How is the degree of cirrhosis determined?

Determining the Degree of Cirrhosis

The degree of cirrhosis is best determined using the Child-Pugh classification system, which stratifies patients into classes A, B, or C based on five clinical and laboratory parameters, with class A representing compensated disease and class C representing the most severe decompensated cirrhosis. 1

Child-Pugh Scoring System

The Child-Pugh score is the gold standard for assessing cirrhosis severity and incorporates both objective laboratory measurements and clinical assessments 1:

Five parameters are scored 1-3 points each:

• Hepatic encephalopathy: None (1 point), Grade I-II (2 points), Grade III-IV (3 points) 1
• Ascites: Absent (1 point), mild-moderate (2 points), severe (3 points) 1
• Bilirubin: <34 μmol/L or <2 mg/dL (1 point), 34-51 μmol/L or 2-3 mg/dL (2 points), >51 μmol/L or >3 mg/dL (3 points) 1
• Albumin: >35 g/L (1 point), 28-35 g/L (2 points), <28 g/L (3 points) 1
• INR: <1.3 (1 point), 1.3-1.5 (2 points), >1.5 (3 points) 1

Classification based on total score:

• Child-Pugh Class A: Score 5-6 (compensated cirrhosis) 1
• Child-Pugh Class B: Score 7-9 (decompensated cirrhosis) 1
• Child-Pugh Class C: Score 10-15 (severely decompensated cirrhosis) 1

Prognostic Significance

The Child-Pugh classification directly correlates with mortality risk 1:

• Class A patients: 5% mortality from variceal hemorrhage over one year 1
• Class B patients: 25% mortality from variceal hemorrhage over one year 1
• Class C patients: 50% mortality from variceal hemorrhage over one year 1

The Child-Pugh score is superior to other predictive factors in determining mortality within 30 days to 6 weeks of acute complications 1.

Alternative Scoring Systems

MELD Score

The Model for End-Stage Liver Disease (MELD) provides an objective alternative using three laboratory values 1:

• Serum bilirubin
• Serum creatinine
• INR

The MELD score ranges from 6 (less ill) to 40 (gravely ill) and is primarily used for liver transplantation prioritization 1. Advantages include objective measurements and inclusion of renal function, but it lacks clinical assessments of ascites and encephalopathy 1. It remains unclear whether MELD is superior to Child-Pugh for predicting survival in non-transplant cirrhosis patients 1.

Clinical Staging

Cirrhosis should be classified into two main prognostic stages 1:

• Compensated cirrhosis: No clinically evident complications (ascites, variceal hemorrhage, hepatic encephalopathy); median survival exceeds 12 years 1
• Decompensated cirrhosis: Presence of complications; median survival only 1.8 years 1

Within compensated cirrhosis, further substaging based on clinically significant portal hypertension (CSPH, defined as HVPG ≥10 mm Hg) provides additional prognostic information 1.

Practical Assessment Algorithm

Initial evaluation should include 1:

1. Laboratory tests: Bilirubin, albumin, INR, AST, ALT, alkaline phosphatase, platelet count, complete blood count, creatinine 1
2. Clinical assessment: Presence and severity of ascites, hepatic encephalopathy grade, signs of portal hypertension (spider angiomas, palmar erythema, splenomegaly) 1
3. Calculate Child-Pugh score to determine class A, B, or C 1
4. Consider MELD score especially if transplant evaluation is anticipated 1

Additional assessments for hepatic functional reserve 1:

• Imaging with ultrasound or MRI elastography to quantify fibrosis 1
• Evaluation for portal hypertension signs on CT/MRI (varices, splenomegaly, portosystemic shunts) 1
• Esophagogastroduodenoscopy to assess for esophageal varices 1

Common Pitfalls and Caveats

The Child-Pugh score has important limitations 1:

• Subjective interpretation of encephalopathy and ascites severity can lead to inter-observer variability
• Does not include assessment of renal function, which is an important prognostic marker 1
• Clinical parameters may be difficult to categorize in borderline cases

MELD score limitations 1:

• Not validated for predicting survival in non-transplant cirrhosis patients 1
• Serum creatinine can be unreliable in cirrhosis patients with muscle wasting 1
• Does not capture important clinical complications like hepatic encephalopathy or refractory ascites 1

Key clinical considerations:

• The Child-Pugh score should be calculated every 6 months for ongoing assessment 2
• Progression from compensated to decompensated cirrhosis can be clinically silent, requiring regular monitoring 1
• The presence of portal hypertension (HVPG ≥10 mm Hg) identifies patients at increased risk for developing varices and clinical decompensation, even before overt complications appear 1