Assessment of Prognosis of Cirrhosis

François Durand, M.D.; Dominique Valla, M.D.

Disclosures

Semin Liver Dis. 2008;28(1):110-122. 

In This Article

Prognosis in the Particular Setting of Nontransplant Surgery

Independent of liver resection for HCC, the probability is relatively high that patients with cirrhosis will require surgery (whether intra- or extra-abdominal) at some time. Unfortunately, patients with cirrhosis also represent a population at especially high risk of surgical morbidity and mortality. The most recent reports indicate that in this population, in-hospital mortality may be as high as 10 to 20%, even though it can be assumed that most patients were carefully selected.[65,66] Mortality is the consequence of a high rate of postoperative decompensation of cirrhosis (especially in cases of intra-abdominal surgery) and an increased risk of bacterial infection.

The issue of surgery and cirrhosis depends on whether there is an alternative to surgery or not. When nonsurgical alternatives exist, prognostic markers should help determine whether the risk of surgery is justified. Child-Pugh score has been used for more than two decades for addressing these issues. More recently, MELD score has also been assessed for predicting non-transplant surgical mortality.[65] The results proved relatively good. In general, there is approximately a 1% increase in mortality risk per MELD point below a score of 20. There is a 2% increase in mortality risk per MELD point over 20.[65] Mortality is higher for intra-abdominal surgery (up to 25%) compared with other types of surgery. The c statistic of the MELD score for predicting 30-day mortality was found to be 0.72 in the whole population of patients undergoing surgery and 0.8 in the subgroup with intra-abdominal surgery. However, there are no simple limits with MELD score such as Child-Pugh grades A, B, and C for estimating patients' risk. In addition, the proper risk of surgery is not balanced against the expected benefit and the existence of nonsurgical alternatives.[67] Simple algorithms based on MELD score for different types of surgery would be helpful to replace Child-Pugh score.

The issue of “rescue” transplantation in cirrhotic patients who have severe decompensation and profound liver insufficiency after liver resection is also important. Indeed, cirrhotic patients have limited liver regeneration capacity. It has been shown that the persistence of a decrease in prothrombin index below 50% of normal (INR of ∼1.7) and an increase in serum bilirubin above 50 μmol/L on postoperative day 5 is associated with a 60% risk of early mortality.[68] These criteria allow early identification of patients who may need emergency transplantation, provided there is no general contraindication.

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