Scoring in liver disease

1. ASSESSMENT OF DISEASE
SEVERITY IN CLD-
SCORING SYSTEM
Presenter: Dr Sushil
Tamang
Moderator: Dr Sangeeta
Deka

2. TOPICS
Child-Pugh Score
MELD score
MELD score derivatives
PELD score
Prognosis according to specific causes of cirrhosis
Prognosis in different setting of non-transplant surgery, ICU and liver
transplantation
Perspectives beyond MELD scores

4. Main objectives of prognostic scores in cirrhotic patients:
 To estimate probability of death within given time interval
 To estimate reserve in terms of liver function
 To estimate capacity to stand up to surgery or other
aggressive therapeutic interventions
Address important issues:
 Help determine most appropriate therapeutic option with
respect to patient’s condition
 Whether a patient has acceptable chance of survival after a
given treatment (liver resection or arterial chemoembolization)
 Whether a resource spending therapy (such as transplantation)
is justified

5. CHILD-PUGH SCORE
Child or Child-Turcotte score: 1964
 Score 5-8: Group A
 Score 9-11: Group B
 Score 12-15: Group C

6. CHILD-PUGH SCORE
Child-Pugh score: 10 years later
Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus
for bleeding oesophageal varices. Br J Surg. 1973;60:646-9

7. CHILD-PUGH SCORE
Total range of points not distributed equally across grades A, B
and C: attempt to mirror more efficiently clinical impact of each
grade in terms of prognosis

8. CHILD-PUGH SCORE
Variables
 Variables represent prognostic markers coming from broader source
than pure assessment of liver functions
 Albumin: hepatic synthetic function, transvascular escape or
clearance (sepsis and ascites)
 Bilirubin: increased in renal insufficiency, hemolysis and sepsis
 Decreased prothrombin index related to activations of coagulation
by sepsis
 Metabolic encephalopathy precipitated by sepsis or renal
insufficiency
 C-P score: multiorgan assessment

9. CHILD-PUGH SCORE
• D'Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in
cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44:217-31.
• Wiesner R, Edwards E, Freeman R, et al. Model for end-stage liver disease (MELD) and allocation
of donor livers. Gastroenterology. 2003;124:91-6.

10. CHILD-PUGH SCORE
Validation
 Initially for evaluation of surgery for portal hypertension
(portocaval shunting and transection of esophagus)
 Multivariate analyses using C-P score: independent prognostic
value
 Ascites, ruptured esophageal varices, subclinical
encephalopathy, HCC, liver surgery, alcoholic cirrhosis,
decompensated HCV related cirrhosis, PSC, PBC, and Budd-
Chiari syndrome

11. CHILD-PUGH SCORE
Applications
 To stratify or to select patients for prognostic analyses,
retrospective assessment of non-randomly administered
therapy, RCTs
 Widely used, at the bedside, as simple descriptive or
prognostic indicator

12. CHILD-PUGH SCORE
Limitations
 Five basic components selected empirically: not all variables
have independent influence (albumin and coagulation factors
in same scoring system)
 Arbitrary use of cut-off values:
 No evidence that these cut-off values are optimal for defining
significant changes in mortality risk
 No evidence that mortality risk increases linearly across
grade A, B and C: ceiling effect

13. CHILD-PUGH SCORE
 Each variable given same weight: weight of bilirubin and INR
differs by factor 1-3 in MELD score
 Cut-off values for quantitative variable (ascites and
encephalopathy) subjective
 Important prognostic factors not taken into account
 Renal function: weight of creatinine more than twice as high
as that of bilirubin in MELD score
 Markers of portal hypertension (esophageal varices, portal
blood velocity and hepatic venous pressure gradient)

14. CHILD-PUGH SCORE
 Does not take into account cause of cirrhosis, possible
coexistence of several causal factors and persistence of
damaging process such as persistent alcohol abuse, ongoing
HBV or HCV replication or inflammatory activity of
autoimmune hepatitis

