Cirrhosis - how to measure

[hcvJames]

I've finished tx. After 7 months I'm getting my 6 mth VL test. Yes, yes, I knowww but that's how so much of tx went. The thing is I never found out how bad the cirrhosis is. At first I was told it was ESLD but from reading around here it appears to have been a big overstatement. Isn't ESLD pretty much an uncompensated liver?

Main question: how is cirrhosis measured. From reading the forum there seems to be three ways. MELD score. And Child-Pugh score, which is a refinement of an earlier method. Which test is best to have?

I have asked the NP twice now how it's measured and she's said she doesn't know that there is a way. When I mentioned MELD scores she seemed to accept that but drew some distinction as to say it wasn't really. Like it's a measure of the liver in general not cirrhosis in particular.

[eureka254]

Although the MELD is the *best* we've got at the moment, it's certainly far from a perfect system.  I'm really glad to hear that you've maintained your MELD with good lifestyle :).  Just staying stable can be a tremendous challenge for sure.

The medical profession continues to fine-tune the guidelines for treating those with liver disease, and in fact, you bring up an important point that MELD is really not as 'objective' in all cases as I might have led some to believe in my first response.  The 'bonus points' you speak of, exception points added to MELD, does exist for HCC, but not in all regions.  

You are correct that it is a disparity in the TP system that exists; some regions accord up to 22 priority points for HCC while other regions do not add any points at all.  My husband has a MELD of 8 and though if he were in say, Tennessee he could have been at the top of the list with a 30 for HCC, where we are in New England, his MELD is too low for listing.  So, there are situations where MELD is not at all an accurate assessment of survival and mortality.

[BigDaddy_59]

I try to pass on what was given so freely to me!
My MELD stays around 10 and has been for many years.
My hepa said there was discussion at AASLD of adding sodium and albumin to it. It can also be raised by "bonus points" (sorry, can't think of the proper term) for HCC (primary liver cancer) although I am not sure how much and maybe it varies as to which OPO area you are in? I am sure Hector knows this one. Most Hep C people go up slowly but some of the other liver diseases can go up rapidly as they approach fulminant liver failure I think...

[eureka254]

During treatment most docs include the bilirubin and INR tests in the monthly blood draws, as it's part of the hepatic function panel.  In regards to MELD, yes, the lower the number the better.  It can fluctuate, but usually progression is gradual.  My husband's MELD was 7 two years ago and fluctuates between 8 and 9 these days; I would hazard to say if you were to jump to say, a 13 MELD, you would DEFINITELY know something was wrong by how you would be feeling.  Hope that helps.

[hcvJames]

Thanks all. This refreshes a memory of working though this before and concluding two of these test essentially say you are compensated or uncompensated. So for a MELD score the lower the better. Unfortunately I've never had a test for bilirubin or INR. The creatinine was only done because one kidney was damaged when a child.
Any comments on how much the MELD score might fluctuate given the range of 1 to 15.? Especially if SVR. One wouldn't expect to score 3 this time, then 13 at a later time, would they?

[eureka254]

" I have learned more how to live my life better since I have found out how sick I am and enjoy it so much more. "

Of all the things we might learn when challenged with a difficult diagnosis, that is certainly the most essential knowledge of all.  Your focus, faith, and positive attitude are an inspiration, and thank you for sharing your thoughts and good cheer.  It's wonderful that you have doctors that you can put your trust in, to worry for you, so that you can live well.  May your spirituality and love of life serve you well :).  

[belle19]

awesome post big daddy.  love all your quotes.  best wishes.  belle

[Bill1954]

http://www.youtube.com/watch?v=RZWXrTMedZg

[BigDaddy_59]

I understand why you want to know "how bad is it" I used to want to know and stress over it and freak out when my blood tests results would go up a little.
My thoughts now on how bad my cirrhosis is?
I really don't let it concern me.
I try and live my life with a positive outlook, take care of myself medically, physically, emotionally, and spiritually. I get blood test and imaging of my liver done every 3 months. I use my MELD score only for transplant related issues
I have learned more how to live my life better since I have found out how sick I am and enjoy it so much more.
My hepa always tells me "go, live your life. Don't you worry about it, that's my job. One of the transplant surgeons said, Dr hepa's job is to keep you alive until you need us, and she does an excellent job of it. My mom always told me that dying is just as an integral part of being born, don't worry about it. My sister says 'life is terminal'. My brother said "If I knew I was going to live this long, I woulda taken better care of myself", then he died. Bobby McFerrin said "Don't worry, be happy". God told me "don't worry, everything will be OK, I've got this for you". I am granting you the serenity to accept the things you cannot change, the courage to change the things you can, and the wisdom to know the difference. I take all this and use it everyday.
Go live your life while you can!
Chris

