What are the treatment recommendations for a patient with acute alcoholic hepatitis, a discriminant function score of 34.5, and a Model for End-Stage Liver Disease (MELD) score of 22?

Management of Acute Alcoholic Hepatitis with mDF 34.5 and MELD 22

This patient has severe alcoholic hepatitis requiring immediate corticosteroid therapy with prednisolone 40 mg daily for 28 days, combined with aggressive nutritional support and infection screening. 1, 2

Disease Severity Classification

Your patient clearly meets criteria for severe alcoholic hepatitis by both scoring systems:

• Maddrey Discriminant Function (mDF) of 34.5 exceeds the threshold of ≥32 that defines severe disease with 30-50% mortality risk at 28 days 1, 3
• MELD score of 22 exceeds the threshold of >20-21 that indicates severe disease with high 90-day mortality 1, 4

Both the American Association for the Study of Liver Diseases and European Association for the Study of the Liver recommend using these thresholds to identify patients requiring immediate pharmacologic intervention. 1, 3

Pre-Treatment Assessment

Before initiating corticosteroids, you must complete the following screening:

• Infection screening: Obtain blood cultures, urine cultures, chest x-ray, and ascites cultures (if ascites present) regardless of whether fever is present 1, 2, 3
• Abdominal ultrasound to exclude other causes of jaundice and assess for complications 1
• Screen for contraindications: Active uncontrolled infection, serum creatinine >2.5 mg/dL, uncontrolled GI bleeding, concomitant HBV/HCV/HIV, hepatocellular carcinoma, acute pancreatitis, multiorgan failure 1

The American Association for the Study of Liver Diseases emphasizes that extensive bacteriological examination must be performed before initiating corticosteroid therapy due to infection risk. 2

Primary Pharmacologic Treatment

Prednisolone 40 mg daily orally for 28 days is the standard first-line therapy. 1, 2 This regimen improves 28-day survival from 65% in untreated patients to 80% in treated patients. 5

Consider adding N-acetylcysteine intravenously in combination with prednisolone, as one study demonstrated improved short-term survival at 1 and 3 months, with decreased risk of hepatorenal syndrome and infections. 3, 6

Response Assessment at Day 7

Calculate the Lille score on day 7 of treatment to identify responders versus non-responders:

• Lille score <0.45: Continue prednisolone for full 28-day course 1, 2
• Lille score ≥0.45: Non-responder with high 6-month mortality (approximately 75%) 1, 2
• Lille score ≥0.56: Null responder—discontinue corticosteroids 2, 6

The European Association for the Study of the Liver and American Association for the Study of Liver Diseases both emphasize that the Lille score is critical for identifying treatment failures early and preventing detrimental effects of prolonged corticosteroid exposure. 1, 2

Nutritional Support

Provide enteral nutrition with goal of >21 kcal/kg daily (some guidelines recommend 30-40 kcal/kg) with 1-1.5 g protein/kg body weight. 1, 3 If the patient cannot eat due to anorexia or altered mental status, place a nasogastric tube for enteral feeding. 3 Parenteral nutrition alone is inadequate. 3

Supplement with B vitamins (especially thiamine), folic acid, and vitamins C and E. 3, 6

Alternative Treatment Options

If contraindications to corticosteroids exist (particularly active infection or hepatorenal syndrome), pentoxifylline 400 mg orally three times daily for 4 weeks can be considered as it reduces hepatorenal syndrome occurrence. 2, 6, 7

However, the evidence for pentoxifylline is weaker than for corticosteroids in terms of survival benefit. 6

Liver Transplantation Consideration

With a MELD of 22, this patient should be referred for early liver transplantation evaluation if they have good insight into their alcohol use disorder and strong social support. 3, 8 The American Association for the Study of Liver Diseases recommends considering transplant referral particularly for patients with MELD >26, but your patient's score of 22 still warrants discussion, especially if they fail to respond to corticosteroids (Lille ≥0.45). 3

Recent evidence demonstrates that carefully selected patients with severe alcoholic hepatitis who fail medical therapy achieve 6-month survival rates of 77-100% with early liver transplantation, comparable to transplantation for other indications. 8

Critical Management Points

• Avoid nephrotoxic agents: No NSAIDs, aminoglycosides, or iodinated contrast, as acute kidney injury predicts multi-organ failure 1, 3
• Cautious diuretic use: AKI is an early manifestation of multi-organ failure in this population 1, 3
• Immediate alcohol abstinence counseling: Long-term abstinence improves 5-year survival to 80% versus 50% with relapse 3, 5
• Monitor for infections closely during corticosteroid therapy 2, 3

Prognostic Context

Even with optimal treatment, your patient faces significant mortality risk. The Korean Association for the Study of the Liver notes that combining MELD and Lille scores provides optimal risk stratification—a patient with MELD 21 and Lille 0.45 has 1.9-fold higher risk of death at 2 months compared to MELD 21 with Lille 0.16 (23.7% versus 12.5% mortality). 1

The Glasgow Alcoholic Hepatitis Score may provide additional prognostic information, as patients with mDF ≥32 but GAHS <9 gain no survival benefit from steroids, while those with GAHS ≥9 have poor prognosis without treatment. 1 Consider calculating GAHS for additional risk stratification.