15. MELD SCORE
To address complex issues of optimal indications for
transplantation and prioritization for the allocation of liver
grafts
Originally created with aim of predicting survival after TIPS
Multivariate analysis using Cox model:
 Among a list of predetermined variables, four objective
variables had a significant and independent impact on survival:
bilirubin, creatinine, INR and cause of cirrhosis (alcoholic and
cholestatic versus others)

16. MELD SCORE

17. MELD SCORE
Logarithmic transformation of quantitative values: lessen influence of
extreme values in statistical analysis
Regression coefficient attributed to each prognostic variables as a
reflect of their proper weight on mortality
Adequately predicts mortality in hospitalized as well as ambulatory
cirrhotic patients
Generalizable to patients of various causes and severity of cirrhosis
Useful scale for assessing very short term (1 week) survival

18. MELD SCORE
Wiesner R, Edwards E, Freeman R, et al. Model for end-stage liver disease (MELD) and allocation of donor livers.
Gastroenterology. 2003;124:91-6.

19. MELD SCORE
Validation
 In contrast to C-P score, the variables of MELD score have
been selected in a given population and the score has been
thereafter validated in independent sample
 MELD is a robust risk score in patients undergoing TIPS
 MELD score tested in setting of ALF and emergency
retransplantation for early graft failure: highly questionable
since neurological status, a crucial prognostic index in this
context is not taken into account

20. MELD SCORE
Applications
 Ranking candidates for transplantation
 In contrast to its ability to evaluate pre-transplant mortality
risk in candidates for transplantation, pre-transplant MELD
score seems to be a poor predictor of post-transplantation
survival, except for extreme values (>35)

21. MELD SCORE
Limitations
 Some important variable might not have been taken into account:
multivariate analysis performed on the basis of variables which
initially were also selected empirically
 Variables like creatinine and bilirubin, though objective can be
altered by therapeutic interventions (diuretics), sepsis or hemolysis
 The choice of INR rather than other markers of coagulation including
PT and prothrombin index: not all centers use INR as marker of
coagulation in cirrhotic patients

22. MELD SCORE
 Does not take into account the cause of cirrhosis and
aggravating factors
 Need for computation: limitation to its usefulness at bedside

23. MELD SCORE DERIVATIVES: MELD-
NA
With implementation of MELD score, refractory ascites was removed
from the list of variables used for assessing prognosis
Persistent ascites and low serum sodium identified a subset of
patients with relatively low MELD scores (below 21) and a high risk of
early death

24. MELD SCORE DERIVATIVES: MELD-
NA
Serum sodium: simple, readiy available, objective marker of
disease severity
 Systemic arterial vasodilation  ADH  dilution hyponatremia
 Correlates with degree of portal HTN
Several studies have shown that hyponatremia is a strong
predictor of early mortality, independent of MELD score

25. MELD SCORE DERIVATIVES: MELD-
NA
Changes in survival pronounced for Na : 120-135 mEq/L
Within this range, a decrease in serum sodium of 1 mEq/L
corresponds to a 12% decrease in 3 month probability of
survival

26. MELD SCORE DERIVATIVES: MELD-
NA
Accuracy of MELD-Na superior to that of MELD in candidates in
transplantation
Effect of hyponatremia higher in patients with low MELD socre
compared with high MELD score

27. MELD SCORE DERIVATIVES: MELD-
NA
Limitations
 Serum sodium concentration changes due to several factors in
cirrhosis: diuretics, intravenous hypotonic fluids

28. MELD SCORE DERIVATIVES: MELD-
XI
INR: highest weight in MELD score
 INR hardly interpretable in patients receiving anticoagulation therapy: portal vein
thrombosis, Budd-Chiari syndrome
 INR artificially increased: MELD score may overestimate disease severity
MELD-XI excludes INR
Relies only on bilirubin and creatinine
Coefficients ascribed to bilirubin and creatinine changed to obtain
optimal linear correlation between MELD and MELD-XI: mortality
comparable to MELD score

