Effectiveness of the MELD/Na Score and the Child–Pugh Score for the Identification of Palliative Care Needs in Patients with Cirrhosis of the Liver

INTRODUCTION

People are “approaching the end of life” when they are likely to die within the next 12 months. Patients with chronic liver disease have a life-limiting illness that causes multiple distressing symptoms and negatively affects quality of life. This population traditionally does not have an instrument for the identification of palliative care needs the “end of life,” the MELD/Na score, and the Child–Pugh score may be useful in its identification.[123]

Patients with cirrhosis of the liver should be treated with specific treatments for the control of symptoms at the end of their life course because of the strong impact of the disease on the patient and the family. To properly care for these patients, it is necessary to identify and organize an interdisciplinary plan of professionals in palliative care, with the intention of reducing the impact of the disease on patients.[45]

MATERIALS AND METHODS

A retrospective study of hospitalized patients with hepatic cirrhosis between January 2015 and December 2016 using the Child–Pugh score and the MELD/Na score in January 2018.

The MELD/Na score is a scoring system for accessing the severity of chronic liver disease using values as serum bilirubin, serum creatinine, and the international normalized ratio for prothrombin time and sodium, to predict survival [Table 1].

Table 1 Interpretation MELD/Na score

The Child–Pugh score is used to access the prognosis of chronic liver disease, mainly cirrhosis. The score employs five clinical measures of liver disease: total bilirubin, serum albumin, prothrombin time, ascites, and hepatic encephalopathy [Table 2].[67]

Table 2 Interpretation Child-Pugh score

RESULTS AND DISCUSSION

During this period, 6493 patients were hospitalized and 47 with liver cirrhosis were included in this study [Table 3].

Table 3 Patient status at the end of the study

The median age was 64.3 years; 95.7% were male. The median hospitalization time was 10.7 days. The overall mortality rate was 68.1%.

Patients were classified according to the Child–Pugh score in Class A (17%), Class B (48.9%), and Class C (34%). The corresponding survival rate was as follows: class A (87.5%), Class B (30.4%), and Class C (31.25%).

The 1-year mortality rate was as follows: class A (12.5%), Class B (65.2%), and Class C (68.75%). The mortality rate after the 1^st year was as follows: class A (0%), Class B (4.3%), and Class C (0%). Palliative care needs were identified in Classes B and C [Table 4].

Table 4 Child-Pugh score of study

The MELD/Na score intervals were >9 (2.15%), score 10–19 (46.8%), score 20–29 (27.7%), score 30–40 (19.1%), and score >40 (4.3%). Nearly 51.1% had a MELD/Na score >20 and 48.9% <20 [Table 5].

Table 5 MELD/Na score of study

In January 2018, 31.9% were alive. About 44.7% had died in <3 months, 10.6% between 3 and 6 months, and 4.3% after 6 months.

The study revealed that 59.6% of patients died before 12 months. They were end-of-life patients who needed palliative care to reduce the impact of the disease.

According to the Child–Pugh score, in <1 year, the mortality rate of patients in Class B was 65.2% and 68.7% in Class C, and according to the MELD/Na score, patients with a score >20 had 51.1% mortality.

Given these percentages, both classes of patients had criteria to be identified as end-of-life patients requiring special care.

Patients had a decrease in quality of life, clinical, psychological, social, and family changes. Therefore, therapeutic adjustment was necessary to control the worsening of the following symptoms: edema, ascites, fever, fatigue, tiredness, drowsiness, confusion, loss of appetite, pain, dyspnea, and increased bleeding.

CONCLUSIONS

According to the MELD/Na score, in a 3-month period after hospitalization, a number between 19.6% and 71.3% of patients had a mortality likelihood of 51.1%. These numbers of patients were in need of palliative care. The confirmed mortality rate was 44.7%, during these first 3 months.

According to the Child–Pugh score, our Classes B and C patients have a mortality of 65.2% and 68.75% at 1 year, respectively, needing palliative care.

The Child–Pugh score and the MELD/Na score represent a viable and easy-to-use tool to identify patients in need of palliative care, among those with liver cirrhosis.