📈 Dual-Staging Engine: Enter standard hepatic biomarkers to simultaneously calculate the Child-Pugh Class (for medication dosing and operative risk) and the MELD-Na Score (for 90-day mortality and transplant allocation).
1 Biomarkers (Blood Panel)
Patient has had ≥ 2 haemodialysis sessions in the past 7 days (or 24 hours of CVVH).
2 Clinical Sequelae
⚠ UNOS Dialysis Protocol Applied: Serum Creatinine has been mathematically forced to 4.0 mg/dL for the MELD-Na calculation per standard UNOS protocols for actively dialysed patients.
Child-Pugh Class
Score: Points
MELD-Na Score
UNOS Transplant Metric
Maddrey's Discriminant Function (mDF)
Identifies patients with severe alcoholic hepatitis who are at high risk for short-term mortality.
Aetiology Confirmed: Patient has a history of recent, heavy alcohol consumption.
Hepatorenal Syndrome (HRS-AKI) Criteria
ICA Criteria for the diagnosis of HRS-AKI in patients with cirrhosis and ascites.
1. Baseline Requirements
2. Exclusion of Pre-Renal Azotaemia
3. Exclusion of Intrinsic Renal Disease
Hepatic Encephalopathy (West Haven Grading)
Select the most severe clinical neurological signs observed in the patient.
Hepatopulmonary Syndrome (HPS) Diagnostics
Evaluates the classic triad: Liver disease, impaired oxygenation, and intrapulmonary vascular dilatations (IPVDs).
📚 Pathway Architecture & Clinical Pearls1. MELD-Na vs Child-Pugh Staging
The Child-Pugh score relies heavily on subjective clinical parameters (ascites and encephalopathy) and is primarily used to adjust pharmacological dosing and assess perioperative mortality risk. The MELD-Na score relies strictly on objective laboratory values and is the international gold standard used by the Organ Procurement and Transplantation Network (OPTN/UNOS) for predicting 90-day mortality and prioritising liver transplantation allocation.
2. Alcoholic Hepatitis & Corticosteroids (mDF)
Maddrey's Discriminant Function (mDF) identifies patients with severe alcoholic hepatitis who are at high risk for short-term mortality. An mDF ≥ 32 indicates a potential survival benefit from corticosteroid therapy (e.g., Prednisolone), provided there are no contraindications.
Clinical Caveat: Historically, Pentoxifylline was considered the alternative if steroids were contraindicated. However, the landmark STOPAH trial (2015) definitively demonstrated that Pentoxifylline offers no survival benefit in severe alcoholic hepatitis. Its routine use is no longer supported by robust evidence.
3. The Hepatorenal Syndrome (HRS) Dilemma
HRS is essentially a diagnosis of exclusion. The defining pathophysiological mechanism is extreme splanchnic vasodilation causing severe renal vasoconstriction. Because the kidneys themselves are structurally intact, the criteria strictly require ruling out intrinsic renal disease (via urinalysis and US) and proving that the AKI does not reverse with simple volume expansion (albumin loading). Confirmed HRS-AKI often requires treatment with splanchnic vasoconstrictors (Terlipressin or Noradrenaline) combined with IV albumin.
4. Hepatopulmonary Syndrome (HPS)
Characterised by the triad of liver disease, impaired oxygenation, and intrapulmonary vascular dilatations (IPVDs). Diagnosis relies on demonstrating a widened A-a gradient or hypoxaemia, combined with a positive contrast-enhanced echocardiogram (showing bubbles in the left atrium 3-6 cardiac cycles after right atrial opacification). Liver transplantation is the only definitive therapy.
⚠ The INR Anticoagulation Trap in Cirrhosis
An elevated INR in a cirrhotic patient represents decreased synthesis of procoagulant factors, but the liver also stops synthesising anticoagulant factors (like Protein C and S). Therefore, a high INR does not mean the patient is "auto-anticoagulated." Cirrhotic patients remain at high risk for VTE and portal vein thrombosis despite an elevated INR. Do not withhold DVT prophylaxis solely based on a high INR.
⚠ Clinical Disclaimer: These algorithms are clinical decision aids. The MELD-Na calculation strictly follows the OPTN/UNOS protocol (capping Creatinine at 4.0 mg/dL, forcing dialysed patients to 4.0 mg/dL, and enforcing a minimum value of 1.0 for Cr, Bili, and INR to prevent mathematical artifacts).
Advanced Hepatic Assessment Pathway — Clinical decision support for educational purposes. Unauthorised reproduction, redistribution, or modification of this tool is prohibited. For permissions, contact mediscuss.org/contact.
Algorithm References & Evidence Base
Pugh RN, et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973.
Organ Procurement and Transplantation Network (OPTN). Policies: MELD Score. US Department of Health and Human Services.
Maddrey WC, et al. Corticosteroid therapy of alcoholic hepatitis. Gastroenterology. 1978.
Angeli P, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. J Hepatol. 2015.
Thursz MR, et al. (STOPAH Trial). Prednisolone or pentoxifylline for alcoholic hepatitis. N Engl J Med. 2015.
