Letter to the Editor: Validation of MELD 3.0 scoring system in East Asian patients with cirrhosis awaiting liver transplantation

Abstract

To the editor, With the continually changing demographics and epidemiology of chronic liver diseases, the allocation scoring system must be adjusted accordingly. Therefore, Kim et al [1] proposed Model of End-Stage Liver Disease (MELD) 3.0 to improve fairness, which was approved by the OPTN last year. However, the development of MELD 3.0 was mainly in Caucasians. Whether MELD is generalizable to Asian patients is unclear. The recent study by Yoo et al, [2] published in Liver Transplantation, found that MELD 3.0 performed better than other models in patients with cirrhosis awaiting liver transplantation in East Asian patients. Although the overall difference was not large, the result was still reassuring because, given East Asia's large population base, a small improvement could be enough to save a large number of lives. We admire their efforts to optimize the existing allocation system in East Asia.All the time, it is a puzzle how to accurately allocate scarce liver sources to maximize the benefit of recipients. Since 2002, the MELD score was used to determine medical urgency for liver transplant candidates, which contributed greatly to the rapid development of liver transplantation in the past 2 decades. Along the way, each MELD improvement led to a more stable and reliable prediction model. The proposal of a new MELD 3.0 may be a big step again. Two recent studies from the same team, published in Hepatology, further proved its superiority. First, due to a variety of reasons, the long-term graft prognosis for adolescents is quite different from children under 12 years of age but similar to young adults. The authors found that MELD 3.0 can also better represent their urgency for liver transplant in adolescents and improve the prediction of waitlist mortality. [3] Second, the MELD score is set at the upper limit of 40 points. However, with the maturity of liver transplantation technology and improvement of perioperative management, will this restriction deprive people with scores above 40 of the chance to survive? To solve this problem, Kim et al [4] examined waitlist mortality and liver transplantation outcomes in patients with MELD 3.0 ≥ 40 and found that uncapping MELD 3.0 improves mortality risk stratification and better represents urgency for liver transplantation for the sickest patients.Overall, so far, except for calculation somewhat more complex, MELD 3.0 seems to be completely superior to the original MELD. Therefore, it is worth replacing the existing MELD with MELD 3.0 in regions that currently use the MELD score.