Child-Pugh score

The score employs five clinical measures of liver disease. Each measure is scored 1-3, with 3 indicating most severe derangement. Measure Total bilirubin, mol/l (mg/dl) Serum albumin, g/l PT INR Ascites Hepatic encephalopathy 1 point <34 (<2) >35 <1.7 None None 34-50 (2-3) 28-35 1.71-2.30 Mild Grade I-II (or suppressed with medication) 2 points 3 points >50 (>3) <28 > 2.30 Moderate to Severe Grade III-IV (or refractory)

Different textbooks and publications use different measures. Some older reference works substitute PT prolongation for INR. In primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC), the bilirubin references are changed to reflect the fact that these diseases feature high conjugated bilirubin levels. The upper limit for 1 point is 68 mol/l (4 mg/dl) and the upper limit for 2 points is 170 mol/l (10 mg/dl).

Interpretation
Chronic liver disease is classified into Child-Pugh class A to C, employing the added score from above.
Points Class One year survival Two year survival 5-6 7-9 A B 100% 81% 45% 85% 57% 35%

10-15 C

Other scoring systems Although the Child-Turcotte scoring system was the first of its kind in stratifying the seriousness of end-stage liver disease, it is by no means the only one. The Model for End-Stage Liver Disease (MELD) is used increasingly to assess patients for liver transplantation, although both

scores seem to be more or less equivalent. The MELD score is perhaps a more accurate assessment of perioperative mortality in patients with hepatic dysfunction. The score is derived from a linear regression model based on serum bilirubin, creatinine levels, and the international normalized ratio (INR). It is more accurate than the Child classification in that it is objective, gives weights to each variable, and does not rely on arbitrary cut-off values. Clinicians can use a website to calculate the 7-day, 30-day, 90-day, 1-year, and 5-year surgical mortality risk on the basis of the patients age, ASA class, INR, serum bilirubin, and creatinine levels. Taken together, the Child classification and the MELD score complement each other and provide an accurate assessment of the risk of surgery in cirrhotic patients.

Model for End-Stage Liver Disease

The Model for End-Stage Liver Disease, or MELD, is a scoring system for assessing the severity of chronic liver disease. It was initially developed to predict death within three months of surgery in patients who had undergone a transjugular intrahepatic portosystemic shunt (TIPS) procedure, and was subsequently found to be useful in determining prognosis and prioritizing for receipt of a liver transplant. This score is now used by the United Network for Organ Sharing (UNOS) and Eurotransplant for prioritizing allocation of liver transplants instead of the older Child-Pugh score. MELD uses the patient's values for serum bilirubin, serum creatinine, and the international normalized ratio for prothrombin time (INR) to predict survival. It is calculated according to the following formula: MELD = 3.78[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.57[Ln serum creatinine (mg/dL)] + 6.43 UNOS has made the following modifications to the score:

If the patient has been dialyzed twice within the last 7 days, then the value for serum creatinine used should be 4.0

Any value less than one is given a value of 1 (i.e. if bilirubin is 0.8, a value of 1.0 is used) to prevent the occurrence of scores below 0 (the natural logarithm of 1 is 0, and any value below 1 would yield a negative result)

In interpreting the MELD Score in hospitalized patients, the 3 month mortality is:

40 or more 71.3% mortality 3039 52.6% mortality 2029 19.6% mortality 1019 6.0% mortality <9 1.9% mortality