Assess Disease Severity and Peri-op Risk Assessment

Top tips:

  1. MELD-Na, Child Pugh are key prognostic scores in cirrhosis
  2. Decompensating events (variceal bleed, ascites, etc.) place patients at higher risk of further complications and death. Decompensation should trigger consideration for liver transplantation.
  3. Patients with cholestatic liver disease (PBC, PSC) have additional models that can be used for prognostication.
Dr. Kamath cartoon

Check out the bottom of the page for short videos from Dr. Kamath!

Assessing Liver Disease Severity

D’Amico’s prognostic sub-stages
  Compensated Cirrhosis Decompensated Cirrhosis
Stage Stage 1 Stage 2
Stage 3
Stage 4
Stage 5
Definition No Varices

no other decomp. complications

Varices

no other decomp. complications

Bleeding

no other decomp. complications

Single non-bleeding decomp. complications

Two decomp. complications

1 year mortality rate 1% 3%
15%
26%
57%

More info on the Child Pugh score and the MELD Na score including prognostic limitations

Child-Pugh score

The Child-Pugh (CP) score is used as a prognostic tool in cirrhosis and is based on 2 clinical (ascites & encephalopathy) and 3 laboratory (albumin, bilirubin & INR) parameters.

  • CP A (5-6 points): mostly compensated
  • CP B patients (7-9 points) more likely to have early decompensation
  • CP C patients (10-15 points) decompensated, typically late stage
Factor 1 point 2 points 3 points
Total Bilirubin (μmol/L) <34 34-50 >50
Serum Albumin (g/L) >35 28-35 <28
PT INR <1.7 1.71-2.30 >2.30
Ascites None Controlled, on diuretics Refractory
Hepatic Encephalopathy None Controlled, on medical therapy Refractory

  Class A Class B Class C
Total Points 5-6 7-9 10-15
1 year survial 100% 80% 45%

MELD-Na Score

The MELD-Na score is a predictor of death in patients with decompensated cirrhosis and is based on one clinical (need for dialysis) and four laboratory (creatinine, bilirubin, INR, and sodium) parameters. For transplant evaluation, this has replaced the original MELD score which does not include the serum sodium. Patients with MELD-Na >15 and evidence of decompensation should be considered for liver transplantation.

MELD-Na Score 90-day Mortality
<17 <2%
17-20 3-4%
21-22 7-10%
23-26 14-15%
27-31 27-32%
≥32 65-66%

Other prognostic considerations

It is important to consider the prognostic limitations of both the Child-Pugh and MELD-Na scores. Other factors that can independently impact prognosis include (but are not limited to):

  1. Hepatocellular Carcinoma
  2. Presence of varices in compensated patients indicates higher likelihood of decompensation
  3.  Serum sodium (only captured in MELD-Na)
  4. Hepatic encephalopathy (only captured in Child-Pugh)
  5. Sarcopenia
  6. Frailty
  7. Cardiovascular disease
  8. Obesity
  9. Ongoing exposure to the etiological precipitant (i.e. obesity, alcohol use)
  10. Serum albumin level

Assessing Surgical Risk

Surgical risk assessment is “as much art as science” (see editorial by Dr. Kamath at PMID 33220099).

**Before using the algorithm below, consider standard factors associated with pre-operative risk assessment  – bleeding risk, cardiopulmonary risk, frailty as well as surgeon and patient preferences. If the patient is still deemed a possible candidate despite these considerations, then apply the algorithms. 

Introducing Dr. Kamath

Video 1 – A brief tour through prognostication in cirrhosis & practical tips that I use for surgical risk assessment in cirrhosis

Patient materials:

You can direct patients to the following:
Patient education for cirrhosis 

Stages of cirrhosis

Calculators:

Use these calculators to help with the diagnosis:

Child Pugh

MELD-Na

MELD

Downloadable content:

You can download these to print or view offline:

References:

This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.

Authors: Michelle Carbonneau NP, Dr. Patrick Kamath, Dr. Juan G. Abraldes, Dr. Puneeta Tandon

References:

  1. D’Amico G et al. Competing risks and prognostic stages of cirrhosis: a 25-year inception cohort study of 494 patients. Aliment Pharmacol Ther 2014; 39:1180-1193. PMID 24654740
  2. D’Amico G et al. Clinical states of cirrhosis and competing risks. J Hepatol 2018 Mar; 68(3):563-576 PMID 29111320
  3. Northup P.G. et al. AGA Clinical Practice Update on Surgical Risk Assessment and Perioperative Management in Cirrhosis: Expert Review. Clin Gastroenterol Hepatol 2019 Mar; 17(4):595-606 PMID 30273751
  4. Reverter E et al. The prognostic role of hepatic venous pressure gradient in cirrhotic patients undergoing elective extrahepatic surgery. J Hepatol 2019 Nov; 71(5):942-950 PMID 31330170
  5. Arroyo V et al. Acute-on-Chronic Liver Failure: Definition, Diagnosis and Clinical Characteristics. Semin Liver Dis 2016 May;36(2):109-16 PMID 27172351
  6. Bajaj JS et al. Acute-on-Chronic Liver Failure: Getting Ready for Prime Time? Hepatology 2018 Oct;68(4):1621-1632 PMID 29689120
  7. Gustot T et al. Acute-on-chronic liver failure vs traditional acute decompensation of cirrhosis. J Hepatol 2018 Dec;69(6):1384-1393 PMID 30195459
  8. D’Amico G et al. Ordinal outcomes are superior to binary outcomes for designing and evaluating clinical trials in compensated cirrhosis. Hepatology 2019 Dec PMID 31837238
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