29. MELD SCORE DERIVATIVES: MELD-
XI
Validation of MELD-XI score shows that its accuracy for
assessing 3-month mortality risk is comparable to that of MELD
 Validation based in population not under anticoagulation
 Patients under anticoagulation: multiple comorbidities 
further validation required

30. MELD SCORE DERIVATIVES: DELTA
MELD
Difference between current MELD and the lowest MELD measured
within 30 days prior to current MELD
Was shown to be predictive of mortality in patients with cirrhosis on
urivariate analysis
No longer predictive of mortality when entered in multivariated model
with current MELD score
Current MELD score: the only predictor of mortality

31. MODIFICATIONS OF MELD

32. PELD SCORE
For childrens <12 years of age.
PELD = 4.80[Ln serum bilirubin (mg/dL)] + 18.57[Ln INR] -
6.87[Ln albumin (g/dL)] + 4.36(<1 year old) + 6.67(growth
failure <2 SD)
Sum predicts risk of death and allows comparision between
patients.
High scores = worse outcomes.( Bourdeaux et al 2005, Barshes

33. PELD SCORE
Use
Accurate predictor of waitlist mortality.
Predicts post OLT survival.

34. PELD SCORE
Limitations
Appears less successful than MELD at predicting outcome: diverse
etiologies and wide variation in progression of pediatric liver disease
(Olthoff et al, 2004)
Underestimates severity of illness in pediatric patients (Schneider et
al)
Lack of scoring for extrahepatic manifestations of liver disease such
as HPS
Doesnot identify patients who are either too sick or too well to
undergo liver transplantation
Potential liver transplant recipients with ALF and certain other
indications such as hepatoblastoma are excluded and need to be

35. PROGNOSIS ACC. TO SPECIFIC
CAUSES OF CIRRHOSIS: ALCOHOLIC
CIRRHOSIS AND ALCOHOLIC HEPATITIS
Alcoholic hepatitis superimposed in alcoholic cirrhosis:
 Potentially reversible condition: likely to improve within the
first month following discontinuation of alcohol, may return to
compensated cirrhosis
 Severe alcoholic hepatitis: Maddrey discriminant function >32

36. PROGNOSIS ACC. TO SPECIFIC
CAUSES OF CIRRHOSIS: ALCOHOLIC
CIRRHOSIS AND ALCOHOLIC HEPATITIS
MELD score: as efficacious as or even superior to Maddrey
discriminant function

37. PROGNOSIS ACC. TO SPECIFIC
CAUSES OF CIRRHOSIS: ALCOHOLIC
CIRRHOSIS AND ALCOHOLIC HEPATITIS
Lille model
 Created on the basis of larger series of patients with alcoholic
hepatitis treated with steroids
 Includes a dynamic variable corresponding to early response
to steroids (change in bilirubin between day 0 and day 7)

38. PROGNOSIS ACC. TO SPECIFIC
CAUSES OF CIRRHOSIS: ALCOHOLIC
CIRRHOSIS AND ALCOHOLIC HEPATITIS
 More accurate than MELD and CP score and Maddrey score for
predicting six month survival
 Patients with score >0.45: 6 month mortality of 75% while
those <0.45 had mortality of only 15%

39. PROGNOSIS ACC. TO SPECIFIC
CAUSES OF CIRRHOSIS: HBV AND
HCV
Patients with decompensated HBV related cirrhosis receiving
antiviral therapy: biphasic survival pattern
 Better survival rates compared to those not receiving therapy
 Mortality rate in first 6 month of antiviral therapy: 15%
 Mortality rate after 6 months: 10 times lower
 Subgroup of patients who survive more than 6 months, 3 year
survival >85%

