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Liver_disease_prognosis by ajizai

VIEWS: 16 PAGES: 11

									To use: fill in the patient's values (light yellow boxes) and the hospital values (green boxes). Prognostic scores appear in red boxes. See also SURVIVAL and SURVIVAL_2 pages
Liver_disease_prognosis spreadsheet by R.N. Cardinal (rudolf@pobox.com), originally 20/21 Sep 2005. Current version 31 July 2007.
PATIENT DETAILS:
Name
Number
Date of birth
Age                                                                                (will be calculated, below, if you do not enter it)
Sex                                                                                          Male                        Female


INPUT VALUES (ON ADMISSION):                                                                 Meanings


Biochemistry                                                                       Enter only one:
Serum creatinine (mg/dl):                                                          } US.   [Merck] Normal <=1.2 mg/dl or <=106 micromoles/l.
Serum creatinine (umol/l or uM):                                                   } UK.   [Marshall2004] Normal 60 to 120 micromoles/l.
                                                                                   Enter only one:
Serum bilirubin (mg/dl):                                                           } US.   [Merck] Normal <=1.3 mg/dl or <=22 umol/l.
Serum bilirubin (umol/l or uM):                                                    } UK.   [Marshall2004] Normal 3 to 20 micromoles/litre.
                                                                                   Enter only one:
Blood urea nitrogen (BUN) (mg/dl):                                                 } US.   [Merck] Normal 7 to 30 mg/dl, or 2.5 to 10.7 mM
Urea (mmol/l or mM):                                                               } UK.   [Marshall2004] Normal 3.3 to 6.7 mM
                                                                                             [NB BUN is different from urea, though often written "urea"; MW 28 versus 60]
Serum albumin (g/l):
Sodium (mM)
Potassium (mM)

Haematology/coagulation
WBC (10^9/l):                                                                                [Merck] Normal 3.8 to 10.8 x 10^9/l
INR:                                                                                         [Merck] Normal 0.9 to 1.1
PT (s):                                                                                      [Merck] Normal 10.0 to 12.5 s


Clinical
Ascites (1/2/3)                                                                              Grade "absent" as 1, "slight" as 2, "moderate or severe" as 3
Ascites - clinically detectable?                                                             Yes                         No
Encephalopathy grade (0-4)                                                                   Stage 0: absent
                                                                                             Stage 1: Euphoria, depression, mild confusion, slurred speech, disordered sleep.
                                                                                             Stage 2: Lethargy, moderate confusion.
                                                                                             Stage 3: Marked confusion, incoherent speech, sleeping but arousable.
                                                                                             Stage 4: Coma, initially responsive to noxious stimuli but later unresponsive.
Has primary biliary cirrhosis?                                                               No                          Yes                                                      used for Childs-Pugh
Dialysis x2 in wk before creat. level?                                                       No                          Yes                                                      used for Childs-Pugh
Cholestatic aetiology (e.g. PBC)?                                                            No                          Yes                                                      used for old MELD
Alcoholic aetiology?                                                                         No                          Yes                                                      used for old MELD
Further transplant predictors
Transplant indication?                                                                       Non-cholestatic cirrhosis Cancer          Metabolic                    Other
                                                                                                                                                     Cholestatic cirrhosis        used by [LewseyDRAFT]
Ethnicity                                                                                    White                       Asian         Other                                      used by [LewseyDRAFT]
Ethnicity (another version)                                                                  White                       Asian         Black         Hispanic                     used by [Thuluvath2003]
Previous upper abdominal surgery?                                                            No                          Yes                                                      used by [LewseyDRAFT]
Diuretic therapy?                                                                            No                          Yes                                                      used by [LewseyDRAFT]
Lifestyle activity score?                                                                    From 1-5                                                                             used by [LewseyDRAFT]
BMI (kg/m^2)                                                                                 <15 near starvation; <20 underweight; normal 20-25 kg/m^2; >25 overweight; >30 obese; >40 morbidly obese
UNOS/Superurgent                                                                             Enter 1 for UNOS-1 (USA) = Superurgent (UK); anything else for anything else
Diagnosis category                                                                           1=PBC, PSC; 2=fulminant hepatic failure; 3=alcoholic/HCV/HBV/autoimmune/cryptogenic/A1ATdef/Wilson's/Budd-Chiari;
                                                                                             4=HHC/HCC/cholangio/other cancers/other
HOSPITAL-SPECIFIC VALUES:
PT control value (s):                                                      12.6              Addenbrooke's Nov 2005                    INR = (PT / Ptcontrolvalue) ^ (power that depends on product batch)
INR power (s) (NB batch-dependent)                                         1.27              Addenbrooke's Nov 2005                    INR calculated from PT and these values:                              ???
Transplant centre 90d mort logit intercept                                -3.21              Addenbrooke's Dec 2005                    Used to calculate 90-day mortality after transplant (see survival page)
                                                                                                                                       Encapsulates information about average patient and average mortality.
CALCULATED VALUES (do not edit directly):
Age (years):
Serum creatinine (mg/dl):
Serum creatinine (uM):
Serum bilirubin (mg/dl):
Serum bilirubin (uM):
Serum albumin (g/l):
Serum albumin (g/dl):
Blood urea nitrogen (mg/dl):
Urea (mM):
PT prolongation (s):
PT ratio:
Serum creatinine (mg/dl) for MELD:
Aetiology score for original MELD:                                             0
Aetiology score for revised MELD:                                          0.643
Transplant indication CODE:
                                                                                             Meanings of MELD, GAHS, etc.: see SURVIVAL page

