Right now, nearly 17,000 people in the United States await a liver transplant; more than 1,500 people die each year while waiting. A recent opinion piece in The Washington Post asks why and recommends a radical alternative to how livers are currently allocated: Stop prioritizing MELD scores and first consider the cause of liver disease in potential patients before allocating organs.

Written by Joshua Mezrich, PhD, an associate professor of surgery at the University of Wisconsin School of Medicine and Public Health, the article reveals some of the decisions that help determine which patients will get transplants. According to Mezrich, each patient is identified by name, age, weight, diagnosis and MELD score—a number based on the results of lab tests that’s used to determine the extent of an individual’s liver damage and how likely he or she is to die before a transplant. Doctors typically begin to consider surgery when a patient has a MELD score of 15; 40, the highest score, means a patient has a greater than 90 percent chance of dying within three months.

Mezrich notes that for the most part, patients at the top of liver transplant waiting lists have one of three diagnoses: alcoholic liver disease (ALD), non-alcoholic steatohepatitis (NASH) or hepatitis C virus (HCV). Less common are patients suffering from rare primary liver diseases, which occur independent of lifestyle factors. Such liver diseases often cause debilitating side effects yet often are associated with MELD scores that hover around the mid-20s—too low to render an individual eligible for a transplant.

Mezrich recalls a medical student of his named Nate who had primary sclerosing cholangitis, a rare primary liver disease with no effective treatment. He writes: “I work hard not to judge my patients…[but] for transplant surgeons such as me, it is hard to watch patients such as Nate—young, motivated, hardworking—suffer. Nate is stuck in MELD purgatory. Too sick to live his life, too ‘healthy’ to get a liver.”

Mezrich suggests a better protocol would favor transplanting livers into people with primary liver diseases, which represent only about 10 to 15 percent of cases, because, Mezrich points out, the main treatment for these patients is a transplant. The rest of the livers, he says, could then be allocated based on MELD scores and other factors, such as the new liver transplant distribution rules set forth by the United Network on Organ Sharing. 

Whether this is fair to patients with ALD, NASH or HCV—who might have developed liver disease as a result of alcoholism, obesity or injection drug use—is questionable. But the article does highlight the ongoing debate regarding just how much weight a MELD score carries when people are awaiting a liver for transplantation.

To learn more about how liver transplants are distributed in the United States, click here.