40. PROGNOSIS ACC. TO SPECIFIC
CAUSES OF CIRRHOSIS: HBV AND
HCV
Specific score: patients receiving lamivudine
HCV related cirrhosis: no specific model for predicting the outcome
according to viral load, genotype and response to therapy
Sustained virological response to interferon shown to improve
outcome by reducing the incidence of liver-related complications

41. PROGNOSIS ACC. TO SPECIFIC
CAUSES OF CIRRHOSIS: PBC
Aim: to determine the optimal timing for transplantation
Mayo risk score
 Probability of survival without transplantation for a risk score
of 7.8 is 63% and 39% at 1 and 2 years respectively
 Risk of post-transplant mortaliy increases significantly when
risk score exceeds 7.8: patients be referred to transplantation
centers before reaching this value

42. PROGNOSIS ACC. TO SPECIFIC
CAUSES OF CIRRHOSIS: PBC
Birmingham risk score
 Survival benefit from transplantation increases when
probability of survival without transplantation falls below 0.85
 In non-transplanted patients, this occurs on average of 8
months before death which in most cases gives sufficient time
to bridge patients to transplantation

43. PROGNOSIS ACC. TO SPECIFIC
CAUSES OF CIRRHOSIS: PBC
MELD:
 No evidence that MELD score misclassify PBC patients
 No evidence that above score are superior to MELD
 However, no discriminant value of MELD established to
specifically identify PBC patients who may benefit from
transplantation

44. PROGNOSIS ACC. TO SPECIFIC
CAUSES OF CIRRHOSIS: PSC
Mayo risk score for PSC
 More accurate that CP score for predicting survival, especially
in the patients with less-advanced disease
 Score <0: low risk
 Score 0-2: moderate risk
 Score >2: high risk
 Five year survival above 90% in low risk group and <40% in
high risk patients

45. PROGNOSIS ACC. TO SPECIFIC
CAUSES OF CIRRHOSIS: PSC
MELD:
Not been specifically assessed for PSC
Unlikely that disease severity is underestimated by MELD
However some patients with low markers of severity have repeated
episodes of cholangitis which has deleterious effect on outcome
Also bilirubin levels are fluctuating

46. PROGNOSIS IN SETTING OF
NONTRANSPLANT SURGERY
Patients with cirrhosis: high risk of surgical morbidity and
mortality
 In-hospital mortality as high as 10-20%
 High rate of post-operative decompensation
 Increased risk of bacterial infection
When non surgical alternatives exist, prognostic markers should
help determine whether the risk of surgery is justified

47. PROGNOSIS IN SETTING OF
NONTRANSPLANT SURGERY
MELD score
 1% increase in mortality risk per MELD point below a score of
20
 2% increase in mortality risk per MELD point above a score of
20
 Mortality higher for intra-abdominal surgery (up to 25%)
compared with other types of surgery

48. PROGNOSIS IN SETTING OF
NONTRANSPLANT SURGERY
Rescue transplantation in cirrhotic patients who have severe
decompensation and profound liver insufficiency after liver
resection
 Persistence of decrease in prothrombin index below 50% of
normal (INR of 1.7) and an increase in serum bilirubin above
50 micromol/L on POD 5 associated with 60% risk of early
mortality: early identification of patients needing emergency
transplantation

49. PROGNOSIS IN SETTING OF ICU
Mortality rates in patients with failure of two or three organ
systems estimated to be 75% and 95% respectively
Mortality much higher than that of noncirrhotic patients with
multi-organ failure
APACHE II and SOFA score: extensively validated in ICU settings
 Superior to liver-oriented prognostic scores

50. PROGNOSIS IN SETTING OF LIVER
TRANSPLANTATION
Sickest first policy adoped widely for organ allocation with aim
of reducing wait list mortality
MELD
 MELD score adopted in USA in 2002 as the reference scoring
system to rank patients for liver transplantation
 12% decrease in total number of new candidates listed for
transplantation
 3.5% reduction in mortality on the waiting list
 10% increase in total number of deceased donor
transplantation
 Threefold increase in number of patients listed with diagnosis
of HCC