MELD score:                                                                                  [UNOS] version: MELD_score = round(10 * ( 0.957 x ln(max(1, min(serum_creatinine_mg_per_dl, 4)))
(requires creatinine, bilirubin, INR)                                                                                    + 0.378 x ln(max(1, serum_bilirubin_mg_per_dl)) + 1.120 x ln(max(1, INR)) + 0.643 ))
MELD before aetiology revision:                                                              In this version, the 0.643 points are only added for non-cholestatic, non-alcoholic aetiologies.
Original MELD (=MELD before revision/10):                                                    [Malinchoc2000]
MELD as per [Sheth2002]                                                                      [Sheth2002] In this version, MELD score = 3.8*loge(total bilirubin, mg/dL) + 11.2*loge(INR) + 9.6*loge(creatinine, mg/dL)


GAHS score:
(requires age, urea, WBC, bilirubin, PT)
… age subscore:
… urea subscore:
… WBC subscore:
… bilirubin subscore:
… PT ratio subscore:


Childs-Pugh grade:                                                                           Grades A (best) to C (worst).
Childs-Pugh score:
(requires albumin, PT/INR, bilirubin, ascites rating, encephalopathy rating)
… albumin subscore:
… PT or INR subscore:                                                                        INR used in preference to PT prolongation in this spreadsheet.
… bilirubin subscore:
… ascites subscore:
… encephalopathy subscore:


Mod. discrim. f. (mDF)                                                                       [Sheth2002] Discriminant Function = 4.6* [patient's PT - control PT] + total bilirubin (mg/dL)
(requires PT, control PT, bilirubin)                                                         … which is a modified version of Maddrey's discriminant function [Maddrey1978]


UKELD score                                                                                  UKELD = 5 x {1.5 x ln(INR) + 0.3 x ln(Creat) + 0.6 x ln(Br) - 13 x ln (Na) + 70}
(requires INR, creatinine, bilirubin, sodium)                                                where INR = International normalised ratio, Creat = serum creatinine (umol/l), Br = serum bilirubin (umol/l), Na = serum sodium (mmol/l)
Information from first sheet shown below. SURVIVAL PROBABILITIES FOR CURRENT PATIENT SHOWN IN BOLD.

