Scoring systems used to grade patients in liver disease , their impact on outcomes in liver transplant and perioperative setting. We describe the history of scoring systems in liver disease, their relevance to liver transplatation, critical care management and operating theater decisions.

1. Scoring Systems for
Liver Disease
Karthik Ponnappan T MD

2. Hippocrates - The Book of Prognostics
It appears to me a most excellent thing for the physician to
cultivate Prognosis; for by foreseeing and foretelling, in
the presence of the sick, the present, the past, and the future,
and explaining the omissions which patients have been guilty
of, he will be the more readily believed to be acquainted with
the circumstances of the sick; so that men will have
confidence to entrust themselves to such a physician. And
he will manage the cure best who has
foreseen what is to happen from the
present state of matters

3. ➔ Where we started
➔ Where we are
➔ Where do we go?

4. Who made the first scoring
system for Chronic Liver
Disease?

5. Child or Turcotte or Pugh?

6. Is Childs criteria, really Childs’??

7. Pugh’s 1973
Modification

8. Meet MELD
Impossible for patients to understand!
Do you want to have a higher or lower
score?
Tip
Tell the audience about
the problem through a
story, ideally a person.

9. 2. Why MELD?
Features
Disease etiology term dropped
Serum creatinine capped at 4.0
Lab values <1.0 set to 1.0
Lowest value 6; highest value 40 for
oran allocation

10. Applications of
MELD Score
• Organ allocation to patients listed for liver transplantation in
the United States(2002),European countries & South
America.
• MELD > 15-17 : Definitely benefit with transplant
• Reliable marker of 1-year and 5-year survival across a broad
spectrum of liver diseases including alcoholic cirrhosis and
alcoholic hepatitis

11. Applications of
MELD Score
• Good prognostic marker in
Variceal bleeding
Spontaneous bacterial peritonitis
Hepatorenal syndrome
• Independent of the cause of cirrhosis, high MELD score was
shown to be associated with a decrease in residual liver
function

12. MELD 40

13. Share 15
“Share 15” (national sharing of livers to candidates with MELD ≥ 15), candidates with
MELD scores > 15 are offered first to a patient within the local OPO and then
regionally. Finally, UNOS offers the organ to national candidates in status 1A or 1B,
national candidates with scores greater than 15, candidates with scores less than 15
locally, regionally, then nationally.

14. Share 35
“Share 35” in June 2013—candidates with MELD scores of 35 and higher within the donor's region—
offers are made within the local OPO, then regionally.
There was a 6.6% increase in the number of transplants performed for patients with MELD ≥ 35,
an increase in regional sharing by 11.4%,
no impact on overall waiting-list mortality
no overall change in posttransplant survival,
no impact on overall liver discard rate, and
similar overall import/export dynamics.

15. Liver-Intestine 29
At a MELD score ≥ 29, a combined liver/intestine offer is
extended first to recipients in local OPO, followed by a
nationwide offer.

17. MELD SCORE
DERIVATIVES
MELD-Na :
• Within 120-135 range, a decrease
in serum sodium of 1 mEq/L
corresponds to a 12% decrease in
3-month probability of survival.
Londono et al. MELD score and serum sodium in the prediction of survival of patients
with cirrhosis awaiting liver transplantation. Gut 2007

18. • MELD-Na and iMELD, are the
most accurate in predicting the
dropout rate of patients with
cirrhosis from the waiting list

19. MELD XI
A modified MELD score
termed MELD-XI (for
MELD excluding INR)
has been proposed.
This modified score
relies only on bilirubin
and creatinine.
Pts on
Anticoagulation??