[eureka254]

Hector's information is correct.  MELD is a an objective calculation; if you have your lab results, you can actually calculate it using this website:

http://www.mayoclinic.org/meld/mayomodel6.html

Child-Pugh classification can be a little more "subjective" as it requires assessment symptoms in addition to labwork.  An easy CP Class calculator at this website:

http://depts.washington.edu/uwhep/calculations/childspugh.htm

In previous discussions with my husband's hepatologists, my understanding is ESLD is Child-Pugh Class C or a MELD of 15 or higher, both which would be decompensated states.  Very wide spectrum when we talk about cirrhosis; having cirrhosis does not make people "end stage" -- alarmist and overly dramatic for cirrhosis to be automatically characterized as ESLD.  Almost a sure bet anyone treating hep c and not being monitored by a transplant center would not be at end-stage.

Hope that clarifies things. Wishing you SVR! ~eureka

[HectorSF]

ALL CIRRHOTICS compensated or decompensated should TREAT for 48 WEEKS as cirrhosis greatly reduces the chance of successfully treating more than any other per-existing factor unfortunately.

Stage 4, Cirrhosis of the liver is when the normal liver cells are replaced by scar tissue. The anatomy of the structure of the liver is changed and the livers surface becomes nodular replacing the smooth, shiny, nutmeg colored liver that you see in a super market of butcher shop. Chicken livers for example.

Yes, End-Stage Liver Disease is decompensated cirrhosis.The difference between compensated and decompensated is the when decompensated the liver is no longer able to perform all of its function and so complications manifest themselves. The classic signs of ESLD are; ascites, hepatic encephalopathy, varices, jaundice (yellowing of eyes and skin).

The Child-Pugh score is usually used to measure the 3 stages of cirrhosis. Class A - compensated cirrhosis (can treatment Hep C with drugs)
Class B - decompensated cirrhosis (very few treat with Hep C drugs too ill)
Class C -

Class A is score 5 - 6
Class B is score 7 - 9
Class C is score >9

****It is rather easy to know if you have had a decompensated complication or not. If you have experienced ascites, hepatic encephalopathy, varices, then you are decompensated. If you haven't had any symptoms or complications other then fatigue than you a compensated Child-Pugh Class A. That does not mean you can't have less liver disease too. MELD score can go up and down over time. The same with Child-Pugh. But once you have a decompensation even t you are considered decompensated.****

"When I mentioned MELD scores she seemed to accept that but drew some distinction as to say it wasn't really. Like it's a measure of the liver in general not cirrhosis in particular."
The NP is incorrect.
MELD is NOT a measure of the liver. It is a measure of the degree of liver disease.

The Model for End-Stage Liver Disease (MELD) is a numerical scale, ranging from 6 (less ill) to 40 (gravely ill), used for liver transplant candidates age 12 and older. It gives each person a ‘score’ (number) based on how urgently he or she needs a liver transplant within the next three months. The number is calculated by a formula using three routine lab test results:
- bilirubin, which measures how effectively the liver excretes bile;
- INR (prothrombin time), which measures the liver’s ability to make bloo
clotting factors; and
- creatinine, which measures kidney function. (Impaired kidney function is
often associated with severe liver disease.)

There are 4 stages on the metavir scale used to measure damage to the liver by hepatitis C. Cirrhosis is stage 4. Which is a measure of the extent of liver disease. It's characteristics are that the liver is scared throughout and nodules both mico and macro form on the surface of the liver.

Most decompensated patient will not be treated. The few that do need the full resources of a transplant center to treat as treatment can cause the liver to fail. Compensated cirrhotics can and do treat with hepatitis drugs and can clear the virus and stop the progression of their liver disease.
Either way ALL CIRRHOTICS should TREAT for 48 WEEKS as cirrhosis reduces the chance of successfully treating more than any other per-existing factor. I hope you get lucky and you don't have a relapse.

Good luck to you.
Hope this helps.
Hector