PATIENT DETAILS:
Name
Number
Date of birth

ORIGINAL MELD SURVIVAL FOLLOWING TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNTING (TIPS) [Malinchoc2000]

risk (original MELD) score of average pt  time (days)                             S0(t)           MELD-predicted probability of survival to time
                                    1.127             1                                   0.990        #VALUE!
                                                      7                                   0.966        #VALUE!
                                                    30                                    0.860        #VALUE!
                                                    90                                    0.707        #VALUE!
                                                   183 (6 months)                         0.621        #VALUE!
                                                   365 (1 year)                           0.551        #VALUE!
                                                   730 (2 years)                          0.428        #VALUE!

APPLICATION OF MELD TO ALCOHOLIC HEPATITIS

The MELD score was not developed for alcoholic hepatitis.
In alcoholic hepatitis, MELD>11 has 30-day survival of 45%, while MELD<=11 has survival of 96% [Sheth2002] [see Forrest2005]

                                        time (days) survival
                                                  30

GLASGOW ALCOHOLIC HEPATITIS SCORE [Forrest2005]

                                        day 1 GAHS day 28 survival                day 84 survival                        day 6-9 GAHS              day 28 survival    day 84 survival
                                                  5                        0.93         0.86                                                   5                  1           1
                                                  6                         0.9         0.79                                                   6               0.92        0.86
                                                  7                        0.87         0.81                                                   7               0.94        0.87
                                                  8                        0.82         0.73                                                   8               0.88        0.76
                                                  9                        0.63         0.56                                                   9                0.7        0.58
                                                 10                        0.33         0.31                                                  10               0.29         0.2
                                                 11                        0.31         0.19                                                  11               0.39        0.28
                                                 12                        0.17         0.17                                                  12                  0           0
                                        <9                                 0.87         0.79                             <9                                    0.93        0.86
                                        >=9                                0.46          0.4                             >=9                                   0.47        0.37

                                        so if the GAHS is from day 1…                                                    … and if the GAHS is from day 6-9:
                                                     day 28 survival              day 84 survival                                                day 28 survival day 84 survival
our patient                                                   #N/A                  #N/A                                                              #N/A         #N/A

