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Prognosis in Decompensated Chronic Liver Failure

  • Brigid Dolan MD
  • Robert Arnold MD

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Background     In 2009, chronic liver disease and cirrhosis resulted in approximately 30,000 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. 

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://reference.medscape.com/calculator/meld-score-end-stage-liver-disease.

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 1.5-2 mg/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. Heron M. Deaths: Leading causes for 2009. National Vital Statistics Reports 2012; 61(7).
  2. D’Amico, et al. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatology. 2006; 44:217–231.
  3. Diehl A. Alcoholic and nonalcoholic steatohepatitis. In: Goldman L, Ausiello D, eds. Cecil Textbook of Medicine. 22nd ed. Philadelphia, PA: Saunders; 2004:935–6.  
  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 Pharmacol 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.  J Hepatology. 2004; 40:897-903.
  6. Cardenas, et al.  Hepatorenal Syndrome: A dreaded complication of end-stage liver disease.  Am J Gastroenterol. 2005; 100:460-467.

Version History:  Originally published September 2007.  Version re-copy-edited in May 2009; then again in July 2015.