Creatinine assay interferences compromises MELD accuracy and may bias liver allocation.

The Model for End-Stage Liver Disease (MELD) score is widely used to prioritize patients for liver transplantation and to estimate short-term mortality in end-stage liver disease. Inaccuracies in serum creatinine measurements, particularly interference from bilirubin, both key components of the MELD, may influence clinical decision-making. However, standardized approaches to address such analytical bias are lacking. Here we show that bilirubin-related interference leads to clinically relevant MELD distortions and associated outcomes. We developed a correction model using controlled in vitro matrices and validated it against representative patient samples. The model was applied to a large cohort from registry data and a separate clinical population. After correction, clinically meaningful score shifts occurred in a substantial proportion of patients, with lower corrected scores associated with altered transplantation probability and mortality estimates. These findings highlight the importance of harmonized, interference-resistant creatinine assays to improve fairness and accuracy in liver transplant allocation.