20. Integrated MELD
score (i MELD)
• MELD
• serum sodium
• recipient age
Luca et al 2007 Liver Transplantation

21. Delta MELD ( MELD)

22. The United Kingdom
MELD (UKELD) score
UKELD 49 - 9% 1 yr mortality- add to
liver transplant waiting list
A UKELD score of 60 indicates a 50%
chance of one-year survival
Not so good in the ICU

23. updated MELD
(u MELD) • Assigns:
– lower weight to creatinine and INR
– higher weight to bilirubin

24. MELD-gender
• Issues with Creatinine levels
• Women at a disadvantage?
Cholongitas 2007

25. D-MELD • Arithmetic product of donor age and
preoperative MELD (DMELD) has been
proposed.
• ≥1600 -high-risk donor–recipient
matches
• Never in practice
Halldorson et al. D-MELD, a simple predictor of post
liver transplant mortality for optimization of
donor/recipient matching. Am J Transplant 2009

26. Donor risk index (DRI)
• ranges from approximately 0.5 to 3.0
• 3-year graft survival rates:
– 81% for organs with a DRI of less than 1.0
– 60% for organs with a DRI of greater than 2.0
• complex!!
• Only as a clinical decision-making tool.
Feng S, Goodrich NP, Bragg-Gresham JL, et al. Characteristics associated with liver graft failure: the concept of a
donor risk index. Am J Transplant 2006;6:783-790.

27. What about these scoring
systems in the ICU?
In ICU, the liver scores have little influence
because many other organ systems play are role in
death or survival. Well-rounded models (SOFA,
APACHE) are better at predicting ICU outcomes
than liver-specific scoring systems
(Levesque et al, 2012)

28. What about these
scoring systems in the
Perioperative setting?
In Surgical patients, CTP score is most
popular and fairly reliable. MELD is as
good as CTP. SOFA is better in icu
setting. Region specific systems are
needed.
(Pandey et al, 2014)

29. CTP remains relevant!- with some help

30. Lactate and Ascites were associated
with Mortality

31. CTP - not of value in ICU
● subjective assessments (ascites and encephalopathy)
● Clinical ascites vs US vs CT evidence of ascites
● Ascites and encephalopathy respond to treatment → use best or
worst numbers.?
● cut-off values are entirely arbitrary
● cut-offs have a certain “ceiling effect”
● completely ignores other influences - kidney/heart

32. MELD- equally bad in
the ICU!!
ACLF- CTP > MELD
ICU MELD > CTP
Surgery,CTP> MELD .

33. ➔Quick SOFA-
works
➔ in Cirrhosis-IF NO
INFECTION!!

34. AKI - CLIF - SOFA
New Friends?

35. AKI - CLIF - SOFA

36. Still no winner- no foolproof scoring!!
Still no winner- no
foolproof scoring!!
- Schmidt LE - Blood LACTATE as a prognostic marker in
acetaminophen-induced acute liver failure. Hepatology
2003.
- Canbay OVERWEIGHT patients are more susceptible for
acute liver failure. Hepatogastroenterology 2005
- Rutherford A Influence of high BODY MASS INDEX on
outcome in acute liver failure. Clin Gastroenterol Hepatol
2006
- e23. Samuel D Prognosis indicator in acute liver failure: Is
there a place for CELL DEATH MARKERS? J Hepatol 2010;

37. HE Grade!!

38. M65 MELD
DID
BETTER!!

39. Take Home
:
➔ Milestones
Child Turcotte→ Sophisticated Statistics→ Back to Child’s with modification
MELD- SOFA- CLIF- APACHE- Anything with Lactate:)
➔ What’s next?
More superhuman statistics- A return to the past - with objective markers of
Ascites and HE
➔ The future- Cell Death Markers- issues of Cost benefit!!

40. What should we do
Figure out a
better scoring
system-
better
statistician?:)
Use CTP- still a
good marker
MELD- NAALF
KCH- AALF
SOFA, APACHE
Don’t forget
Lactate!!

41. Calculate all the scores for
all the ICU patients-- Its
free -- ( tests are done
anyways)

42. Build institutional outcome
model- Use for prognosis
and end of life discussions!!

43. “The best
physician is
one who could
prevent and
predict”