PREDICTED SURVIVAL AFTER LIVER TRANSPLANTATION [LewseyDRAFT]
                                                                              NB odds ratio = exp(logit coefficient)
Recipient factor                                        Coefficient           odds ratio 95% CI odds ratio lower 95% CI odds ratio upper current patient
Cause of liver disease                  NB these must be in alphabetical order for the LOOKUP function
                                        Cancer                          0.19          1.21                     0.51                 3.24       #N/A
                                        Cholestatic cirrhosis           0.37          1.44                     0.86                 2.78
                                        Metabolic                         0.1         1.11                     0.32                 3.33
                                        Non-cholestatic cirrhosis          0             1
                                        Other                           0.17          1.18                     0.48                 2.46
Age                                                                     0.01          1.01                        1                1.019       #N/A
Sex                                     Male                               0             1                                                     #N/A
                                        Female                          0.17          1.18                     0.95                 1.47
Ethnicity                               Asian                           0.45          1.57                     1.06                 2.15       #N/A
                                        Other                           0.49          1.64                     1.09                 2.36
                                        White                              0             1
Previous upper abdominal surgery        No                                 0             1                                                     #N/A
                                        Yes                             0.24          1.27                     0.97                 1.59
Diuretic therapy                        No                                 0             1                                                     #N/A
                                        Yes                            -0.21          0.81                     0.63                 1.11
Lifestyle activity score                            1                      0             1                                                     #N/A
                                                    2                   0.02          1.02                     0.57                 2.34
                                                    3                   0.45          1.58                     0.88                 3.35
                                                    4                   0.36          1.43                     0.72                 3.52
                                                    5                     0.8         2.23                     1.12                 5.29
Encephalopathy grade                                0                      0             1                                                     #N/A
                                                    1                  -0.09          0.91                     0.67                 1.15
                                                    2                  -0.08          0.93                     0.54                 1.49
                                                    3                     0.7         2.01                     0.86                 4.07
                                                    4                   0.92          2.51                     1.15                 5.16
Clinically detectable ascites           No                                 0             1                                                     #N/A
                                        Yes                             0.29          1.33                     1.02                 1.75
BMI (kg/m^2)                                                           0.018        1.018                     0.999                 1.04       #N/A
INR                                                                    0.062        1.064                     0.966                1.148       #N/A
Bilirubin (uM)                                                         0.001        1.001                         1                1.001     #VALUE!
Albumin (g/l)                                                         -0.014        0.986                     0.969                1.009     #VALUE!
Creatinine (uM)                                                        0.002        1.002                         1                1.004     #VALUE!
Sodium (mM)                                                           -0.015        0.985                     0.965                1.007       #N/A
Potassium (mM)                                                         0.226        1.253                     1.028                1.498       #N/A
Interactions:
Creatinine × Cancer                                                   0.0003      1.0003                    0.991                       1.006  #N/A
Creatinine × Metabolic                                                 0.004        1.004                   0.994                       1.011  #N/A
Creatinine × Cholestatic cirr.                                        -0.003        0.997                   0.992                       1.001  #N/A
Creatinine × Others                                                    0.004        1.004                   0.999                       1.011  #N/A
                                                      higher numbers are bad (and total logit of 0 corresponds to p = 0.5)
                                                      Patient total 90d mortality log-odds                                                     #N/A
                                                      Transplant centre 90d mort. intercept logit                                                   -3.21
                                                      Total 90d mortality log-odds score                                                       #N/A
                                        So after transplant… mortality probability
                                                      90-day                              p = odds / [1+odds] = exp(logit) / [1+exp(logit)]    #N/A
                                                      90-day survival probability                                                              #N/A
                                                      Since predictors are correlated, conf. Intervals are not independent (can't just sum them).
                                                      NEED TO PUT IN STRATIFIED OBSERVED CONFIDENCE INTERVALS (Fig. 3 of Lewsey paper).
                                                      (See LewseyNotes page.)

PREDICTED SURVIVAL AFTER LIVER TRANSPLANTATION [Thuluvath2003]

                                        score (0-30)       score (0-30)           score (0-30)
                                        1month             1year                  5years

Age                                                    1                     3               4
BMI                                          #N/A                   #N/A             #N/A
UNOS listing                                 #N/A                   #N/A             #N/A
Diagnosis category                           #N/A                   #N/A             #N/A
Bilirubin                                            8                       6
Creatinine                                          10                       9      5
Race                                                                         #N/A
Total                                       #N/A             #N/A            #N/A
                                        1month        1year               5years
                                        Refer to graphs on ThuluvathNotes page for survival probabilities from these scores
SURVIVAL AFTER LIVER TRANSPLANTATION [DawwasDRAFT]

