Primary Scoring Systems in Chronic Liver Disease Management
The most important scoring systems for managing chronic liver disease (CLD) are the Model for End-Stage Liver Disease (MELD) score, Child-Turcotte-Pugh (CTP) score, and CLIF-C scores, with MELD being the primary tool for liver transplant allocation due to its superior objective measurement of mortality risk. 1, 2
Model for End-Stage Liver Disease (MELD) Score
- MELD score is calculated using three objective laboratory parameters: serum bilirubin, serum creatinine, and international normalized ratio (INR), making it a reliable predictor of 90-day mortality in patients with end-stage liver disease 1, 3
- The formula is: MELD Score = 3.8 × log(bilirubin in mg/dL) + 11.2 × log(INR) + 9.6 × log(creatinine mg/dL) + 6.4 4
- A MELD score ≥15 is generally recommended as a threshold for listing patients for liver transplantation 1
- MELD score ≥18 indicates poor prognosis in alcoholic hepatitis 4
- MELD-Na is an updated version that incorporates serum sodium to improve predictive accuracy, particularly for waiting list mortality 5, 6
Child-Turcotte-Pugh (CTP) Score
- Includes five parameters: encephalopathy, ascites, bilirubin, albumin, and prothrombin time/INR, with each parameter scored from 1-3 points 2
- Classification: Class A (5-6 points), Class B (7-9 points), and Class C (10-15 points) 2
- Prognostic value: Class A patients have approximately 90% 5-year survival, Class B approximately 80% 5-year survival, and Class C have higher mortality with more than one-third dying within 1 year 2
- Unlike MELD, CTP includes subjective clinical parameters (encephalopathy and ascites), which can limit standardization 2, 6
CLIF Consortium Scores
- CLIF-C ACLF score: Specifically developed for patients with Acute-on-Chronic Liver Failure (ACLF), combines the CLIF-C Organ Failure score with age and white cell count 4
- Studies show CLIF-C ACLF score provides more accurate information than MELD, MELD-Na, and Child-Pugh scores in predicting 28-day and 90-day mortality in ACLF patients 4
- CLIF-C AD score: Used for patients with acute decompensation of cirrhosis without ACLF, stratifies patients into risk levels for 3-month mortality 4
- High risk: CLIF-C AD score ≥60 (>30% 3-month mortality)
- Intermediate risk: CLIF-C AD score 46-59 (2-30% 3-month mortality)
- Low risk: CLIF-C AD score ≤45 (<2% 3-month mortality) 4
Alcoholic Hepatitis Specific Scores
- Maddrey Discriminant Function (MDF): Calculated as MDF = 4.6 × (Patient's PT - control PT) + total bilirubin (mg/dL) 4
- Poor prognosis indicated by MDF ≥32 4
- Glasgow Alcoholic Hepatitis Score (GAHS): Includes age, white blood cell count, blood urea nitrogen, PT ratio, and bilirubin 4
- Poor prognosis indicated by GAHS ≥8 4
Barcelona-Clinic Liver Cancer (BCLC) Staging System
- Specifically designed for hepatocellular carcinoma (HCC) patients 4
- Combines variables related to tumor stage, liver functional status, physical status, and cancer-related symptoms 4
- Links staging with treatment modalities and provides estimation of life expectancy 4
- Identifies patients who may benefit from curative therapies, palliative treatments, or those at end-stage with poor life expectancy 4
Clinical Application and Limitations
- MELD score is superior for organ allocation but may be inaccurate in predicting survival in 15-20% of cases 3, 7
- Hepatic encephalopathy is a strong independent predictor of death that is not captured in the MELD score but is included in CTP 8
- For alcoholic hepatitis, guidelines recommend using the Maddrey Discriminant Function to stratify risk, with additional serial MELD score calculations to evaluate condition over time 4
- For ACLF patients, the CLIF-C ACLF score should be used sequentially to provide prognostic information 4
- In clinical practice, a sequential approach using different scoring systems based on the specific clinical scenario is often most effective 4