New treatment algorithm can predict benefit of treatment in end-stage liver disease

The algorithm, presented at The International Liver CongressTM in Barcelona, Spain, is based on a combination of pre-morbid liver function and Acute-on-Chronic Liver Failure (ACLF) grade, and allows physicians to help determine patients who were likely to benefit from intensive care unit (ICU) treatment compared with those who would not.

ACLF is a relatively common syndrome and occurs in 31% of hospitalised patients with cirrhosis who have an acute complication of their liver disease.1 In these patients, ACLF is the most common cause of death.1 ACLF is distinct from severe liver damage (decompensated cirrhosis) as organ failure and mortality rates are high.1 Furthermore, patients with ALCF tend to be younger, have more scarring of the liver as a result of alcohol, and have less liver scarring as a result of Hepatitis C virus, compared to those with decompensated cirrhosis.2

"When patients are very ill, physicians must ensure that our concern for the patient should not result in the recommendation of treatment that will be of no benefit," said Dr Katrine Lindvig, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark and lead study author. "We now have well validated data that allows us to more accurately predict who is likely to benefit from treatment compared with previous measures."

Researchers collected data on 354 patients hospitalised with cirrhosis from centres in Belgium, Austria and Denmark. The new algorithm, based on commonly used scales to assess disease severity including Child-Pugh Score, Model for End-Stage Liver Disease (MELD) and the CLIF-SOFA-score, separated patients into two groups: those likely to benefit and survive ICU and those who were unlikely to benefit or survive intensive care therapy if needed.

The algorithm correctly predicted outcomes in 96% of cases and an odds ratio (a measure of association) for death of 4.7 (2.50-9.05 95% confidence interval).

"If the first duty of a physician is to do no harm, then we must continually review our decision-making tools and favour those that have the highest predictive value of treatment success and -- importantly -- treatment failure. This study adds to our knowledge of existing, well-recognised scoring systems, and provides an interesting approach for review and wider discussion by the liver community," said Professor Tom Hemming Karlsen, EASL Vice-Secretary.

Child-Pugh Score

The Child-Pugh score is a scoring system to measure the severity of chronic liver disease. The score takes into account bilirubin, INR, serum albumin (a measure of a protein made by the liver), ascites (the accumulation of fluid in the abdomen), and the presence of hepatic encephalopathy (a condition observed in patients with cirrhosis characterised by personality changes, intellectual impairment and depressed levels of consciousness). The Child-Pugh score can range from 5, for those with less severe disease, to 15, for those who are critically ill.3

MELD score

The MELD score is a reliable, numerical measure of mortality risk in patients with end-stage liver disease and helps to prioritise allocation of livers for transplant. The score ranges from 6, for those with less severe disease, to 40, for those who are critically ill. The score determines how urgently someone requires a transplant within three months and takes into consideration results from three routine lab tests, which include bilirubin (a measure of the ability of the liver to excrete bile), the International Normalised Ratio (INR) of Prothrombin Time (a measure of the liver's ability to make blood clotting factors), and creatinine (a measure of kidney function).4

CLIF-SOFA score

The Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) is a modified version of the original SOFA scoring system (used to determine success of liver transplantation) adding in additional values developed for End Stage Liver Disease.5

References

References

1 Moreau R, Arroyo V. Acute-on-chronic Liver Failure. Clin Gastroenterol Hepatol. 2015;13(5):836-841.
2 Moreau R, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013;144:1426-1437.
3 Weerakkody Y, et al. Child-Pugh score. Available from: http://radiopaedia.org/articles/child-pugh-score. Last accessed: March 2016.
4 United Network for Organ Sharing. Talking about transplantation: Questions & answers for transplant candidates about MELD and PELD. Available from: https://www.unos.org/wp-content/uploads/unos/MELD_PELD.pdf. Last accessed: March 2016.
5 Lee M, et al. CLIF-SOFA scoring system accurately predicts short-term mortality in acutely decompensated patients with alcoholic cirrhosis: a retrospective analysis. Liver Int. 2015 Jan;35(1):46-57.