Explanation of indications for transplant
overall    n/a
ALF        Acute liver failure (ALF)
           Fulminant hepatic failure; acute hepatic necrosis (type A; type B- HBsAg+; type non A- non B; type C; type D,
            type B and C; type B and D; drug induced- paracetamol; drug (not paracetamol)/ toxin- induced; aetiology unknown; other)
CLD        chronic liver disease, not otherwise specified
PBC        Primary biliary cirrhosis
PSC        Primary sclerosing cholangitis (with Crohn’s disease; ulcerative colitis; no bowel disease or other)
           Alcoholic liver disease
ALD (alcoholic liver disease)
           Alcoholic cirrhosis; acute alcoholic hepatitis
           Autoimmune and cryptogenic cirrhosis (AID)
AID (autoimmune liver disease)
           Cirrhosis (autoimmune; cryptogenic; drug/ industrial exposure)
HCV        Hepatitis C cirrhosis (HCV)
           Cirrhosis (type C; type B and C, type non A, non B); alcoholic cirrhosis with hepatitis C
HBV        Hepatitis B cirrhosis (HBV)
           Cirrhosis (type B- HBsAg+; type B and D; type D)
cancers Primary liver malignancy (hepatocellular carcinoma (HCC)- non-cirrhotic; HCC and cirrhosis; fibrolamellar; cholangiocarcinoma;
           hepatoblastoma; hemangioendothelioma-hemangiosarcoma; other); bile duct cancer; secondary hepatic malignancy
metabolic Alpha-1-antitrypsin deficiency; Wilson's disease(acute; chronic); haemochromatosis – haemosiderosis; glycogen storage disease type I;
           glycogen storage disease type II; hyperlipidemia type II- homozgyous hypercholestrolaemia; tyrosinemia;
           primary oxalosis/oxaluria- hyperoxaluria; maple syrup urine disease; other specify
other      Cirrhosis (type A; chronic active hepatitis- aetiology unknown; fatty liver (NASH); other); secondary biliary cirrhosis (Caroli's disease;
           choledochal cyst; other); familial cholestasis (Byler's disease; other); cholestatic liver disease-other; neonatal cholestatic liver disease;
           neonatal hepatitis; biliary atresia or hypoplasia (extrahepatic; biliary hypoplasia-nonsyndromic paucity; biliary hypoplasia- Alagille’s syndrome; other);
           congenital hepatic fibrosis; cystic fibrosis; Budd-Chiari syndrome; benign tumour (hepatic adenoma; polycystic liver disease; other);
           TPN/hyperalimentation-induced liver disease; graft versus host disease; trauma); other, not already noted above; unknown

Survival
            overall
time since transplant ALF         CLD         PBC         PSC        ALD         AID        HCV         HBV         cancer     metabolic other

would need numbers that make up Fig1 of Dawwas paper to do survival curve
figure is this:
Sources:                                               Abbreviation      Full source

Normal values (UK units)                               [Marshall2004]    Marshall WJ & Bangert SK (2004) Clinical chemistry. Mosby, London.
Normal values (US units)                               [Merck]           http://www.merck.com/mrkshared/mmanual/tables/296tb2.jsp

MELD (Mayo End-stage Liver Disease) score              [UNOS]            http://www.unos.org/waitlist/includes_local/pdfs/meld_peld_calculator.pdf
MELD (Mayo End-stage Liver Disease) score                                www.medal.org
Malinchoc M et al. (2000) Hepatology 31: 864-871.      [Malinchoc2000]   http://dx.doi.org/10.1053/he.2000.5852
GAHS (Glasgow Alcoholic Hepatitis score)                                 see [Forrest2005] below

Molecular weight of creatinine (113 g/mol)                               http://www.google.co.uk/search?hl=en&q=%22molecular+weight+of+creatinine%22&meta=
Molecular weight of bilirubin (584 g/mol)                                http://www.google.co.uk/search?hl=en&q=%22molecular+weight+of+bilirubin%22&meta=
Molecular weight of urea (60 g/mol)                                      http://www.google.co.uk/search?hl=en&q=%22molecular+weight+of+urea%22&meta=
Contribution of nitrogen (BUN) to urea is 28 g/mol                       http://www.oup.co.uk/pdf/medicine/otcn3ch2_1.pdf

Sheth et al. (2002) BMC Gastro 2:2                     [Sheth2002]       http://www.biomedcentral.com/1471-230X/2/2
Forrest et al. (2005) Gut 54: 1174                     [Forrest2005]     http://dx.doi.org/10.1136/gut.2004.050781

Childs-Pugh score                                                        http://www.factsandcomparisons.com/assets/hospitalpharm/may2004_ct.pdf

Discriminant function                                  [Maddrey1978]     http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=retrieve&dopt=abstract&list_uids=352788

Liver transplant survival                              [DawwasDRAFT]     Dawwas M, Gimson A, Lewsey J, Copley L, van der Meulen J (DRAFT) Survival after liver transplantation in the United Kingdom and Ireland compared with the United States

