FAST FACT AND CONCEPT #189: Prognosis in Decompensated Chronic Liver Failure

Authors: Brigid Dolan MD and Robert Arnold MD  

Background In 2004, liver failure resulted in over 26,000 deaths, making it the twelfth leading cause of death in the United States. Patients with compensated chronic liver failure (without ascites, variceal bleeding, encephalopathy, or jaundice) have a median survival of 12 years. After decompensation, median survival drops to ~ 2 years. This Fast Fact reviews prognosis in chronic liver failure, focusing on two validated prognostic indices. Of note, these indices predict prognosis for patients without liver transplantation.

The Child’s-Turcotte-Pugh (CTP) score includes 5 variables, each scored 1-3:

Patients are grouped into three classes based on the total CTP score, which is simply the sum of the scores for each of the 5 variables. Patients scoring 5-6 points are considered to have ‘Class A’ failure; their 1 and 2 year median survivals are 95% and 90%, respectively. A score of 7-9 is considered Class B with median survivals of 80% at 1 year and 70% at two years. Class C patients (10-15) have far greater mortality: 1-year median survival is 45% and 2-year is 38%. Variations in the timing and subjectivity inherent in the scoring of the CTP (e.g. in grading ascites or encephalopathy) are its major limitations. In addition, the scale does not include renal function, an important prognostic factor in liver failure.

The Model for End-stage Liver Disease (MELD) score was developed in 2000 to overcome the above-mentioned limitations and determine survival benefit from transjugular intrahepatic portosystemic shunting. It is currently used to help determine organ allocation for liver transplantation, and there is increasing evidence that it can also be used generally to predict survival in patients with chronic liver failure. The MELD score relies on laboratory values alone (serum creatinine, total bilirubin, and INR). An additional benefit over CTP is that it can predict prognosis on the order of months with more precision – making it helpful for determining hospice eligibility in the US. The formula to calculate MELD score is complex, and a calculator can be found at: http://www.unos.org/resources/meldPeldCalculator.asp.

 Other important prognostic variables The hepatorenal syndrome (HRS) – renal failure from renal arterial under-filling due to decompensated liver failure – portends a particularly poor prognosis. Most patients with type-1 HRS (rapid and severe renal failure) die within 8-10 weeks even with therapy. Median survival with type-2 HRS (chronic, less severe renal failure with serum creatinine usually 1.5-2mg/dL) is around 6 months. Both older age and hepatocellular carcinoma also adversely affect survival. While the CTP and MELD systems provide objective guidance to prognostication in liver failure, clinical judgment, patient comorbidities, the rate of decompensation, and the likelihood of transplantation all should additionally affect the assessment and communication of a patient’s prognosis in liver disease.

References

1. Minino et al. Deaths: Preliminary Data for 2004. National Vital Statistics Reports. June 28 2006; 54 (19) :1-52.
2. D’Amico et al. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. Journal of Hepatology. 2006; 44: 217–231.
3. Diehl, A. Cecil Textbook of Medicine. 22nd ed. Philadelphia: Saunders; 2004. Ch. 156 Cirrhosis and Its Sequelae. 937-938.
4. Cholongitas et al. Systematic review: the model for end-stage liver disease – should it replace Child-Pugh’s classification for assessing prognosis in cirrhosis? Alimentary Pharmacology & Therapeutics. 2005; 22: 1079-1089.
5. Said et al. Model for end stage liver disease score predicts mortality across a broad spectrum of liver disease. Journal of Hepatology 2004; 40:897-903.
6. Cardenas et al. Hepatorenal Syndrome: A dreaded complication of end-stage liver disease. American Journal of Gastroenterology 2005; 100:460-467.

Fast Facts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For comments/questions write to: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu.

Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Dolan B, Arnold R. Fast Fact and Concept #189. Prognosis in Decompensated Chronic Liver Failure. September 2007. End-of-Life/Palliative Education Resource Center ( www.eperc.mcw.edu).

Disclaimer: Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Purpose: Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Patient Care, Medical Knowledge

Keyword(s): Disease Categories

Specific Disease and Organ System Category(s): Gastrointestinal Diseases & Nutrition