title: Recalibrating the Child-Turcotte-Pugh Score to Improve Prediction of Transplant-Free Survival in Patients with Cirrhosis.
abstract: The Child-Turcotte-Pugh (CTP) score is a widely used and validated predictor of long-term survival in cirrhosis. However, the cutpoints for stratifying laboratory variables in CTP have never been validated.
  
  
  
  The objective of this study was to identify evidence-based cutpoints for the CTP laboratory subscores to improve its predictive capacity for transplant-free survival.
  
  
  
  Retrospective observational study.
  
  
  
  Using a cohort of 30,897 cirrhotic US Veteran patients with at least 5 years of follow-up, we performed Cox proportional hazard survival model iterations varying the upper and lower cutpoints for INR, total bilirubin and albumin CTP subscores. Cutpoints yielding the highest Harrell's C-statistics for concordance with transplant-free survival were incorporated into a modified CTP (mCTP) score. Validation of the mCTP was performed at multiple time frames within the follow-up period of the cohort and within subsets defined by disease etiology.
  
  
  
  Modification of CTP cutpoints increased the Harrell's C-statistic for age- and gender-adjusted Cox proportional hazard models from 0.701 ± 0.002 to 0.709 ± 0.002 and the risk ratio per unit change from 1.49 (1.48-1.50) to 1.53 (1.52-1.54). The modified cutpoints showed superiority in predicting 5-year transplant-free survival in various disease etiology subgroups. A mCTP substituting serum creatinine for INR performed superiorly for predicting 5-year transplant-free survival.
  
  
  
  We propose an evidence-based recalibration of CTP score cutpoints that optimizes this model's capacity to predict transplant-free survival in patients with cirrhosis. The CTP score remains the best predictor of 5-year overall and transplant-free survival in patients with cirrhosis.
authors.affiliation: Gastroenterology Section, Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Bldg. 21, Room A422, Philadelphia, PA, 19104, USA. dakaplan@mail.med.upenn.edu.
authors.forename: David E
authors.initials: DE
authors.lastname: Kaplan
authors.affiliation: VA Connecticut-Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.
authors.forename: Feng
authors.initials: F
authors.lastname: Dai
authors.affiliation: VA Connecticut-Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Skanderson
authors.affiliation: VA New York Harbor Health Care System, 800 Poly Place, Brooklyn, NY, 11209, USA.
authors.forename: Ayse
authors.initials: A
authors.lastname: Aytaman
authors.affiliation: Boston VA Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA.
authors.forename: Michelle
authors.initials: M
authors.lastname: Baytarian
authors.affiliation: VA Connecticut-Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.
authors.forename: Kathryn
authors.initials: K
authors.lastname: D'Addeo
authors.affiliation: San Francisco VA Medical Center, 4150 Clement Street, San Francisco, CA, 94121, USA.
authors.forename: Rena
authors.initials: R
authors.lastname: Fox
authors.affiliation: James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY, 10468, USA.
authors.forename: Kristel
authors.initials: K
authors.lastname: Hunt
authors.affiliation: Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA.
authors.forename: Astrid
authors.initials: A
authors.lastname: Knott
authors.affiliation: VA Connecticut-Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.
authors.forename: Rajni
authors.initials: R
authors.lastname: Mehta
authors.affiliation: Boston VA Healthcare System, 150 S. Huntington Avenue, Boston, MA, 02130, USA.
authors.forename: Marcos
authors.initials: M
authors.lastname: Pedrosa
authors.affiliation: Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA.
authors.forename: Christine
authors.initials: C
authors.lastname: Pocha
authors.affiliation: Bayer HealthCare Pharmaceuticals, 100 Bayer Blvd, Whippany, NJ, 07981, USA.
authors.forename: Adriana
authors.initials: A
authors.lastname: Valderrama
authors.affiliation: VA Connecticut-Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.
authors.forename: Tamar
authors.initials: T
authors.lastname: Taddei
mesh_terms: D000328:Adult; D000368:Aged; D001663:Bilirubin / Q000097:blood*; D003404:Creatinine / Q000097:blood*; D018450:Disease Progression; D058625:End Stage Liver Disease; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D019934:International Normalized Ratio; D008103:Liver Cirrhosis / Q000097:blood* / Q000401:mortality / Q000601:surgery; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012709:Serum Albumin / Q000378:metabolism*; D012720:Severity of Illness Index; D014481:United States; D014728:Veterans
chemical_list: D012709:Serum Albumin; D003404:Creatinine; D001663:Bilirubin
keywords: Cirrhosis; Creatinine; Human; MELD; Natural history; Predictive models; Survival