Liver Transplant Access in the MELD 3.0 Era: Progress, Limitations, and Lingering Gaps

As liver transplantation continues to evolve, so too does the scoring system that determines which patients receive access to life-saving organs. In this segment of Liver Lineup: Updates and Unfiltered Insights, hosts Kimberly Brown, MD, and Nancy Reau, MD, unpack new data examining MELD 3.0 and whether it meaningfully addressed long-standing inequities in transplant access, particularly for women and other disadvantaged patient groups.

Check out the full episode on advances in liver transplantation and hepatocellular carcinoma here.

Brown opened the discussion by providing context on why MELD 3.0 was developed in the first place. She notes that the MELD score has been repeatedly refined over time, including the addition of serum sodium, in response to concerns that certain patient populations may be unfairly advantaged or disadvantaged.

One of the most prominent concerns, she explains, relates to sex-based differences, largely because serum creatinine is influenced by muscle mass. Because women generally have lower muscle mass than men, Brown emphasizes that they may receive artificially lower MELD scores despite similar disease severity.

She and Reau walk through the design of a study presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025, which analyzed OPTN data from > 60,000 adult liver transplant candidates between 2020 and 2024, 40% of whom were women. Investigators focused on transplant access, including receipt of a top-5 organ offer and the likelihood of undergoing deceased donor liver transplantation, although Brown cautioned that MELD was originally designed to predict mortality rather than organ offers, a distinction she urges listeners to keep in mind when interpreting the results.

Brown explains that during the MELD 3.0 “burn-in” period, women experienced a significant increase in top-5 offers and transplant rates compared with men. However, she notes that this improvement was not sustained over time, with odds ratios eventually returning to pre-implementation levels, echoing prior discussions suggesting that height and overall size may play a larger role than sex alone.

Reau builds on this observation, highlighting the practical challenges of transplanting very small patients, noting that size mismatch often leads surgeons to decline offers. While women are more frequently affected, she emphasizes that very small men face similar barriers.

Both experts agree that while MELD 3.0 represented progress, it did not fully resolve structural inequities. Brown acknowledges that factors such as age and height continue to influence access, while Reau underscores the importance of maintaining a dynamic scoring system that can adapt to changing indications and patient populations.

Editors’ note: Relevant Disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal.

References

1. Tanaka T, Shane D, Lai J. MELD 3.0 Failed to Sustainably Address Sex Disparities in US Liver Transplant Allocation. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.