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Assessment of Liver Function

July 3, 2024

  • FLR ( future Liver Remnant) = Predictive of Outcome after resection
  • CT/MRI volumetry = Software Calculation
  • FLR/TLV ratio is calculated = Radiological
  • TELV (total estimated Liver volume) = Based on BSA
  • Urata Formula= TELV = -794+1267x BSA

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  • Standardized FLR (sFLR)= FLR/TELV
  • TELV >> TLV

Volumetric Thresholds

  • Normal liver = 20-30%
  • Damaged Liver = Steatosis/ Chemotherapy = 30-40%
  • Cirrhosis = 40-50%

Assessment after Hypertrophy

  • DH (degree of Hypertrophy) - Absolute Difference in FLR
    • 5% in normal liver after PVE
  • Kinetic Growth Rate = DH/No of weeks
    • KGR = should be more than 2%
  • KGR > sFLR > DH ( for hepatic insufficiency after liver resection)
  • if the values of DH and KGR are less than minimum ⇒ the liver is not responding to PVE ⇒ liver cannot regenerate after resection

CTP Score

  • Risk of death in patients who have Cirrhosis
  • Surgery is safe in Child A and Early B or MELD <10

  • ONLY IN CIRRHOSIS, NO MENTION OF PHTN

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The ranges for Bilirubin are: **<34 µmol/L** = 1 point **34-50 µmol/L** = 2 points **>50 µmol/L** = 3 points

The ranges for Bilirubin are:
<34 µmol/L = 1 point 34-50 µmol/L = 2 points >50 µmol/L = 3 points

MELD Score

  • used in Liver Transplantation to allocate organs
  • Bilirubin, Creatinine & INR
  • Na is also added for Na MELD
  • ONLY IN CIRRHOSIS

  • MELD > 8 = higher rate of liver decompensation

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  • Current expert review practice guidelines from the American Gastroenterological Association for acute alcoholic hepatitis recommend referral for transplant if the model for end-stage liver disease (MELD) is greater than 26 given high short-term mortality. ( sabi)

  • There is general agreement that most patients with low MELD scores (less than 15) do not benefit from transplantation, and this has been reflected in national allocation policies. (sabi)

ALBI Score

  • Albumin - Bilirubin score
    • A1, A2, A3
  • Liver dysfunction is not mandatory ( but for CTP and MELD are scored after cirrhosis sets in)

ICG Clearance

  • Water soluble Tricarbocyanine dye
  • binds to albumin
  • exclusively cleared by Liver - Bile
  • Blood flow, Hepatocyte uptake and biliary excretion
  • ICG R 15 = Venous blood sample at 5 minutes and then every 15 mins
  • Pulse spectrophotometry is used
  • 14-20% ICG R15: Indicates prediction of liver failure if liver resection is performed.
  • LIMITATIONS:
    • Not reliable in cases of jaundice
    • affected by intrahepatic shunting/ sinusoidal capillarization
    • Measures Global Liver function, not FLR function

Nuclear Imaging

  • 99 Tc labelled galactosyl serum albumin ( GSA scintigraphy)
  • Tc-GSA + SPECT -CT = functional imaging and FLR assessment both
  • MEGX scan - Lidocaine metabolism by P450 cytochrome

MRI

  • Best & latest
  • Gd-EOB-DTPA ( Gadolinium ethoxybenzyl dimenglumine)
  • Liver specific contrast agent.
  • measurement of Liver function, characterization of lesion
  • FUNCTIONAL ASSESSMENT OF PLANNED FLR ONLY
  • SUPERIOR TO sFLR and ICG R15

Bullet points for MCQ’s

  • sFLR is better than than FLR/TLV to measure postoperative hepatic insufficiency
  • CT volumetry is most accurate to measure Liver volume
  • Limitations of ICG clearance : JAUNDICE AND INTRAHEPATIC SHUNTING and sinusoidal capillarization { PHTN IS NOT A LIMITATION }
  • For both anatomic and functional aspects of liver
    1. Hepatobiliary scintigraphy
    2. MRI with Gd EOB DTPA contrast
    3. if specifically asked about FLR assessment then only MRI with Gd EOB DTPA is the best answer