Decompensated Cirrhosis: Complications, MELD and Child-Pugh

Decompensated cirrhosis is the stage at which a scarred liver can no longer cope and complications appear: ascites, bleeding from varices, jaundice, hepatic encephalopathy, kidney failure or liver cancer. Its severity is graded with the MELD-Na and Child-Pugh scores, and once any feature of decompensation appears, the patient should be assessed for a liver transplant, the only curative treatment.

Dr. Sandeep K Jha, then Consultant Liver Transplant, Manipal Hospital, New Delhi, India, framed decompensation for referring doctors as the moment when the question changes. Before it, the work is to control the cause and watch the liver. After it, the question is whether, and how soon, the patient needs a new liver. This article covers the complications, the scores and the transplant pathway. The causes of cirrhosis and its early diagnosis are covered in the liver cirrhosis complete guide and its companion article on causes, prevention and early diagnosis.

Why cirrhosis decompensates: portal hypertension

In advanced cirrhosis the liver shrinks and becomes so hard that blood cannot flow through it. Blood returning from the intestines and spleen through the portal vein meets that resistance, and pressure in the portal system rises (portal hypertension). Dr. Jha traced the main complications to this single mechanism: fluid forms in the abdomen, the spleen enlarges and vomiting of blood can occur. At the same time, the failing liver can no longer clear toxins or make the proteins the body needs.

Not every patient with cirrhosis reaches this stage. The data Dr. Jha cited show that about 5% of patients with cirrhosis decompensate each year. Because no one can predict how long a given cirrhotic liver will last, patients are tested every six months: a deterioration in results, or new fluid in the abdomen, is the signal that the liver is failing.

The complications of decompensated cirrhosis

Ascites

Ascites is the accumulation of fluid in the abdominal cavity. It is often the first visible sign of decompensation, and the swollen abdomen is the typical picture of late cirrhosis. Dr. Jha described the first-line treatment as salt restriction, diuretic tablets and tapping of the fluid (paracentesis).

Variceal bleeding

Raised portal pressure forces blood into fragile, dilated veins in the food pipe, known as oesophageal varices. Dr. Jha showed an endoscopy image of torrential bleeding from varices. Bleeding can present as vomiting of blood or as black, tarry stools, the colour coming from blood that has passed through the gut.

Hepatic encephalopathy

When the liver can no longer clear toxins, they affect the brain. Dr. Jha listed the signs: the patient becomes confused and very drowsy, may talk nonsense, fails to recognise faces, cannot hold a conversation or becomes very irritable.

Hepatorenal syndrome

A failing liver also damages the kidneys. This is hepatorenal syndrome, and its marker is a rising serum creatinine.

Liver cancer

Patients with cirrhosis carry a very high risk of developing liver cancer (hepatocellular carcinoma). Dr. Jha showed an image of a small tumour developing inside a cirrhotic liver.

Jaundice, wasting and the physical picture

Persistent yellowing of the eyes and skin reflects the liver's failure to clear bilirubin. Dr. Jha described the typical patient with late cirrhosis as having swelling of both legs, a swollen abdomen, severe loss of muscle mass (in his words, no biceps and no triceps left) and some gynaecomastia, the enlargement of breast tissue in men. The spleen may also be very large.

Refractory ascites: the point at which only a transplant helps

Most ascites responds to salt restriction, diuretics and periodic tapping. Refractory ascites is different. Dr. Jha's working definition is fluid that returns quickly after tapping: the abdomen is drained, and within a few days to a week it fills again.

In that situation, he was clear that no other long-term treatment exists. The patient keeps losing protein in the fluid, grows progressively weaker and faces a very high risk of infection in the ascitic fluid. Such patients should be referred for a liver transplant as soon as possible. Until then, the only measures available are tapping at least twice a week and giving albumin. International guidelines (EASL 2018) also list a transjugular intrahepatic portosystemic shunt (TIPS), a stent placed through the liver to divert portal blood and lower portal pressure, as an option for selected patients with refractory ascites.

MELD-Na and Child-Pugh scores: grading decompensated cirrhosis

Two scoring systems are used to measure how severe cirrhosis is and to recommend patients for a liver transplant.

MELD-Na score

The Model for End-Stage Liver Disease (MELD) score, in its sodium-adjusted form (MELD-Na), is calculated from laboratory values: serum bilirubin, the international normalised ratio (INR, a standardised measure of clotting time), serum creatinine and serum sodium. Scores run from 6 to 40; the higher the score, the sicker the patient.

Dr. Jha gave the figures that make the score meaningful at the bedside:

• With a MELD score above 30, up to 52% of patients do not survive beyond three months.
• At a score of around 35, the chance of not surviving three months is about 50%.

