historical patients with cirrhosis from the 1980s.patients with primary biliary cirrhosis (PBC).outpatients with non-cholestatic cirrhosis.hospitalized patients with decompensated cirrhosis.The group tested the model in four different patient populations: In 2001, a consortium of investigators studied the generalizability of the MELD to predict survival in patients with a broader range of disease severity and etiology. *Internal normalized ratio for prothrombin time. The predicted probability of death within 3 months of placement of TIPS is read off this scale. The point on the middle scale is connected to creatinine and the line extended to the predicted probability scale. Connect the bilirubin to the INR and extend the line to the middle scale. To use the nomogram the actual values of bilirubin (mg/dL), INR for prothrombin time, and creatinine (mg/dL) are plotted. The authors of this study developed a nomogram that could be used to predict the likelihood of dying within 3 months after placement of TIPS and all you need is a ruler to measure it!Ĭaption from original Malinchoc et al paper: "Nomogram for predicting the probability of death within 3 months of placement of TIPS stent for patients with cirrhosis due to alcoholic or cholestatic liver disease. In the original study conducted in 2000, assessing the performance of the model, MELD was better able to predict survival compared to the Child-Pugh classification in 231 patients undergoing TIPS for prevention of variceal rebleeding or for refractory ascites. The MELD model was originally developed to assess short-term prognosis of patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS) procedures. a patient with a bilirubin of 4 mg/dL is assigned the same number of points as a patient with a bilirubin of 15 mg/dL!)Ĭlearly, we needed a better system to prioritize patients on the liver transplant waiting list.
Not all were equal! A patient with a variceal bleed and a bilirubin of 30 could share this status with a patient with refractory ascites subjective interpretation of ascites and encephalopathyBecause of this, the system was often gamed for status 2A patients.Though this was the best predictive model that existed at the time, it had several limitations including: Status 2A: Patients deemed “at risk of dying within seven days”: But this is subjective and not based on validated criteria!.Using these classifications, in the past, UNOS defined three categories of disease severity for listing: Similarly, with hepatic encephalopathy, treatment with lactulose +/- rifaximin could bring a score from 3 to 1.Īccording to this classification system, one-year survival rates for patients within each category are as follows: For ascites, for example, a patient may present with moderate-severe ascites and get a score of 3, but once Lasix and spironolactone are started, the score may decrease to 2 or even 1. Note, that using this classification, scores for ascites and encephalopathy could be dramatically different depending on whether a patient is adequately controlled on treatment. More to come on this in Part 2….Įach of these variables is then assigned a numerical score and by adding the numerical scores of the individual components, Child-Pugh Class is calculated! These elements are likely very important in predicting survival but are not captured in the current Child-Pugh and MELD scores. Today, the field of frailty/disability/performance status research is HOT. **Maybe the Child-Turcotte score was on to something with inclusion of nutritional status. In 1972, the score was revised by Pugh to exclude nutritional status** (see footnote below) and to add prothrombin time. George Wantz from Cornell University Medical College were the first to describe a predictive model that very closely resembles the one we give Child and Turcotte credit for! Check out thisNEJM article published in 1961, three years before Child and Turcotte.
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