice guideline by the AASLD and the American Society of Transplantation. Hepatology 2014;59:1144–65. doi:10.1002/hep.26972
  7. Sterling RK, Lissen E, Clumeck N, et al. Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection. Hepatology 2006;43:1317–25. doi:10.1002/hep.21178 — FIB-4 = age × AST ÷ (platelets × √ALT).
  8. Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, et al. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology 2023;77:1797–835. doi:10.1097/HEP.0000000000000323 — Table 5: FIB-4 <1.3 rules out, ≥2.67 rules in advanced fibrosis, not accurate under 35; Figure 2 legend: cut-off >2.0 above age 65, not for acutely ill patients; referral when >2.67 (text).
  9. McPherson S, Hardy T, Dufour JF, et al. Age as a confounding factor for the accurate non-invasive diagnosis of advanced NAFLD fibrosis. Am J Gastroenterol 2017;112:740–51. doi:10.1038/ajg.2016.453 — derived and validated FIB-4 lower cut-off 2.0 for age ≥65.
  10. Jophlin LL, Singal AK, Bataller R, et al. ACG Clinical Guideline: Alcohol-associated liver disease. Am J Gastroenterol 2024;119:30–54. doi:10.14309/ajg.0000000000002572 — Recommendations 17 (steroids, strong/moderate), 18, 20 (IV NAC, graded strong/moderate in Table 1; the narrative says NAC “may be used” and notes other societies do not recommend it), 21; Key concepts 20, 23, 26, 27, 28; steroid dose, duration and contraindications (text).
  11. Crabb DW, Im GY, Szabo G, Mellinger JL, Lucey MR. Diagnosis and treatment of alcohol-associated liver diseases: 2019 practice guidance from the AASLD. Hepatology 2020;71:306–33. doi:10.1002/hep.30866 (the current AASLD guidance; no newer AASLD alcohol-associated hepatitis guidance was found as of Oct 2026).
  12. Carithers RL Jr, Herlong HF, Diehl AM, et al. Methylprednisolone therapy in patients with severe alcoholic hepatitis. Ann Intern Med 1989;110:685–90. doi:10.7326/0003-4819-110-9-685 — discriminant function 4.6 × (PT − control) + bilirubin (µmol/L)/17.1.
  13. Louvet A, Naveau S, Abdelnour M, et al. The Lille model: a new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids. Hepatology 2007;45:1348–54. doi:10.1002/hep.21607 — coefficients as reproduced in trial statistical analysis plans (NCT03775109) and reference calculators.

Educational reference only — not a substitute for clinical judgment, institutional protocols, or specialist advice. Calculations run in your browser; nothing you enter is sent or stored.