What clinical scores are used to assess cirrhosis severity and what do they measure?

Clinical Scoring Systems in Cirrhosis: Assessment and Prognostic Value

The most important clinical scoring systems used in cirrhosis are the Child-Turcotte-Pugh (CTP) score, Model for End-Stage Liver Disease (MELD), and Acute-on-Chronic Liver Failure (ACLF) scores, which measure liver function, predict mortality, and guide treatment decisions including transplantation eligibility.

Child-Turcotte-Pugh (CTP) Score

The CTP score is one of the oldest and most widely used scoring systems for cirrhosis assessment:

• Components: Measures 5 parameters 1:

  • Encephalopathy (grade 1-4)
  • Ascites (absent/slight/moderate)
  • Bilirubin (mg/dL)
  • Albumin (g/dL)
  • Prothrombin time/INR

• Scoring and Classification:

  • Class A: 5-6 points (90% 5-year survival)
  • Class B: 7-9 points (80% 5-year survival)
  • Class C: 10-15 points (<35% 1-year survival without transplant)

• Clinical Utility:

  • Risk stratification before procedures
  • Assessment of disease severity
  • Simple bedside calculation

• Limitations:

  • Includes subjective parameters (encephalopathy, ascites)
  • Not formally validated as a prognostic tool 1
  • Limited discrimination within classes

Model for End-Stage Liver Disease (MELD)

MELD has become the primary tool for liver transplant allocation:

• Components: Objective laboratory values 1, 2:

  • Serum bilirubin
  • Serum creatinine (capped at 4.0 mg/dL)
  • International Normalized Ratio (INR)

• Formula: MELD = 3.78 × log(bilirubin mg/dL) + 11.2 × log(INR) + 9.6 × log(creatinine mg/dL) + 6.4 2

• Mortality Risk by MELD Score 2:

  MELD Score	Mortality Risk
  6-9	1.9%
  10-19	6%
  20-29	19.6%
  30-39	52.6%
  40+	71.3%

• Clinical Utility:

  • Organ allocation for transplantation
  • Prediction of 3-month mortality
  • Objective assessment without subjective parameters
  • Transplant listing recommended at MELD ≥15 2

• Limitations:

  • Doesn't account for complications like hepatic encephalopathy
  • May not accurately represent certain conditions (HCC, metabolic disorders) 3

MELD-Na (Sodium-modified MELD)

An important modification of the original MELD score:

• Components: Adds serum sodium to the original MELD formula
• Clinical Utility: Better predicts mortality in patients with ascites and hyponatremia
• Advantage: Accounts for the prognostic significance of hyponatremia in cirrhosis

Acute-on-Chronic Liver Failure (ACLF) Scores

These newer scoring systems assess patients with acute decompensation:

CLIF-C Organ Failure (CLIF-C OF) Score

• Components: Assesses six organ systems 1:

  • Liver
  • Kidney
  • Brain
  • Coagulation
  • Circulation
  • Respiration

• Clinical Utility:

  • Diagnosis of ACLF
  • Assessment of ACLF severity
  • Prediction of 28-day mortality
  • Sequential assessment of response to intervention 1

CLIF-C ACLF Score

• Components: Combines CLIF-C OF with age and white blood cell count
• Clinical Utility: More accurate prediction of mortality in ACLF patients

NACSELD ACLF Score

• Components: Assesses four organ systems (brain, kidneys, circulation, respiration) 1
• Limitation: Underestimates mortality risk compared to CLIF-C criteria 1

Disease-Specific Scores

Maddrey Discriminant Function (mDF)

• Components: Bilirubin and prothrombin time 1
• Clinical Utility:
  • Identifies severe alcoholic hepatitis (mDF ≥32)
  • Guides corticosteroid therapy decisions

Glasgow Alcoholic Hepatitis Score (GAHS)

• Components: Age, bilirubin, blood urea, prothrombin time, and white blood cell count 1
• Clinical Utility: Identifies patients who benefit from corticosteroid treatment (GAHS ≥9)

ABIC Score

• Components: Age, bilirubin, INR, and creatinine 1
• Clinical Utility: Stratifies alcoholic hepatitis patients into low, intermediate, and high risk of death

Clinical Application and Comparative Value

• Transplant Evaluation: MELD is the primary tool for organ allocation, with a score ≥15 recommended for listing 2

• ACLF Management: CLIF-C scores are recommended for diagnosis and monitoring of ACLF 1

• Alcoholic Hepatitis: Multiple specialized scores (Maddrey DF, GAHS, ABIC) provide similar efficacy in predicting short-term survival 1

• Sequential Assessment: Regular monitoring of scores is essential as they can change over time, particularly in ACLF where sequential assessment at days 3-7 improves prognostic accuracy 1

Practical Considerations

• Timing of Assessment: Regular reassessment is crucial, especially with clinical deterioration

• Score Selection: Choose the appropriate score based on clinical context:

  • For transplant evaluation: MELD/MELD-Na
  • For ACLF: CLIF-C OF/ACLF scores
  • For alcoholic hepatitis: Maddrey DF, GAHS, or ABIC

• Limitations: No single score captures all aspects of cirrhosis; clinical judgment remains essential

• Mortality Prediction: ACLF-specific scores outperform conventional cirrhosis scores (MELD, CTP) for critically ill patients 1

The appropriate use of these scoring systems enables better risk stratification, treatment decisions, and resource allocation for patients with cirrhosis across the spectrum of disease severity.