Liver transplantation (LT) has been the prominent treatment option in patients with end-stage liver failure, however procurement of adequate number of liver grafts remains a major problem. “The model of end-stage liver disease (MELD)” was described in 2006 in order to provide a fair allocation of the grafts. Despite MELD enabled an important decrease in death rates on waiting list, 1-year survival has also been decreased from 90% to 80% owing to prioritization of patients with poorer MELD scores. This situation led to discuss MELD score in different points of view.

In Turkey, patients who are candidate to cadaveric liver transplantation (CLT) for the treatment of hepatocellular carcinoma (HCC) gain a substantial amount of additional MELD score according to tumor size. This may push end-stage patients who do not have HCC but need earlier CLT urgently regarding other MELD criteria (high total bilirubin, creatinin and INR levels, uncontrolled ascites or hepatic encephalopathy [HE]) down in the waiting list and result in lower survival rates. Therefore additional MELD scores for HCC patients should be revised. Patients with metabolic disease or unresectable parasitary disease (alvelolar hydatid cyst) are effected by the same issue. A large amount of these patients cannot reach required MELD score and progress into more complicated disease which hinder previously possible improved survival.

Acute on chronic liver failure is a novel concept in prognosis of liver disease which is not accepted as an indication for urgent CLT in Turkish Liver Allocation System. Patients with acute on chronic liver failure are not considered as acute liver failure, whereas outcome after graft procurement is promising in this group.

In our country, Central Transplantation Coordination System procures grafts to the end-stage liver disease patients with a MELD score more than 14, whereas liver transplantation centers are allowed to manage living donor transplantation (LDT) with an insitutional internal-auditing. Social security institution finances CDT as well as LDT. The advantage of this financing is controversial and revisions should be considered for LDT.

In conclusion, a health care service should fight for good health, but not only for good results.