51. PROGNOSIS IN SETTING OF LIVER
TRANSPLANTATION
 Transplant survival benefit steadily increased in increasing
MELD score
 Only patients with MELD score exceeding 15-17 derive a
significant benefit from transplantation
 Patients with lower MELD score would have higher risk of
dying from transplantation than they have of dying from
complications of cirrhosis

52. PROGNOSIS IN SETTING OF LIVER
TRANSPLANTATION
Candidates with HCC: compensated cirrhosis and low MELD score and
unlikely to be transplanted unless receiving extra points
Listed with a MELD score equivalent to a 10% (20 points) and 15% (24
points) risk of death within 3 months according to which the tumor is
classified as stage I or II
 Stage I: single nodule less than 2 cm
 Stage II: single nodule between 2 and 5 cm, or 2 or 3 nodules each less than 3 cm
If not transplanted within 3 months, receive additional MELD points
equivalent to a 10% increase in pre-transplant mortality every 3
months until transplanted or determined unsuitable for
transplantation due to excessive tumor progression

53. PROGNOSIS IN SETTING OF LIVER
TRANSPLANTATION
MELD Exceptions
February 27, 2002 allocation of livers to waitlisted transplant
candidtes based on urgency-based disease severity model: MELD
Imperfect correlation between MELD score and waitlist outcome
Some patients may be sicker than their MELD score and have
mortality equivalent to those of higher MELD score, due to multiple
complications of portal HTN, inaccurate measurement of renal
function due to a low creatinine from low muscle mass, or have
complications of liver disease requiring timely transplant that are not
captured by the MELD score
Exception points: to award increased waitlist priority

54. PROGNOSIS IN SETTING OF LIVER
TRANSPLANTATION
Standardized exceptions: sufficient data to warrant allocating
automatic exception points to patients meeting formalized exception
criteria i.e. HCC, HPS, cholagiocarcinoma, familial amyloid
polyneuropathy, cystic fibrosis, POPH
Non-standardized exceptions: conditions deemed important by
transplant team but risk of mortality not clear cut requiring review on
a case-by-case basis; regional review board within each UNOS region:
hyponatremia, refractory ascites or variceal bleeding, failure to thrive,
recurrent cholangitis

55. PERSPECTIVES BEYOND MELD
SCORES
PORTAL HYPERTENSION
Variables related to portal hypertension: size of esophageal
varices and history of GI bleed: additional information
HVPG:
 Independent predictive value in majority of available
multivariate analyses including CP sscore or its components
 Still not clear when the most predictive HVPG value should be
collected: presentation or few months of follow-up
 More informative on patients with compensated than with
decompensated cirrhosis

56. PERSPECTIVES BEYOND MELD
SCORES
 HVPG <10 mm Hg associated with 90% probability of not
developing clinical decompensation in a media follow up of 4
years

57. PERSPECTIVES BEYOND MELD
SCORES
NUTRITIONAL STATUS
Poor nutritional status: strongly associated with worsening CP
class
What remains to be clarified is the optimal index for nutrition in
terms of reproducibility, clinical availability and prognostic
performance

58. PERSPECTIVES BEYOND MELD
SCORES
GLUCOSE TOLERANCE
Multivariate analyses have shown independent negative effect
of glucose intolerance or frank diabetes

59. PERSPECTIVES BEYOND MELD
SCORES
Karnofsky Performance Status Scale
Assessment tool for functional
impairment
Used to compare effectiveness of
different therapies
Assess prognosis in individual
patients
In liver transplant
Pts with cirrhosis listed for
transplant poor performance scale
based on KPS was associted with
increased mortality( Orman et al)
Unable to objectively assess
fraility and elucidate underlying

60. THANK YOU