LAUSR

BACKGROUND AND AIMS Since implementation of the MELD score to determine waitlist priority in liver transplant (LT) in 2002, the score has been capped at 40. Recently, the MELD 3.0 score was proposed to improve upon MELD-Na. Here, we examine waitlist mortality and LT outcomes in patients with MELD 3.0 ≥40 to assess the potential impact of uncapping the score. APPROACH & RESULTS Adult waitlist registrations for LT from January, 2016 to December, 2021 were identified in the registry data from the Organ Procurement and Transplant Network. All MELD 3.0 scores were calculated at registration and thereafter. Waitlist mortality for up to 30 days was calculated as well as post-LT survival. There were 54,060 new waitlist registrations during the study period, of whom 2,820 (5.2%) had MELD 3.0 ≥40 at listing. The 30-day waitlist mortality was high in these patients; yet it increased further in proportion with MELD 3.0 up to a score of 55 with 30-day mortality of 58.3% for MELD 3.0 40-44 and 82.4% for ≥50. The multivariable hazard ratio was 1.13 for each point of MELD 3.0, adjusting for several variables including acute-on-chronic liver failure. The number of LT recipients with MELD 40 at transplant increased from 155 in 2002 to 752 in 2021. Post-transplant survival were comparable across MELD strata including MELD 35-39. CONCLUSION MELD 3.0 scores beyond 40 are associated with increasing waitlist mortality without adversely affecting post-transplant outcome. Uncapping the MELD score in waitlist candidates may lead to greater survival benefit from LT.