What is the significance of the Madrey (Model for End-Stage Liver Disease) score in assessing alcoholic hepatitis and guiding treatment?

The Significance of the Maddrey Score in Alcoholic Hepatitis

The Maddrey Discriminant Function (MDF) score is a critical prognostic tool for identifying severe alcoholic hepatitis, with scores ≥32 indicating high mortality risk (30-50% at 1 month) and serving as the primary threshold for initiating corticosteroid treatment. 1

Understanding the Maddrey Score

Calculation and Interpretation

• Formula: MDF = 4.6 × (Patient's PT - control PT in seconds) + total bilirubin (mg/dL) 1
• Traditional severity threshold: ≥32 indicates severe alcoholic hepatitis 1
• Mortality risk:
  • MDF ≥32: 30-50% mortality at 1 month 1
  • MDF <32 but symptomatic: Still carries ~10% mortality at 6 months and ~20% at 1 year 1

Clinical Application

• Primary use: Identifying patients who would benefit from corticosteroid therapy 1
• Terminology evolution: Patients with MDF <32 should no longer be called "non-severe" but rather "moderate" alcoholic hepatitis due to significant mortality risk 1
• Treatment threshold: Corticosteroid treatment must be offered when MDF ≥32 1

Comparison with Other Scoring Systems

MELD Score

• Alternative prognostic model with comparable accuracy to MDF 2
• Formula: MELD = 3.8 × log(bilirubin in mg/dL) + 11.2 × log(INR) + 9.6 × log(creatinine mg/dL) + 6.4 1
• Threshold: MELD ≥21 has sensitivity and specificity of 75% for predicting 90-day mortality 2
• Advantages: May be more useful in patients with ascites or hepatic encephalopathy 1

Other Scoring Systems

• Glasgow Alcoholic Hepatitis Score (GAHS): Useful for identifying subgroups of patients who may benefit from steroids among those with MDF ≥32 1
• ABIC (Age, Bilirubin, INR, Creatinine) Score: Categorizes patients into low, intermediate, and high risk of death 3
• Lille Score: Used after 7 days of corticosteroid therapy to identify non-responders (score ≥0.45) 1

Prognostic Value and Treatment Decisions

Treatment Algorithm Based on Maddrey Score

1. Calculate MDF score at presentation
2. If MDF ≥32: Initiate corticosteroid therapy (after screening for infections) 1, 3
3. Calculate Lille score after 7 days of treatment
4. If Lille score ≥0.45: Patient is a non-responder with poor prognosis
5. If Lille score ≥0.56: Stop corticosteroids (null responder) 1

Combined Prognostic Models

• Combining static scores (MDF, MELD) with dynamic scores (Lille) improves prognostic accuracy 4
• MELD+Lille combination provides better prediction than either score alone 4

Clinical Pitfalls and Caveats

• Important limitation: MDF is a prognostic score, not a diagnostic score 1
• Common misinterpretation: Assuming MDF <32 means "non-severe" disease (still carries ~20% 1-year mortality) 1
• Practical challenge: Requires control prothrombin time, which may vary between laboratories
• Clinical context: Should be used alongside other clinical parameters, not in isolation
• Response assessment: Must be combined with Lille score after 7 days to determine treatment continuation 1

Recent Developments

• Terminology change: The French Association for the Study of the Liver recommends using "moderate" for MDF <32 and "severe" for MDF ≥32 in symptomatic alcoholic hepatitis 1
• Early Lille score calculation: Some evidence suggests Lille score could be calculated at day 4 with similar prognostic performance as day 7 (requires further validation) 1
• Combined models: Integration of static and dynamic scoring systems may provide more accurate prognostication 4

The Maddrey score remains a cornerstone in the assessment and management of alcoholic hepatitis, guiding critical treatment decisions and helping predict patient outcomes.