What scoring systems are used to assess the severity of cirrhosis?

Scoring Systems for Assessing Severity of Cirrhosis

The two primary scoring systems used to assess the severity of cirrhosis are the Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) score, each with distinct applications in clinical practice.

Child-Turcotte-Pugh (CTP) Score

The CTP score is a well-established and validated scoring system that includes:

• Components: 5 parameters 1, 2

  • 3 laboratory parameters: albumin, bilirubin, and prothrombin time/INR
  • 2 clinical parameters: encephalopathy and ascites

• Scoring calculation: 1

Category	1 point	2 points	3 points
Encephalopathy	None	Grade I/II	Grade III/IV
Ascites	Absent	Mild-moderate	Severe
Bilirubin (μmol/l)	<34	34-51	>51
Albumin (g/l)	>35	28-35	<28
INR	<1.3	1.3-1.5	>1.5

• Classification:

  • Class A: 5-6 points (compensated cirrhosis)
  • Class B: 7-9 points
  • Class C: 10-15 points (decompensated cirrhosis)

• Advantages:

  • Easy to perform at bedside
  • Incorporates clinical parameters
  • Well-validated for estimating liver function
  • Predicts mortality over 1-5 years 1

• Limitations:

  • Contains subjective elements (encephalopathy, ascites)
  • Limited dynamic range (e.g., bilirubin of 5 mg/dl and 15 mg/dl would both be scored identically) 1

Model for End-Stage Liver Disease (MELD) Score

The MELD score is a more objective scoring system that has become the standard for liver transplant allocation:

• Components: 3 laboratory parameters 1, 2

  • Serum bilirubin
  • Serum creatinine
  • International Normalized Ratio (INR)

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

• Mortality risk by MELD score: 2

  • 6-9: 1.9% mortality
  • 10-19: 6% mortality
  • 20-29: 19.6% mortality
  • 30-39: 52.6% mortality
  • 40+: 71.3% mortality

• Advantages:

  • Objective assessment
  • Better predictor of short-term (3-month) mortality 1, 3
  • More sensitive dynamic range than CTP 1
  • Superior for prioritizing liver transplantation 4

• Limitations:

  • Does not include clinical parameters
  • Less predictive in patients with low MELD scores
  • May not accurately reflect mortality risk in certain conditions (e.g., hepatocellular carcinoma)

Clinical Applications

When to Use Each Score

• CTP Score:

  • Best for daily clinical practice and bedside assessment 2
  • Useful for classifying severity of cirrhosis
  • Predicts long-term outcomes (1-5 years)

• MELD Score:

  • Superior for liver transplant allocation 2, 3
  • Better for predicting short-term mortality (3 months) 1
  • More objective for research purposes
  • MELD ≥15 is the threshold for liver transplant listing 2

Monitoring Recommendations

• Assess liver function with laboratory tests and calculate both CTP and MELD scores every 6 months in stable patients 5
• More frequent monitoring (every 1-3 months) if clinical deterioration occurs 2

Transplantation Considerations

• Consider liver transplantation evaluation when:
  • MELD score ≥15 2
  • Major complications of cirrhosis occur (ascites, variceal bleeding, hepatic encephalopathy) 2
  • CTP class C 5

Other Emerging Scoring Systems

• MELD-Na: Incorporates serum sodium to improve predictive accuracy
• Acute-on-Chronic Liver Failure (ACLF) scores: For patients with acute decompensation
• Hepatic venous pressure gradient (HVPG): Measures portal hypertension, which correlates with clinical outcomes 1

Clinical Pearls

• Progression from CTP class A to class B accurately measures worsening of health status and increased mortality risk 1
• Patients with MELD score >10 have higher likelihood of experiencing decompensation and liver-related clinical events 1
• The benefits of liver transplantation typically emerge when MELD exceeds 14 1, 2
• MELD score has been shown to be superior to CTP classification in predicting surgical outcomes in patients with cirrhosis 4

By understanding and appropriately applying these scoring systems, clinicians can better assess prognosis, guide treatment decisions, and determine timing for liver transplantation referral in patients with cirrhosis.