Prognosis in advanced liver disease has been widely studied to assess readiness for liver transplantation. Clinical symptoms and signs and laboratory values contained within the Child-Turcotte classification as modified by Pugh, not included here, have been shown to correlate significantly with early mortality. Some of these variables, with the addition of other clinical syndromes associated with mortality, are shown below.
Although accurate, albeit complex, prognostic indices based on multivariate analyses have been developed, they are still controversial. They are not recommended here since:
1. All the required elements may not be available to hospice programs at the time of referral.
2. The computing power needed to calculate these scores may not be available to many hospice admissions staff.
3. Nearly every study on prognosis in advanced liver disease has been done outside the US, and World Health Organization data reveals that patterns of death from liver disease, as well as risk factors such as alcoholism and hepatitis B, can differ widely among countries.
The following factors have been shown to correlate with poor short-term survival in advanced cirrhosis of the liver due to alcoholism, hepatitis, or uncertain causes (cryptogenic). Their effects are additive; i.e. prognosis worsens with the addition of each one. Clinical judgment is vital.
The following factors should be followed and reviewed over time.
Patients should have end-stage cirrhosis; those who are newly decompensated, i.e. in their first hospitalization, may improve dramatically with treatment compared to those who are in the terminal phase of a chronic process.
The patient should not be a candidate for liver transplantation.
I. Laboratory indicators of severely impaired liver function
Patients with this degree of impairment have a poor prognosis. The patient should show both of the following:
. Prothrombin time prolonged more than 5 sec. over control.
. Serum albumin < 2.5 gm/dl.
II. Clinical indicators of end-stage liver disease
The patient should show at least one of the following:
. Ascites, refractory to sodium restriction and diuretics, or patient non-compliant.
. Maximal diuretics generally used: Spironolactone 75-150 mg/day plus furosemide >40 mg/day.118
. a. Spontaneous bacterial peritonitis.
. Median survival 30% at one year; high mortality even when infection cured initially if liver disease is severe or accompanied by renal disease.
. a. Hepatorenal syndrome.
. In patient with cirrhosis and ascites, elevated creatinine and BUN with oliguria (400 ml/da) and urine sodium concentration <10 mEq/l.
. Usually occurs during hospitalization; survival generally days to weeks.
. Hepatic encephalopathy, refractory to protein restriction and lactulose or neomycin, or patient non-compliant.
. Manifested by: decreased awareness of environment, sleep disturbance, depression, emotional lability, somnolence, slurred speech, obtundation.
. Physical exam may show flapping tremor of asterixis, although this finding may be absent in later stages.
. Stupor and coma are extremely late-stage findings.
. a. Recurrent variceal bleeding.
. Following initial variceal hemorrhage, one third died in hospital, one third rebled within six weeks; two thirds survived less than 12 months.
. Patient should have rebled despite therapy, or refused further therapy, which currently includes:
. a. Injection sclerotherapy or band ligation, if available.
. b. Oral beta blockers.
. c. Transjugular intrahepatic portosystemic shunt (TIPS).
III. The following factors have been shown to worsen prognosis and should be documented if present
. Progressive malnutrition
. Muscle wasting with reduced strength and endurance.
. Continued active alcoholism, i.e. > 80 g ethanol per day
. Hepatocellular carcinoma
. HBsAg positivity
Adapted from U.S. Department of Health and Human Services. Assistant Secretary for Planning and Evaluation. Important questions for hospice in the next century. Internet. Accessed on April 29, 2010.