Prediction of liver transplant survival                [LewseyDRAFT]     JD Lewsey, M Dawwas, LP Copley, A Gimson, JHP van der Meulen (DRAFT) Developing a prognostic model for mortality at 90 days after liver transplantation based on pre-transplant recipient factors

Thuluvath et al. (2003) Liver Transplantation 9: 527   [Thuluvath2003]   http://dx.doi.org/10.1053/jlts.2003.50089

Jacob et al. (2005) Transplantation 80: 52             [Jacob2005]       http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16003233&dopt=Citation

UKELD score                                                              E-mail, Kate Nash, 31 July 2007
GAHS

                                        Score
                                                1             2          3

Age                                     <50         >=50          n/a
WCC (10^9/l)                            <15         >=15          n/a
Urea (mmol/l)                           <5          >=5           n/a
PT ratio (PT:control PT for hospital)   <1.5        1.5-2.0       >2.0
Bilirubin (umol/l)                      <125        125-250       >250




[Forrest2005] In patients with serum bilirubin >80 uM and recent alcohol excess
(clinical diagnosis of alcoholic hepatitis)
and without viral hepatitis, autoimmune liver disease, or HCC
… then day 1 GAHS <9 predicts 87% survival at day 28 and 79% survival at day 84
… whereas day 1 GAHS >=9 predicts 46% survival at day 28 and 40% survival at day 84
Similar predictions from day 6-9 GAHS.
Full survival curves in [Forrest2005].
Sex, ascites, sodium, ALT, AST, AlkP were not good predictors.
Albumin and encephalopathy were also associated with 28-day mortality.
AST/ALT ratio was also associated with 84-day mortality.
MELD score:
http://www.unos.org/waitlist/includes_local/pdfs/meld_peld_calculator.pdf
                     Score
                                1          2          3

MELD_score = round(10 *
        ( 0.957 x ln(max(1, min(serum_creatinine_mg_per_dl, 4)))
        … + 0.378 x ln(max(1, serum_bilirubin_mg_per_dl))
        … + 1.120 x ln(max(1, INR))
        … + 0.643
        … ))

That is, laboratory values <1 are rounded up to 1 first. If creatinine >4, assume creatinine = 4.

Special cases: if patient has had dialysis twice in the week prior to the creatinine measurement, assume serum_creatinine_mg_per_dl = 4

ln means natural logarithm (log to the base e)

The 0.643 was originally only added for non-cholestatic, non-alcoholic causes (see below).
At the July 2001 meeting of the Liver and Intestinal Organ Transplantation Committee, the Committee agreed to add the 0.643 points for etiology to all patients in order to make the MELD score comparable to previously published data.

For use with patients >12y (for paediatrics, use PELD score).


http://www.medal.org/visitor/www%5CActive%5Cch11%5Cch11.04%5Cch11.04.11.aspx

Overview:
The Model for End-Stage Liver Disease (MELD) can be used to evaluate short term survival in an adult with end-stage liver disease. This can help stratify candidates for liver transplantation. The original authors are from the Mayo Clinic, Beth Israel Deaconess Medical Center, University of Minnesota and Rotterdam University Hospital.

Parameters:
(1) serum creatinine in mg/dL
(2) serum total bilirubin in mg/dL
(3) international normalized ratio (INR) for the prothrombin time
(4) cause of the cirrhosis (see table below)

Cause of cirrhosis                   Points
cholestatic (PBC, etc.)                       0
alcoholic                                     0
other                                         1

The parameters are measured at the time of "initial presentation".

original MELD score = (0.957 * LN (serum creatinine)) + (0.378 * LN(serum bilirubin)) + (1.12 * LN(INR)) + (0.643 * (points for cause))

probability for survival over a time interval t = S0(t) ^ (EXP((MELD) 1.127))
where 1.127 was the MELD score for the average patient (from page 867, Malinchoc et al)

time interval in days                S0(t)
         1                               0.990
         7                               0.966
        30                               0.860
        90                               0.707
       183 (6 months)                    0.621
       365 (1 year)                      0.551
       730 (2 years)                     0.428

from Table 5, page 868, Malinchoc et al (2000)

