*Purpose: Assessing the survival benefit of transplantation in patients with chronic liver failure is critical in guiding the decision-making process for liver allocation. Current protocols prioritize patients for transplantation by severity of illness as reflected by higher Model for End-Stage Liver Disease (MELD) scores. Previous guidance in the field has been to avoid transplantation below a MELD of approximately 18, based on retrospective studies that demonstrated increased mortality risk for those transplanted below that score compared to candidates who remained on the waitlist. Given improved short-term outcomes of liver transplantation and a changing landscape of liver disease, we aimed to evaluate the survival benefit of liver transplantation at lower MELDs using intent-to treat analysis, with specific attention to the risk of transplant at low MELD scores.

*Methods: This retrospective cohort study used the UNOS database to analyze 161,823 candidates who were waitlisted for liver transplantation between March 1, 2002 and December 31, 2017. Stratified MELD cohorts were used to compare patients who were transplanted in a MELD score group to those listed in the same MELD group (omitting any who were transplanted in the same MELD group as listing) and then followed in an intent-to-treat manner. Kaplan-Meier analysis and multivariable Cox proportional hazard regression analysis were used to compare mortality between the transplantation and intent-to-treat cohorts.

*Results: While the survival benefit of transplantation does increase with increasing MELD scores, a survival benefit was shown for transplantation even at the lowest MELD scores. Most notably, those transplanted at a MELD between 6-11 showed a 10% reduction in mortality (HR = 0.90 [95% CI, 0.85-0.94]; p < 0.001), compared to the intent-to-treat cohort listed at this MELD. This mortality benefit increased to a 28% reduction for those transplanted at MELD between 12-14 (HR = 0.72 [95% CI, 0.68-0.75]; p < 0.001) and a 38% reduction for those transplanted at a MELD between 14-17 (HR = 0.62 [95% CI, 0.59-0.65]; p < 0.001).

*Conclusions: These findings challenge the current practice of deferring liver transplant below a particular MELD score such as 18, even if a possible match is offered, by showing a survival benefit for transplant patients even at the lowest MELD scores. Further analysis into the justification of transplantation at any MELD score could have strong implications in the allocation and management of patients waitlisted for liver transplant.

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