Available online 11 September 2023, 101867

Author links open overlay panel, Abstract

Alcohol-associated liver disease (ALD) and alcohol-associated hepatitis (AH) are dynamic disorders whose prognosis can be challenging to determine. A number of prognostic models have been developed to determine likelihood of death, when to refer for liver transplant (LT) and the role for glucocorticoids. Often these models were created with a specific application in mind but were found to have additional applications with further study. Those prognostic models that have stood the test of time are easy to use, have clear interpretations and employ objective parameters. These parameters most often include total bilirubin, INR and creatinine among other data points. Ideally, these models could be utilized at all phases of disease but in most, it is important for clinicians to consider drinking history and how it might alter the determined scores. Herein we provide a brief review of prognostic models in ALD and AH and provide practical tips and considerations to successfully make use of these tools in a clinical setting.

Section snippetsBuilding the perfect prognostic model

The key elements of the perfect prognostic model are shown in Table 1. For many of the prognostic models in use in alcohol-related liver disease (ALD) and alcohol-related hepatitis (AH), the instruments may apply equally to many liver diseases rather than applying exclusively to alcohol-related diseases. For example, the tools used to predict the likelihood of death, or determine whether a patient warrants referral to a liver transplant center are often not specific to a single form of liver

Child-Turcotte-Pugh (CPT) score

This is the ‘grandaddy’ of the liver prognostic models, first introduced by Drs. Turcotte and Child of the University of Michigan as a gradation of three classes of risk of dying from portal decompressive surgery in patients with portal hypertension and cirrhosis. The model was converted into a points score by Pugh to make it easier to use. In order to reduce subjectivity and improve consistency, Pugh substituted prothrombin time for nutritional status (Table 2) [1]. The strength of the CPT

Assessment of prognosis in AH

There are four static composite scoring systems for assessing prognosis in AH and determining if patients are good candidates for glucocorticoids [5]. As shown in Table 2, they share many common elements. All scoring systems need to be used in the appropriate clinical context, and indeed in patients with AH in whom the total bilirubin is falling with standard nursing care, it may be advantageous to delay starting corticosteroids irrespective of the static prognostic score [13]. Maddrey's

Practice points•

Key elements for prognostic models in ALD include: clear prognostic end-points, objective parameters, ease of use and accuracy at all phases of disease.

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It is essential to consider the influence of a patient's drinking history in any prognostic model for alcohol-associated liver disease.

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There is considerable overlap between scoring systems for AH and the most common elements include total bilirubin, INR and creatinine.

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The MELD score has been validated to predict mortality across a wide spectrum

Research agenda•

The ideal MELD threshold to start steroids for AH should be elucidated in prospective studies.

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Additional studies on “re-compensation” are needed.

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Objective scoring systems to predict the prognosis of AUD after LT would be highly valuable in the LT evaluation process.

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The Standard Integrated Psychosocial Assessment for Transplantation (SIPAT) score needs confirmation of accuracy in a large prospective cohort.

Declaration of competing interest

The authors declare that they have no personal relationships or financial interests which may be considered as potential competing interests.

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D.W. Crabb et al.Diagnosis and treatment of alcohol-related liver diseases: 2019 practice guidance from the American association for the study of liver diseases

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Published by Elsevier Ltd.