Kamath et al (2001) modified the original score by multiplying the original factors by 10:
modified MELD score = 10 * (original MELD score)

                          three-month mortality rate
modified MELD             hospitalized           ambulatory          ambulatory
                                                 noncholestatic      PBC
<=9                              4%                     2%                1%
10 to 19                       27%                   5.60%               13%
20 to 29                       76%                     50%                0%
30 to 39                       83%               NA                  NA
>=40                          100%               NA                  NA

References:
Chalasani N, Kahi C, et al. Letter to the Editor: Model for End-Stage Liver Disease (MELD) for predicting mortality in patients with acute variceal bleeding. Hepatology. 2002; 35: 1282-1284.
Kamath PS, Wiesner RH, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001; 33: 464-470.
Malinchoc M, Kamath PS, et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000; 31: 864-871.
[LewseyDRAFT]
[Thuluvath2003]

Variable                     One month                                        One year                                   Five years
                             (total score 0-30)                               (total score 0-30)                         (total score 0-30)

Age
           <60 y                              0                                                 0                                             0
           >=60                               1                                                 3                                             4
BMI
           <35 kg/m^2                           0                                               0                                             0
           >=35                                 2                                               1                                             2
UNOS listing
           other than 1                         0                                               0                                             0
           1 (superurgent)                      4                                               2                                             2
Diagnosis category
                            1                   0                                               0                                         0
                            2                   4                                               4                                         5
                            3                   2                                               3                                         5
                            4                   5                                               9                                        12
Bilirubin (mg/dl)
           <2.1                                 0          <10                                  0
           2.1-20                               4          >=10                                 6
           >20                                  8
Creatinine (mg/dl)
           <1.1                                 0          <1.1                                 0                <1.1                         0
           1.1-2.4                              5          1.1-1.6                              3                >=1.1                        5
           >2.4                                10          >1.6                                 9
Race       sorted into alphabetical order for LOOKUP function
           Asian                                                                                                                              5
           Black                                                                                                                              4
           Hispanic                                                                                                                           0
           White                                                                                                                              0




These figures are from [Thuluvath2003], copyright (C) 2003 the American Association for the Study of Liver Diseases
Childs-Pugh                       Score
                                                       1                           2                      3

serum albumin                     >3.5 mg/dl               2.8-3.5 mg/dl               <2.8 mg/dl

PT or INR                         PT <4s prolonged         PT 4-6s prolonged           PT >6s prolonged
                                  or INR<1.7               or INR 1.7-2.3              or INR >2.3

serum bilirubin                   <2 mg/dl                 2-3 mg/dl                   <3 mg/dl

ascites                           absent                   slight                      moderate/severe

encephalopathy                    absent                   moderate (stage I-II)       severe (stage III-IV)


Childs-Pugh score is then converted to a Childs-Pugh grade:

                                  Score                    Grade
                                  5 to 6                   A
                                  7 to 9                   B
                                  10 to 15                 C

Special cases:
Patients with primary biliary cirrhosis are assigned 1 point for bilirubin < 4 mg/dl, 2 points for bilirubin between 4 and 10 mg/dl, and 3 points for bilirubin > 10 mg/dl

Notes:
Stages of hepatic encephalopathy:
Stage 1: Euphoria, depression, mild confusion, slurred speech, disordered sleep.
Stage 2: Lethargy, moderate confusion.
Stage 3: Marked confusion, incoherent speech, sleeping but arousable.
Stage 4: Coma, initially responsive to noxious stimuli but later unresponsive.
[Jacob2005]

This is a clinician-reported lifestyle scale.

Functional status       Meaning
                      1 able to carry out normal activity without restriction
                      2
                      3
                      4
                      5 completely reliant on nursing and medical care

								
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