Let's move to our next case.
A 53-year-old man is seen in clinic
for follow-up of his hepatitis C cirrhosis.
In the past year, his ascites has worsened,
now requiring weekly large volume paracentesis.
He is adherent his low sodium diet and takes
maximal doses of furosemide and spironolactone.
Vitals are notable for blood pressure
of 95/62 mmHg but otherwise normal.
His physical exam shows jaundice, spider angiomata,
abdominal distention with ascites and splenomegaly.
No asterixis is noted.
His model for end-stage liver
disease or MELD score is 25.
So what is the best next step in management?
So he now has worsening
decompensated cirrhosis with ascites
that is refractory to both
diuretics and low sodium diet.
And his MELD score is quite high.
We'll discuss what that means next.
So, the first question to consider
is, is he a candidate for TIPS?
As you recall, TIPS is a procedure we can sometimes do to
manage ascites that’s refractory to medical management.
The next question is, should he
be referred for transplantation?
So, we'll consider these things
when we answer this question.
Let's first discuss what these
different risk calculators are.
So with cirrhosis we have two systems
for determining patient's prognosis.
The first is the MELD score and
the second is the Child-Pugh score.
Both of them can help you predict
mortality or survival rate, and risk of surgery.
They take into account slightly different variables
and when you calculate your score for your patient,
This threshold's to know, or if your
MELD is greater than or equal to 15,
at this point, you should refer
that patient for a transplant evaluation
because we know that their mortality
becomes quite high at this point.
On the other hand, Child-Pugh scores
correlate to a different tyoe of class
and we know that in one year, those with class
A Child-Pugh may have a 100% survival rate
whereas once you have progressed to class C,
you have only a 45% chance of surviving in one year.
So we spoke about liver trasnplantation.
evaluation is very complicated.
There are many different contraindications
to receiving a liver transplantation
and every transplant center
may have its own list of criteria.
Here is a brief general
list that you may think of.
So, patients who have severe cardiopulmonary disease,
uncontrolled infections or cancer outside of the liver,
severe psychiatric illness
or substance dependence,
inability to comply in the
past with medical management
or a lack of social support or advanced age.
All of these factors may be limiting in your
consideration for receiving a liver transplantation.
So now let's go back to our case.
Our 53-year-old man with now
worsening decompensated cirrhosis.
We know his ascites has been refractory
to both diuretics and sodium restriction
and his MELD score is quite elevated.
So, now that we know his MELD
score is high, above the threshold of 15,
we know the next step is to
refer for liver transplantation.
If you thought about the TIPS procedure, this is actually
contraindicated when a MELD score higher than 15-18
due to very high risk of mortality
associated with the procedure.
Thank you very much
for your attention today.