What are the scoring systems used to assess chronic liver disease (CLD) with and without alcohol use?

Scoring Systems in Chronic Liver Disease With and Without Alcohol

Universal Scoring Systems (Used for All CLD Etiologies)

For all chronic liver disease regardless of etiology, use Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease (MELD) scores as your primary prognostic tools. 1, 2

Child-Turcotte-Pugh (CTP) Score

• CTP incorporates five parameters: encephalopathy (grade 0-3), ascites (absent/mild/moderate), serum bilirubin (mg/dL), serum albumin (g/dL), and prothrombin time/INR 1, 2
• Each parameter receives 1-3 points based on severity thresholds 1
• Classification: Class A (5-6 points), Class B (7-9 points), Class C (10-15 points) 1
• Prognostic stratification: Class A patients have approximately 90% 5-year survival, while Class C patients have >33% mortality within 1 year 1
• Key advantage: Can be performed at bedside and effectively distinguishes compensated (Class A) from decompensated cirrhosis (Classes B and C) 2
• Limitation: Includes subjective clinical assessments (ascites, encephalopathy) which introduce variability 2

Model for End-Stage Liver Disease (MELD) Score

• MELD uses three objective laboratory parameters: serum bilirubin, serum creatinine, and INR 1, 2
• Formula: MELD = 3.8 × log(bilirubin mg/dL) + 11.2 × log(INR) + 9.6 × log(creatinine mg/dL) + 6.4 1, 2
• Score range: 6-40, with higher scores indicating worse prognosis 2
• MELD ≥15 is the threshold for liver transplant listing 1, 2
• Key advantage: Uses only objective laboratory values, eliminating observer variability 2
• Unique feature: Incorporates renal function (creatinine), which is an important prognostic marker absent from CTP 2
• Primary use: Superior for liver transplant allocation due to objective mortality risk assessment 1

Comparative Performance: CTP vs MELD

• Both systems share bilirubin and PT/INR as core parameters 2
• In most clinical scenarios, CTP and MELD have similar discriminative ability 3
• For patients not on transplant waiting lists, it remains unclear whether MELD is superior to CTP 2
• MELD has not been validated as a survival predictor in cirrhotic patients not on transplant lists 2

Alcohol-Specific Scoring Systems

For alcoholic hepatitis specifically, use Maddrey Discriminant Function (MDF) as your primary severity stratification tool, supplemented by MELD, Glasgow Alcoholic Hepatitis Score (GAHS), or ABIC score. 4, 5

Maddrey Discriminant Function (Modified)

• Formula: MDF = 4.6 × (Patient's PT - control PT) + total bilirubin (mg/dL) 4
• MDF ≥32 defines severe alcoholic hepatitis with 28-day mortality of 30-50% without treatment 4, 5
• MDF <32 indicates non-severe disease with <10% risk of one-month mortality 4
• This is the most widely used score in clinical practice and clinical trials 4
• Limitation: Although continuous, it functions as a categorical classifier once the threshold of 32 is exceeded 4

MELD Score in Alcoholic Hepatitis

• MELD ≥18 indicates poor prognosis in alcoholic hepatitis 4, 1
• MELD >20 identifies high risk of 90-day mortality 4, 5
• MELD ≥21 provides high sensitivity and specificity for detecting poor prognosis 4
• More useful when ascites or hepatic encephalopathy are present 4
• Combine MELD with Lille score for optimal short and medium-term mortality risk evaluation 5

Glasgow Alcoholic Hepatitis Score (GAHS)

• Incorporates five variables: age, white blood cell count, blood urea nitrogen, PT ratio, and bilirubin 4, 1
• Scoring thresholds: Age <50 vs ≥50; WCC <15 vs ≥15; Urea <5 vs 5-10 vs >10 mmol/L; PT ratio <1.5 vs 1.5-2.0 vs >2.0; Bilirubin <7.3 vs 7.3-14.6 vs >14.6 mg/dL 4
• GAHS ≥8 (or ≥9 in some studies) indicates poor prognosis 4
• Can be calculated on hospital day 1 or day 7 4
• Identifies patients with MDF ≥32 who will benefit from corticosteroids: those with GAHS ≥9 have poor prognosis without steroids and show 84-day survival benefit with treatment 4

ABIC Score

• Components: Age, serum Bilirubin, INR, and serum Creatinine 4, 1
• Stratifies patients into risk categories for mortality prediction 4
• Developed to overcome limitations of other models 4

Lille Score (Dynamic Model)

• Incorporates change in bilirubin from day 0 to day 7 along with age, albumin, creatinine, PT/INR, and bilirubin 4, 5
• Lille score ≥0.45 indicates poor response to corticosteroid therapy with high 6-month mortality 5
• Use after 7 days of corticosteroid treatment to assess response 5
• Represents a dynamic model that incorporates changes over time 4

Acute-on-Chronic Liver Failure (ACLF) Scoring

CLIF-C ACLF Score

• Specifically developed for ACLF patients 1
• Combines CLIF-C Organ Failure score with age and white cell count 1
• Provides more accurate 28-day and 90-day mortality prediction than MELD, MELD-Na, or Child-Pugh in ACLF patients 1
• Use sequentially to provide ongoing prognostic information 1

CLIF-C AD Score

• For acute decompensation of cirrhosis without ACLF 1
• Stratifies patients into risk levels for 3-month mortality 1

Clinical Algorithm for Score Selection

Step 1: Identify the clinical scenario

• Stable cirrhosis (any etiology): Use CTP and MELD 1, 2
• Acute alcoholic hepatitis: Use MDF first, then add MELD, GAHS, or ABIC 4, 5
• ACLF: Use CLIF-C ACLF score 1
• Acute decompensation without ACLF: Use CLIF-C AD score 1

Step 2: For alcoholic hepatitis severity stratification

• Calculate MDF: if ≥32, patient has severe disease requiring treatment consideration 4, 5
• Calculate MELD: if >20, patient has high 90-day mortality risk 4, 5
• If MDF ≥32, calculate GAHS: if ≥9, patient will benefit from corticosteroids 4

Step 3: For treatment response monitoring in alcoholic hepatitis

• Calculate Lille score at day 7 of corticosteroid therapy 5
• If Lille ≥0.45, discontinue steroids due to poor response 5

Step 4: For transplant evaluation

• Use MELD as primary tool for allocation 1
• MELD ≥15 is threshold for listing 1, 2
• For severe alcoholic hepatitis with MELD >26, consider early transplant referral 5

Common Pitfalls to Avoid

• Do not use MELD alone in alcoholic hepatitis without calculating MDF first - MDF remains the standard for defining severe disease 4
• Do not ignore the dynamic nature of alcoholic hepatitis - serial calculations and Lille score at day 7 are essential 5
• Do not apply MELD cutoffs from transplant literature to non-transplant cirrhosis populations - MELD has not been validated for survival prediction in non-waitlisted patients 2
• Do not rely solely on categorical thresholds - recognize that MDF >32 indicates higher risk but doesn't specify exact mortality 4
• Do not overlook renal function - MELD's inclusion of creatinine makes it superior when kidney injury is present 2
• Do not use CTP alone for transplant allocation - MELD is superior due to objective parameters 1