Grading alcoholic hepatitis
Authors: Ewan Forrest, Saket Singhal, Geoffrey Haydon, Christopher Day, Neil Fisher, Alison Brind, Peter Hayes
Journal: Hepatology (2005)

The paper by Dunn et al. sought to establish the Model for End-Stage Liver Disease (MELD) as an accurate predictor of mortality in alcoholic hepatitis.1 However, this study has retrospectively assessed a heterogeneous population. Of the 73 patients studied, a large proportion (21.9%) had gastrointestinal bleeding. The prognosis of patients with a clinical diagnosis of alcoholic hepatitis with gastrointestinal bleeding is not necessarily the same as that of those without bleeding. The patients with gastrointestinal bleeding will also benefit from MELD's predictive potential, because MELD was conceived to assess prognosis in variceal hemorrhage.2 Dunn et al. have also included 11 patients with either chronic viral hepatitis or possible acetaminophen toxicity, and also 12 patients who had received either corticosteroids or etanercept. It is difficult to draw conclusions regarding a prognostic score when patients with co-existent diseases and patients given disease-modifying drugs are studied. Despite having the advantage of using patients with gastrointestinal bleeding, the MELD score was only equivalent to the modified discriminant function (mDF). This is similar to another study of 34 patients with alcoholic hepatitis.3 Another analysis of 98 patients determined that MELD was equivalent to the Child-Turcotte-Pugh score, but no comparison with the mDF was made.4 In our study of prognostic factors in alcoholic hepatitis we analyzed 241 patients and have described the Glasgow Alcoholic Hepatitis Score (GAHS) (Table 1). This has been validated in an additional 195 patients.5 No patient had co-existent liver disease. None had received corticosteroids, pentoxifylline, or anti–tumor necrosis factor (TNF) treatment. GAHS was significantly more accurate than the mDF in patients with either a clinical diagnosis or histological confirmation of alcoholic hepatitis. GAHS appears to be accurate regardless of whether the International Normalized Ratio (INR) or the prothrombin time ratio is used, and it is easy to calculate without a handheld computer or website calculator. In contrast to MELD, GAHS does not use serum creatinine, as some laboratories still use the Jaffe reaction for this measurement, which will underestimate serum creatinine in the context of hyperbilirubinaemia. Another difficulty with the MELD assessment of alcoholic hepatitis is in finding the optimal cut point. Dunn et al. identify two cut points: 22 for 30-day mortality and 21 for 90-day mortality. Sheth et al. identified the optimal cut point to be 11. In our validation study we assessed the MELD in 46 patients for whom the optimal cut point was 15. GAHS has a constant cut point of 9 for scores calculated on day 1 or on day 7 for both 28- and 84-day mortality. Using this cut point, GAHS appears to identify those patients who may benefit from corticosteroid treatment.6 In conclusion, we agree with Dunn et al. that the identification of subsets of patients with significant disease is vital for the management of alcoholic hepatitis. The published studies of MELD in alcoholic hepatitis all have demonstrated that MELD is not superior to mDF. GAHS is more accurate than mDF and is an easy-to-calculate scoring system that can guide treatment decisions. Ewan Forrest*, Saket Singhal , Geoffrey Haydon , Christopher Day?, Neil Fisher?, Alison Brind**, Peter Hayes , * Glasgow Royal Infirmary, Glasgow, United Kingdom, Sandwell General Hospital, West Bromwich, United Kingdom, University Hospital, Birmingham, United Kingdom, ? University of Newcastle, Newcastle-upon-Tyne, United Kingdom, ? Dudley Hospitals, West Midlands, United Kingdom, ** University Hospital, North Staffordshire, United Kingdom, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.