Impact of MELD-Na Based Liver Allocation on Liver Transplantation Outcomes

Impact of MELD Score and Sodium Integration
📌 The Model for End-Stage Liver Disease (MELD score) primarily uses creatinine, INR, and bilirubin to determine sickness and organ allocation priority.
📈 A higher MELD score indicates sicker liver status, unlocking more regional and national organ-sharing opportunities.
💧 Since 2016, sodium (hyponatremia) has been added to the MELD calculation because it was identified as an independent risk factor for death among transplant waitlisted patients.

The Share 15 Rule and Study Objectives
📜 The Share 15 Rule dictates that an available organ preferentially goes to someone with a MELD score greater than 15, either locally or regionally, before returning to the local center for someone with a MELD score less than 15.
🔬 The rationale for the original Share 15 rule, based on a 2005 study, suggested that patients with MELD scores less than 15 might experience lower mean survival even after transplantation compared to staying on the waitlist.
🤔 This study aimed to re-evaluate outcomes in the contemporary MELD-Sodium era (post-Jan 2016) to see how hyponatremia affects outcomes and if the survival benefit cut-offs have shifted.

Study Findings and Waitlist Outcomes
📉 In the MELD era (pre-2016), hyponatremia significantly increased the risk of death on the waitlist across all levels.
🛡️ In the MELD-Sodium era, the negative impact of hyponatremia decreased, and patients with low MELD and low sodium scores no longer faced a significant risk of waitlist mortality.
⬆️ Waitlist 90-day mortalities significantly decreased when transitioning to the MELD-Sodium era, without negatively affecting one-year graft survival.

Survival Benefit and Policy Recommendation
📊 Transplant survival benefit is calculated by comparing the hazard of dying post-transplant versus those on the waitlist with a similar MELD score (Hazard Ratio < 1 indicates a benefit).
📈 In the MELD era, a survival benefit was seen above MELD scores of roughly 15.
💡 In the MELD-Sodium era, a significant survival benefit from transplant was only observed above MELD scores of roughly 21.
🔄 Based on these findings, the proposal is to change the Share 15 rule to a Share 21 rule to align organ access with demonstrated survival benefit in the current MELD-Sodium system.

Key Points & Insights
➡️ Hyponatremia's impact is less severe in the MELD-Sodium calculation system compared to the older MELD system.
➡️ 90-day waitlist mortality decreased following the introduction of MELD-Sodium scoring without compromising one-year transplant outcomes.
➡️ The threshold for survival benefit from transplantation appears to have risen from a MELD score of 15 to MELD $\approx 21$ in the current era.
➡️ Actionable Insight: Policymakers should consider raising the organ allocation cutoff from Share 15 to Share 21 to ensure patients receive an actual survival benefit from transplantation.

📸 Video summarized with SummaryTube.com on Feb 22, 2026, 23:09 UTC