Scoring and Grading Liver Biopsies

When you receive the results of your liver biopsy, you will hear the terms inflammatory grade and fibrotic stage. Health care providers use these terms to indicate the amount of injury to the liver.
There are three different methods used for scoring liver biopsies. This can cause confusion for both patients and health care providers. Be aware that the scoring systems are also subject to interpretation by the pathologist who examines your biopsy.

The three scoring and grading systems for liver biopsies are the Original HAI (Histology Activity Index), the Modified HAI, and the Metavir. There are important things to know about how biopsies are scored in order to understand what your score means.

• A score for a given biopsy characteristic in one system does not mean the same thing in the other systems.
  
   
• The scores for all of the characteristics of the tissue sample are added together for a final score, except as specified in the notes under the table for that system (see below Tables 1-5).
  
   
• A final score from one biopsy may have the same score as that of a follow-up biopsy, but the scores for individual characteristics may have changed. This means your situation could actually be better or worse depending on the individual characteristic scores.

Until there is a single biopsy scoring system, there are things you need to know and track regarding your liver biopsy results.

• What system did the pathologist use to grade each of your biopsies?
  
   
• If you have had more than one biopsy, you need to look at changes in both the individual characteristics and the overall score.

Make sure your health care provider completely explains the results of your biopsy to you. Ask for an explanation of the individual scores as well as the overall score. You should be given a description of the inflammatory grade and fibrotic stage. Ask to speak with the pathologist who evaluated your biopsy if your health care provider is unable to provide this information.

Biopsies are invasive and therefore, you are not likely to have one done often. For this reason, it is very important that you understand the results of your liver biopsy so you can use this information to help you make decisions about your health care.

The following tables comparing the three systems used to score liver biopsies are courtesy of David Kleiner, MD of the National Cancer Institute.

http://www.hepcchallenge.org/manual/progression_final.htm

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Table 1. Comparison of Scoring Systems: Periportal Necroinflammatory Changes
Score	Original HAI[a](3)	Modified HAI(4)	Metavir[b](5)
0	None	Absent	Absent
1	Mild piecemeal necrosis	Mild (focal, few portal areas)	Diffuse alteration of the periportal tract in some portal tracts or focal
2		Mild/Moderate (focal, most portal areas)	Diffuse alteration of the periportal tract in some portal tracts or focal
3	Moderate piecemeal necrosis (involves less than 50% of the circumference of most portal tracts	Moderate (continuous around <50% of tracts or septae)	Diffuse alteration of the periportal plate in all portal tracts
4	Marked piecemeal necrosis (involves more than 50% of the circumference of most portal tracts	Severe (continuous around >50% of tracts or septae)
[a]  The Periportal component of the Knodell HAI has been split into a Periportal piecemeal necrosis and a bridging/confluent necrosis component for better comparison to the other scoring systems. In order to recreate the original scale, the bridging/confluent necrosis component should be added to the Periportal piecemeal necrosis component.
[b] The Periportal component of the METAVIR score is used with the focal necrosis score to determine overall inflammatory activity.

 

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Table 6 shows how the HAI inflammation scores relate to the grade of histological injury. In the HAI system, the various inflammation scores are added together. These numbers are directly related to the descriptive grade of inflammation.

Staging Cirrhosis

Hepatitis has 4 stages.  Stage 4 Hepatitis = Cirrhosis.

Then,

There's 3 stages to Cirrhosis:
Stage A ("compensated"; not too sick)
Stage B (beginning to decompensate; complications beginning to appear)
Stage C ("decompensated"; end stage)

Doctors use something called a CTP Score, to see what Stage of cirrhosis that a person is in.

The CTP Score is based on FIVE QUESTIONS.
You receive a point value (score) for each of the answers.

Here's how it works:

1. Total Serum Bilirubin
.....if Bilirubin is <2 mg/dl: score 1 point
.....if Bilirubin is 2-3 mg/dl: score 2 points
.....if Bilirubin is >3 mg/dl: score 3 points

2. Serum Albumin
.....if Albumin is >3.5 g/dl: score 1 point
.....if Albumin is 2.8 to 3.5 g/dl: score 2 points
.....if Albumin is <2.8 g/dl: score 3 points

3. INR
.....if INR is <1.70: score 1 point
.....if INR is 1.71 to 2.20: score 2 points
.....if INR is >2.20: score 3 points

4. Ascites
.....No Ascites: score 1 point
.....Ascites controlled medically: score 2 points
.....Ascites poorly controlled: score 3 points

5. Encephalopathy
.....No Encephalopathy: score 1 point
.....Encephalopathy controlled medically: score 2 points
.....Encephalopathy poorly controlled: score 3 points

Total your score.

Sum total score gives grades of:
5 to 6 points = Stage A Cirrhosis
7 to 9 points = Stage B Cirrhosis
10 to 15 points = Stage C Cirrhosis

A person has to be at least Stage B or Stage C, in order to get referred for an "Evaluation" for a chance at the liver transplant waiting list.  (Stage A Cirrhosis is not sick enough to think about a referral for an evaluation).

iCTP scores and MELD scores are two completely different things.

MELD scores are use for allocation of donor livers

PS- There's more examples of these scorecards at 112.1 (you can scroll through about a dozen of them there)

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