Alcoholic Hepatitis Maddrey Score

The scoring system explained

This is a discriminant method that predicts short term prognosis of patients with alcoholic hepatitis.

It provides a mortality risk percentage and a recommendation as to which patients could benefit from corticosteroid therapy.

The three variables accounted for in the Maddrey score are explained in the table below:

The discriminant function is calculated based on the following formula:

DF = 4.6 x (Prothrombin time - Control time) + Bilirubin in mg/dL

If bilirubin is provided in μmol/L, the equation can be adapted:

DF = 4.6 x (Prothrombin time - Control time) + (Bilirubin in μmol/L)/17.1

Result interpretation

The numeric result provided after the discriminant function is calculated is interpreted (by a clinician) according to the following rule.

All Maddrey score results above 32 are indicative of a poor prognosis with 35-45% mortality risk within first month. The patient may benefit from corticosteroid therapy and should undergo a liver biopsy.

Whilst initially the score was only used for stratification of mortality risk, in time it was attributed value in the management of hepatitis (initiation or not of corticosteroid therapy).

The main limitation of the study is linked to the fact that it only offers short term prognosis and cannot account for progression of the disease in time.

About the study

This stratification method was designed in 1978 by Maddrey et al. following a 28- to 32-day randomized double blind treatment trial study (prednisolone 40 mg vs placebo) on 55 patients with alcoholic hepatitis.

Of 31 placebo-treated patients, 4 died during the trial interval and 2 died within 5 days of trial completion. Of 24 prednisolone-treated patients, only 1 died.

Stepwise discriminant analysis of laboratory factors associated with exitus showed that prolongation of prothrombin time and elevation of serum bilirubin have an independent predictive value.

It was also found that corticosteroid therapy significantly decreased mortality. However, no effect on the development of portal hypertension was observed.

Alcoholic hepatitis guidelines

Patients who are diagnosed with alcoholic cirrhosis also have superimposed alcoholic hepatitis compensated or not. In severe cases, corticosteroid therapy (is recommended) has shown an improvement in short term survival.

The cause of AH is increased alcohol consumption. Heavy alcohol intake is a controversial subject with sources citing it starts at daily ingestion of more than 10 – 20 g for women and 20 – 40 g for men.

In time, excessive alcoholism leads to hepatic symptoms and affectation of the liver function. These are some of the conditions that can develop:

■ Alcoholic fatty liver disease;

■ Steatohepatitis;

■ Alcoholic hepatitis;

■ Cirrhosis.

Alcoholic hepatitis can be treated successfully with corticosteroid medication such as prednisolone but it is essential that the patient discontinues alcohol and is regularly monitored for alcohol withdrawal symptoms, with assessments such as CIWA-Ar. Mortality rates are high if AH is left untreated:

■ For severe AH: 25 to 45% (short term);

■ For mild to moderate AH: 10% (90 days).

Original source

Maddrey WC, Boitnott JK, Bedine MS, Weber FL Jr, Mezey E, White RI Jr. Corticosteroid therapy of alcoholic hepatitis. Gastroenterology. 1978; 75(2):193-9.

Validation

Soultati AS, Dourakis SP, Alexopoulou A, Deutsch M, Vasilieva L, Archimandritis AJ. Predicting utility of a model for end stage liver disease in alcoholic liver disease. World J Gastroenterol. 2006; 12(25):4020-5.

Other references

1. Kadian M, Kakkar R, Dhar M, Kaushik RM. Model for end-stage liver disease score versus Maddrey discriminant function score in assessing short-term outcome in alcoholic hepatitis. J Gastroenterol Hepatol. 2014; 29(3):581-8.

2. Monsanto P, Almeida N, Lrias C, Pina JE, Sofia C. Evaluation of MELD score and Maddrey discriminant function for mortality prediction in patients with alcoholic hepatitis. Hepatogastroenterology. 2013; 60(125):1089-94.