Child Pugh

• Child and Turcotte First published in 1964 to assess prognosis in patient with cirrhosis, using serum albumin, bilirubin, ascites, encephalopathy and nutritional status; and constructed 3 stages: A, B and C.
• In 1972, Pugh modified the Child-Turcotte classification by changing nutrition to PT time as nutritional status was very subjective.
• Child Pugh is used to prognosticate liver cirrhosis.

MELD

• Before MELD score was developed, Malinchoc et al published in 2000 the “Mayo TIPS model”, a risk score to assess short term prognosis of liver cirrhosis patient undergoing an elective transjugular intrahepatic porto-systemic shunt (TIPS) procedure.
  • Components of the score included serum bilirubin, serum creatinine, international normalized ratio (INR) for prothrombin time, and the cause of the underlying liver disease.
• The reason MELD was developed:
  • Because survival following portosystemic shunts was found to be predominantly determined by the severity of the underlying liver disease, hepatologists and surgeons hypothesized that the same model could be used as a prognostic indicator for survival for patients with advanced chronic liver disease.
• MELD was initially terms “Mayo End-Stage Liver Disease” however to avoid association with the Mayo organization, it was changed to “Model for End-Stage Liver Disease”- thought to lead to wider acceptance.
• Kamath and colleagues found that:
  • the MELD score was highly predictive of death within 3 months in several cohorts of patients with varying degrees of liver disease severity, measured at different times, from different geographic locations;
  • inclusion of the more subjectively measured complications of portal hypertension (e.g. ascites, encephalopathy, or variceal bleeding) did not affect the accuracy of the MELD score and could be omitted from the formula and,
  • etiology of liver disease contributed very little to MELD's predictive power. These three findings together validated an entirely objective new method of assessing liver disease severity.
• Success of implementing MELD resulted in
  • Reduction in waiting list registration
  • Reduction in waiting list mortality and median waiting times
  • Increase in number of patients transplanted within 30 days

Evolution of Child-Turcotte Classification to MELD-Na score for Prognosis Assessment in Chronic Liver Disease

Refinements to MELD

• in 1976, Arroyo and colleagues found that patients with hyponatremia had significantly higher plasma concentrations of epinephrine, higher aldosterone and renin activity, significantly reduced mean arterial pressure, and elevated resistance of renal arteries when compared to patients without hyponatremia.
• Many studies including predictive models, since then have shown that when sodium levels are added to the MELD score, it becomes a better prediction of mortality.
• 2016, MELD-Na was implemented.