Severity Scoring — Child–Pugh, MELD & Frailty
"Perioperative risk in cirrhosis correlates with the degree of hepatic dysfunction. Child–Pugh and MELD both predict mortality; elective surgery is generally acceptable in Child A, cautious in Child B, and contraindicated in Child C or a high MELD until the patient is optimised or transplanted."
Synthesised from Miller's Anesthesia & Stoelting's Co-Existing Disease.Child–Turcotte–Pugh (CTP)
| Parameter | 1 point | 2 points | 3 points |
|---|---|---|---|
| Albumin (g/dL) | >3.5 | 2.8–3.5 | <2.8 |
| Bilirubin (mg/dL) | <2 | 2–3 | >3 |
| INR | <1.7 | 1.7–2.3 | >2.3 |
| Ascites | None | Mild / controlled | Moderate–severe / refractory |
| Encephalopathy | None | Grade I–II | Grade III–IV |
| Class | Score | Approx. peri-operative mortality (major/abdominal surgery) |
|---|---|---|
| A | 5–6 | ~10% |
| B | 7–9 | ~17–31% |
| C | 10–15 | ~63–82% |
Advantage: easy, familiar. Disadvantage: ascites & encephalopathy are subjective, and it does not include renal function. Mnemonic — "A BEAn": Albumin, Bilirubin, Encephalopathy, Ascites, INR.
MELD & MELD-Na
- Uses creatinine, bilirubin, INR ("C-B-I") — objective, and importantly includes renal function (the main CTP weakness). Range 6–40.
- Predicts 3-month mortality and correlates with post-operative complications: <10 low, 10–15 moderate, >15 high; ≥26 very high risk.
- 90-day mortality by MELD: <10 ≈ 2% · 10–19 ≈ 6% · 20–29 ≈ 20% · 30–39 ≈ 52% · >40 ≈ 71%.
- MELD-Na adds serum sodium (hyponatraemia = worse prognosis) — used for transplant allocation.
- CTP → 1-month mortality · MELD → 3-month mortality · MELD-Na → 1-year mortality. High-risk scores → involve the patient in shared decision-making and consider deferring elective surgery.
Frailty & sarcopenia
The Liver Frailty Index (LFI) — grip strength, timed chair-stands and balance — captures the sarcopenia that scores miss: <3.2 robust, 3.2–4.4 pre-frail, ≥4.5 frail. Higher LFI predicts wait-list mortality, longer length of stay and worse functional recovery. Look for temporal wasting and muscle loss at the bedside.