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search of the Medline Database done on August 1,2004, using "MELD and liver transplantation" A as the search terms, retrieved 84 citations with the first citation dating to 2001. This is evidence that over a 3-year period, the model for end-stage liver disease (MELD) score has been scrutinized more closely and rigorously than any other method for liver allocation and arguably more than any prognostic model in healthcare to date. This interest has been widespread throughout the world, with investigators from Europe, Asia, and South and North America all publishing reports examining various aspects of MELD, its use for and impact on liver allocation, and the results of liver transplantation.2 Implementation of the MELD liver allocation system in the United States has been keenly followed, and there are efforts in several other areas of the world to utilize similar continuous disease severity scores for liver allocation. Why the interest? Why the acceptance? Why the scrutiny?
In the United States, prior to implementation of the MELD-based liver allocation plan, candidates for liver transplantation were prioritized by location of care (outpatient, inpatient facility, or intensive care unit), and Child-Turcotte-Pugh score,3 which included subjective measures of encephalopathy and ascites, and time waiting on the list. As waiting lists grew, liver transplant practitioners became increasingly aware that these parameters were not good measures of disease severity and were subject to manipulation. Hence, there was dissatisfaction with the system in use at the time. At the same time, the US government required that the US liver allocation policy should use objective medical criteria to prioritize waiting candidates based on the severity of liver disease.* This necessitated development of a more objective measure of liver disease severity. The MELD score had been previously validated as a predictor of 3-month mortality for patients with chronic liver disease.