D-MELD Balance of Risk — Dutkowski et al. 2009
Donor & Recipient Factors
years
years
Current laboratory MELD
hours
BAR Score
Balance donor and recipient risk for post-liver-transplant survival.
Guidelines & Evidence
Verified
Last Review: 2026-07-17
When to Use
When to Use
To predict 3-month post-liver-transplant survival using both donor and recipient factors
To guide donor-recipient matching at the time of organ offer
To identify transplant pairs with prohibitively high risk
To support informed consent and shared decision-making
To complement the SOFT score for comprehensive risk assessment
The BAR Principle
The BAR score simultaneously accounts for both sides of the transplant risk equation — donor factors (age, cold ischaemia time) and recipient factors (MELD, age, life support, retransplant status). A BAR score ≤ 6 is associated with > 80% 3-month survival, while BAR ≥ 18 is associated with > 70% mortality.
How it Works
Scoring Components
01
Donor Age > 40 (2 pts) / > 60 (4 pts): Older donor age increases graft vulnerability and risk.
02
Recipient Age > 40 (1 pt) / > 60 (3 pts): Older recipients have reduced physiological reserve.
03
MELD 20-30 (2 pts) / 30-40 (4 pts) / > 40 (6 pts): The dominant recipient risk factor.
04
Cold Ischaemia 6-10 h (1 pt) / > 10 h (3 pts): Longer ischaemia exacerbates reperfusion injury.
05
Life Support (5 pts): Pre-transplant ICU dependency is the single strongest recipient risk indicator.
06
Retransplant (3 pts): Retransplantation carries higher mortality due to previous surgery, sensitisation, and urgency.
Score Range and Interpretation
BAR Score = Sum of all component points (range 0-27)
BAR 0-6: 3-month mortality < 5% (Low risk)
BAR 7-12: 5-25% 3-month mortality (Moderate risk)
BAR 13-18: 25-70% 3-month mortality (High risk)
BAR > 18: > 70% 3-month mortality (Prohibitive)
Clinical Pearls
BAR vs. SOFT
BAR and SOFT are complementary tools. SOFT uses only recipient factors and can be applied early in the evaluation process (well before a donor is identified). BAR incorporates donor factors and is most useful at the time of organ offer, when a specific donor-recipient pair is being evaluated. Both scores were developed in the MELD era and are validated in multiple international cohorts.
Limitations
BAR was derived from SRTR data (2002-2007) — contemporary outcomes may differ
Does not include steatosis, donor liver biochemistries, or operative factors
The life support definition includes both ventilator and inotropes — these may carry different risks
Centre experience with high-BAR donors varies significantly
Next Steps
Clinical Application
01
BAR ≤ 6: Proceed with transplant. Excellent expected outcomes.
02
BAR 7-12: Acceptable risk. Standard perioperative care with close monitoring.
03
BAR 13-18: High risk. Consider preoperative optimisation, enhanced intraoperative monitoring, and postoperative ICU planning.
04
BAR > 18: Individualised decision-making required. May consider alternative strategies or decline the offer if recipient is stable.
The Evidence
Original Derivation
Are there better guidelines for allocation in liver transplantation? A novel score targeting justice and utility in the model for end-stage liver disease era.
Dutkowski P et al. • Ann Surg.. 2011;254(5):745–753. n = 17,335. C-statistic 0.73 for 3-month mortality.
View SourceOrigins & History
Development
The BAR score was developed by Dr. Philipp Dutkowski and colleagues at the University of Zurich, Switzerland. The score was designed to address a perceived limitation of the MELD system: that it allocates organs based solely on waitlist urgency (justice) without accounting for post-transplant outcomes (utility). BAR was intended to balance these two ethical principles.
Last Comprehensive Review: 2026-07-17