Child-Pugh score

The Child-Turcotte-Pugh (CTP) score combines laboratory values with clinical findings. It scores five items: serum bilirubin, serum albumin, INR or prothrombin time, the degree of ascites and the degree of hepatic encephalopathy. Totals run from 5 to 15 and fall into three classes: A (5 to 6), B (7 to 9) and C (10 to 15).

On the chart Dr. Jha presented, a CTP score of 13 to 15 carried a three-month mortality close to 40%, a rate he described as very alarming.

Survival in decompensated cirrhosis

Once a patient has decompensated cirrhosis, one-year survival is about 75% and five-year survival is less than 50%, on the figures Dr. Jha gave. Both scores answer the same question from different directions: how much longer can this liver sustain the patient? Decompensation is therefore the point at which a decision about transplantation has to be made. The thresholds used to refer and the conditions that rule a patient out of transplant are covered in Dr. Jha's later masterclass, in liver transplant indications, contraindications and referral.

When decompensated cirrhosis needs a liver transplant

Dr. Jha's rule for referring doctors is simple: when any one of the features of decompensation appears in a patient with cirrhosis, that patient should be considered for a liver transplant. The scores then help decide how urgent the transplant is.

Two emergencies sit outside the usual course of cirrhosis and demand faster action still:

• Acute liver failure: a previously healthy liver fails suddenly. Dr. Jha listed drug-induced liver injury, paracetamol poisoning, rat poison and hepatitis A or E among the usual triggers.
• Acute-on-chronic liver failure (ACLF): a patient with existing chronic liver disease deteriorates abruptly.

Both carry very high short-term mortality. Dr. Jha noted that patients can die within 10 to 15 days, and that only a liver transplant can save them. Some patients with acute liver failure, particularly after paracetamol poisoning treated early, do recover with intensive medical care alone, so transplant listing is decided case by case.

Deceased or living donor transplant: the same outcome for the patient

There are two broad types of liver transplant.

• Deceased donor liver transplant (DDLT): organs, including the liver, heart, kidneys and lungs, are retrieved from a brain-dead donor and allocated to patients with organ failure. This model needs a large national infrastructure and is performed frequently in the United States and other developed countries.
• Living donor liver transplant (LDLT): about 60% of a healthy donor's liver is removed and transplanted into the recipient, whose failing liver is taken out. The liver regrows, so the same liver is enough for both. Because deceased donation is limited in developing countries, and is not performed much in India or across South-East Asia, living donation is the dominant model there.

Dr. Jha stressed that, for the patient, the success rate is the same with both techniques; each has its own advantages and disadvantages.

In a living donor transplant, the graft taken from the donor's liver is placed in the position of the removed liver (an orthotopic transplant), and the blood vessels are connected so that blood flows into the new liver and it begins to function. Donor safety comes first: every donor undergoes extensive evaluation, including two CT scans, an MRI and a wide range of blood tests. After surgery, the team monitors the hepatic artery, the portal vein and the hepatic veins, because the graft works only if blood flows in and out properly. The first 7 to 10 days are critical to how the patient accepts the graft. The donor work-up and the operation are covered in detail in living donor liver transplant: a complete guide and living liver donor evaluation.

Donor and recipient success rates and recovery

For the donor

Dr. Jha counsels every donor that liver donation is major surgery. Large international reviews put the risk of a donor dying at about 0.2%, roughly one donor in 500, with right-lobe donation carrying more risk than left-lobe donation. It is a rare event, and the operation has become progressively safer as experience has grown.

Recovery is quick. The donor stays in hospital for about seven days, is walking, eating and relatively pain-free by the third or fourth day, and is discharged on day six or seven. After an outpatient visit on day 10, a donor who is doing well can return to his or her home country, office work and light household work. The only restriction is on lifting heavy weights.

For the recipient

The recipient success rate is 90% to 95%. Even after a well-performed transplant, 5% to 10% of recipients do not survive, a figure that includes both surgical risk and complications after the transplant. Dr. Jha tells patients that the first 10 days of recovery are as important as the surgery itself, because the body has to adjust to the new liver in ways that cannot always be predicted.

Recovery depends on how sick the recipient was before surgery. A weak, very ill patient takes longer; a well-preserved patient recovers sooner. The recipient typically stays in hospital for about 18 days: the first discharges come around day 12 or 13, and about 95% of recipients are discharged by day 18. International patients then remain near the hospital for two to three weeks of follow-up before returning home to continue follow-up there. Complete recovery, a return to normal muscle mass and full function, takes two to three months, because the new liver has to rebuild the body.

Care after the transplant is explored in liver transplant complications from ICU care to follow-up, and indicative costs are on the liver transplant cost page. Doctors' questions on refractory ascites, donor risk and recovery are collected on the Live Discussion page.