New system outperforms existing measures, with potential to spare medically fragile patients from intensive treatment that has no curative benefit
April 15, 2016, Barcelona, Spain: A new algorithm designed to help physician decision-making in End-Stage Liver Disease (ESLD), was able to accurately predict death in 96% of patients with ESLD. 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.
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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
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
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
About The International Liver Congress™
This annual congress is the biggest event in the EASL calendar, attracting scientific and medical experts from around the world to learn about the latest in liver research. Attending specialists present, share, debate and conclude on the latest science and research in hepatology, working to enhance the treatment and management of liver disease in clinical practice. This year, the congress is expected to attract approximately 10,000 delegates from all corners of the globe. The International Liver Congress™ takes place from April 13 – 17, 2016, at the Fira Barcelona Gran Via, Barcelona, Spain.
About EASL (www.easl.eu)
Since EASL’s foundation in 1966, this not-for-profit organisation has grown to over 4,000 members from all over the world, including many of the leading hepatologists in Europe and beyond. EASL is the leading liver association in Europe, having evolved into a major European Association with international influence, with an impressive track record in promoting research in liver disease, supporting wider education and promoting changes in European liver policy.
For more information, please contact the ILC Press Office at:
- Email: ILCpressoffice@ruderfinn.co.uk
- Telephone: +44 (0)7841 009 252
Onsite location reference
Cirrhosis (2), Hall 8.0-A1
Friday 15 April 2016, 16:00 – 18:00
Presenter: Katrine Lindvig, Denmark
Abstract: PS059, When is intensive care treatment futile in patients with organ failure and end-stage liver disease?
Author disclosures of interest
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.