Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 58-year-old man is evaluated in follow-up for hepatitis C-related cirrhosis that is complicated by nonbleeding small esophageal varices and ascites. His ascites has recently worsened and has required large-volume paracentesis three times per month. He has been on a low-salt diet, spironolactone, and furosemide.

On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 98/60 mm Hg, pulse rate is 65/min, and respiration rate is 16/min; BMI is 26. He appears chronically ill. Scleral icterus, jaundice, and spider angiomata are noted. The abdomen is distended with ascites. The spleen tip is palpable.

Laboratory studies reveal a serum creatinine level of 2.2 mg/dL (194.5 µmol/L).

The Model for End-Stage Liver Disease (MELD) score is 21.

Which of the following is the most appropriate next step in management?

A. Continuation of current medical therapy
B. Evaluation for liver transplantation
C. Surgical portosystemic shunt
D. Transjugular intrahepatic portosystemic shunt

MKSAP Answer and Critique

The correct answer is B. Evaluation for liver transplantation.

The most appropriate next step in management is an evaluation for liver transplantation. This patient has decompensated cirrhosis as manifested by ascites and has a moderately elevated Model for End-Stage Liver Disease (MELD) score. The MELD score is an equation that incorporates the bilirubin, INR, and creatinine levels and was derived initially as a way to accurately predict 3-month and 1-year survival in patients undergoing a transjugular intrahepatic portosystemic shunt (TIPS) procedure. The MELD score has also been validated as a tool for accurately predicting 3-month survival in patients with cirrhosis. This score is the basis for considering referral for liver transplantation (MELD =15) and organ allocation. Patients with cirrhotic-stage liver disease and a MELD score of 15 or greater have better survival with liver transplantation than without.

Diuretics have been unsuccessful in this patient owing to the development of kidney dysfunction. Further administration of diuretics may precipitate the development of hepatorenal syndrome; therefore, diuretics should be discontinued.

Patients with MELD scores greater than 10 are at risk of hepatic decompensation and mortality from any surgery, and especially with higher-risk surgeries such as a surgical portosystemic shunt. Therefore, surgical portosystemic shunt should not be performed in this patient, who has a MELD score of 21.

A TIPS can be an attractive option for patients whose ascites does not improve with medical management with a low-sodium diet (<2 g/d) and the usual diuretics (spironolactone and furosemide). However, a TIPS is contraindicated in patients with MELD scores greater than 15 to 18 or serum bilirubin levels greater than 4 mg/dL (68.4 µmol/L), owing to high risk of mortality.

Key Point

• Patients with cirrhotic-stage liver disease and a Model for End-Stage Liver Disease (MELD) score of 15 or greater have better survival with liver transplantation than without.

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