Scoring systems and screening tools – MUST, Child-Pugh, MELD

MUST (Malnutrition Universal Screening Tool)

Purpose:

The MUST score is designed to quickly identify patients at risk of malnutrition and guide appropriate nutritional interventions across hospital, care home, and community settings.

Criteria Used

1. Body Mass Index (BMI):
   • BMI > 20 → Score 0
   • BMI 18.5–20 → Score 1
   • BMI < 18.5 → Score 2
2. Unintentional Weight Loss (in the past 3–6 months):
   • <5% → Score 0
   • 5–10% → Score 1
   • 10% → Score 2
3. Acute Disease Effect:
   • Score 2 if the patient is acutely ill and has had little or no nutritional intake for >5 days.

Scoring and Interpretation

• Score 0: Low risk of malnutrition.
• Score 1: Medium risk.
• Score ≥2: High risk.

Treatment Implications

Low Risk (Score 0)

• Provide routine nutritional advice.
• Repeat screening:
  • Hospital: Weekly
  • Care homes: Monthly
  • Community (e.g. age >75): Annually

Medium Risk (Score 1)

• Monitor dietary intake for 3 days.
• If intake is adequate:
  • Hospital: Weekly
  • Care homes: Monthly
  • Community: Every 2–3 months
• If intake is inadequate:
  • Involve a dietitian and follow local policy to improve intake.

High Risk (Score ≥2)

• Refer to a dietitian immediately.
• Initiate nutritional support therapy.
• Monitor:
  • Hospital: Weekly
  • Care homes: Monthly
  • Community: Monthly

Child-Pugh Score

Purpose:

Assesses the severity and prognosis of chronic liver disease, especially cirrhosis. It helps guide management decisions and the need for liver transplantation.

Criteria Used (Each parameter scored 1–3)

Classification

• Child-Pugh A (5–6 points): Well-compensated liver disease.
• Child-Pugh B (7–9 points): Significant functional compromise.
• Child-Pugh C (10–15 points): Decompensated liver disease.

Estimated 1-Year Survival

• A: ~100%
• B: ~80%
• C: ~45%

Treatment Implications

• Child-Pugh A:
  • May be managed with lifestyle modifications and medical therapy.
• Child-Pugh B/C:
  • Require intensive management of complications (e.g. ascites, variceal bleeding, encephalopathy).
  • Evaluate for liver transplantation.

MELD Score (Model for End-Stage Liver Disease)

Purpose:

Used to predict 90-day mortality in patients with advanced liver disease, especially those being considered for liver transplantation.

A modified version, MELD-Na, includes sodium to improve accuracy.

Criteria Used

• Serum Bilirubin – Reflects excretory function.
• Serum Creatinine – Reflects renal function.
• INR – Reflects liver synthetic capacity.
• Serum Sodium (in MELD-Na variant) – Low sodium indicates poorer prognosis.

Interpretation

The MELD score is derived from a logarithmic formula. Higher scores indicate greater mortality risk and prioritisation for transplant.

Scoring and Management

• MELD <10:
  • Low short-term mortality.
  • Manage medically and monitor regularly.
• MELD 10–19:
  • Moderate risk.
  • Monitor closely and manage complications.
• MELD 20–29:
  • High risk of short-term mortality.
  • Referral to liver transplant team is typically recommended.
• MELD ≥30:
  • Very high risk.
  • Requires urgent transplant assessment and close inpatient care.

General Transplant Consideration:

• A MELD score ≥15 is often used as the threshold for transplant referral.