Wednesday, September 8, 2010

Child pugh score - has drawbacks...still good.....but out of favour

CG Child
1908-1991
CTP- easily one of the most commonly heard score from medical school!
Child(in photo) & Turcotte came up with  a classification to assess the operative risk in cirrhotic patients undergoing  shunt surgery,which was modified by Pugh in 1973.It has 5 variables-  ascites, encephalopathy, PT  and serum bilirubin and albumin, classifying patients in class A, B or C. This classification was subsequently used to predict the outcome of surgery in cirrhotic patients in general, and more recently, to stratify patients on the waiting list for liver transplantation (LT). 


Drawbacks with CTP - The common problem is that,the degree of both ascites and hepatic encephalopathy are subjective assessments and so can vary widely.Also patients may be on diuretics, lactulose etc which may alter their severity( and there is no consensus on whether to grade them at their best or their worst)

Then lets take the bilirubin grading. The cut offs are arbitrary. For example...someone with a bilirubin of 4mg/dl will be in the same severity score as someone with a bilirubin of 15mg/dl. This is called 'the ceiling effect'. Albumin grading also has a similar kind of problem- someone with an albumin of 2.5mg/dl will have the same severity score as someone with a albumin of 1 mg/dl. This is called 'the floor effect'. Prothrombin time (PT) can vary between labs due to the difference in the thromboplastin agent used in each lab. So INR can overcome this problem...as it is standardised by WHO. But it should be remembered that INR was designed to standardize the anticoagulation effect of warfarin and not to evaluate the severity of liver disease. 


In spite of these drawbacks recent studies comparing CTP with MELD  has shown that both scores predict3,12 & 36 month mortality equally well in cirrhotic patients undergoing elective or emergency TIPS.
In a study(correspondence in Hepatology) comparing the two scores in predicting mortality in cirrhotic patients with acute variceal bleed,both scores predicted in-hospital and 1 year mortality without any significant difference between them. Both scores were able to predict short and medium term mortality in pts with chronic liver disease as well.


But MELD is being preferred these days because it is objective, and includes creatinine(which we all know...is an independent predictor of mortality).And importantly MELD has been found to be better at organ allocation than CTP.We can discuss about MELD at a later date!

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