Child-Pugh Score — Liver Disease Severity
Bilirubin (µmol/L)
Albumin (g/L)
PT prolongation (sec) or INR
Ascites
Hepatic Encephalopathy
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The Child-Pugh score (also known as the Child-Turcotte-Pugh or CTP score) is a well-established clinical scoring system used to assess the severity of chronic liver disease and cirrhosis. First described by Child and Turcotte in 1964 and later modified by Pugh in 1972, it was originally developed to predict operative mortality in patients undergoing portosystemic shunt surgery. The score evaluates five clinical and laboratory parameters: serum bilirubin, serum albumin, prothrombin time or INR, degree of ascites, and degree of hepatic encephalopathy. Each parameter is assigned 1 to 3 points depending on severity, yielding a total score between 5 and 15. Patients are classified into three prognostic classes: Class A (5–6 points) indicates good hepatic reserve with expected one-year survival of 100% and two-year survival of 85%; Class B (7–9 points) indicates significant functional impairment with surgical mortality around 30%; and Class C (10–15 points) represents decompensated cirrhosis with surgical mortality approaching 75% and markedly reduced life expectancy. Unlike the MELD score, which is entirely laboratory-based, the Child-Pugh score includes two subjective clinical assessments (ascites and encephalopathy grading), which introduces some inter-observer variability. Nevertheless, it remains in widespread clinical use for hepatic function classification, guiding drug dosing decisions, surgical risk stratification, and communication with patients about prognosis.
Child-Pugh Score = points(bilirubin) + points(albumin) + points(PT prolongation or INR) + points(ascites) + points(encephalopathy); Class A = 5–6 pts, Class B = 7–9 pts, Class C = 10–15 pts
- 1Assess serum bilirubin: assign 1 point for <2 mg/dL, 2 points for 2–3 mg/dL, 3 points for >3 mg/dL (for primary biliary cholangitis/sclerosing cholangitis thresholds differ: 1pt <4, 2pt 4–10, 3pt >10).
- 2Assess serum albumin: assign 1 point for >3.5 g/dL (normal), 2 points for 2.8–3.5 g/dL, 3 points for <2.8 g/dL.
- 3Assess prothrombin time prolongation or INR: 1 point for PT prolongation <4 sec (INR <1.7), 2 points for 4–6 sec (INR 1.7–2.3), 3 points for >6 sec (INR >2.3).
- 4Grade ascites clinically: 1 point for none, 2 points for mild/controlled with diuretics, 3 points for moderate-to-severe or refractory ascites.
- 5Grade hepatic encephalopathy using West Haven criteria: 1 point for none (grade 0), 2 points for grade 1–2 (mild confusion, flapping tremor), 3 points for grade 3–4 (stupor or coma).
- 6Sum all five domain scores to obtain the total Child-Pugh score (range 5–15) and assign the class (A, B, or C) based on the total.
- 7Use the Child-Pugh class to guide clinical decisions: surgical risk estimation, liver transplant evaluation, drug dose adjustment in hepatic impairment, and prognostic counselling.
Surgical mortality ~10%, 1-year survival ~100%
All five parameters are in the best-scoring category. This patient has well-preserved liver function and excellent short-term prognosis.
Actually Class C at 10 points — significant impairment
Mid-range values across all five domains result in a Class C score, highlighting how even moderate abnormalities in each parameter compound rapidly.
Surgical mortality ~75%, requires urgent transplant evaluation
All parameters in the worst category. This patient has severely decompensated liver disease with extremely poor surgical prognosis.
Upper limit of Class A — reassess encephalopathy carefully
The presence of even mild encephalopathy shifts one parameter to 2 points, but the score remains Class A at 6. Clinicians should reassess and manage the encephalopathy to prevent Class B progression.
Surgical risk stratification: surgeons and anaesthesiologists use Child-Pugh class to assess operative risk before any major abdominal, cardiac, or orthopaedic surgery in patients with known liver disease.. This application is commonly used by professionals who need precise quantitative analysis to support decision-making, budgeting, and strategic planning in their respective fields
Drug dosing: pharmaceutical prescribing information routinely uses Child-Pugh A/B/C classification to define dose reductions or contraindications for hepatically metabolised medications.. Industry practitioners rely on this calculation to benchmark performance, compare alternatives, and ensure compliance with established standards and regulatory requirements
Transplant evaluation: although MELD-Na is the allocation score, Child-Pugh class B and C are commonly used as triggers for transplant evaluation referral.. Academic researchers and students use this computation to validate theoretical models, complete coursework assignments, and develop deeper understanding of the underlying mathematical principles
Prognosis communication: hepatologists use Child-Pugh class to frame honest prognostic conversations with patients and families about life expectancy and quality of life.. Financial analysts and planners incorporate this calculation into their workflow to produce accurate forecasts, evaluate risk scenarios, and present data-driven recommendations to stakeholders
Clinical research: Child-Pugh class is used as an inclusion/exclusion criterion and stratification variable in clinical trials for liver diseases and hepatocellular carcinoma treatments.. This application is commonly used by professionals who need precise quantitative analysis to support decision-making, budgeting, and strategic planning in their respective fields
Cholestatic liver disease bilirubin adjustment
{'title': 'Cholestatic liver disease bilirubin adjustment', 'body': 'For primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC), different bilirubin thresholds apply: 1 point for <4 mg/dL, 2 points for 4–10 mg/dL, 3 points for >10 mg/dL, because cholestatic disease naturally produces higher bilirubin levels than hepatocellular disease.'} When encountering this scenario in child pugh score calculations, users should verify that their input values fall within the expected range for the formula to produce meaningful results. Out-of-range inputs can lead to mathematically valid but practically meaningless outputs that do not reflect real-world conditions.
Treated ascites
{'title': 'Treated ascites', 'body': 'Ascites should be graded based on the clinical state after adequate diuretic therapy. A patient whose tense ascites has been well-controlled with diuretics to a clinically mild level may score 2 rather than 3, but clinical judgement is essential.'} This edge case frequently arises in professional applications of child pugh score where boundary conditions or extreme values are involved. Practitioners should document when this situation occurs and consider whether alternative calculation methods or adjustment factors are more appropriate for their specific use case.
Covert hepatic encephalopathy
{'title': 'Covert hepatic encephalopathy', 'body': 'West Haven Grade 0 (no clinical encephalopathy) scores 1 point even if psychometric testing reveals covert HE. The Child-Pugh score was designed for clinically manifest encephalopathy and does not routinely capture covert HE.'} In the context of child pugh score, this special case requires careful interpretation because standard assumptions may not hold. Users should cross-reference results with domain expertise and consider consulting additional references or tools to validate the output under these atypical conditions.
Drug dosing classification
{'title': 'Drug dosing classification', 'body': 'Pharmaceutical labelling often uses Child-Pugh class directly: Child-Pugh A = mild hepatic impairment, B = moderate, C = severe. Some drugs approved only in Child-Pugh A/B are absolutely contraindicated in Class C due to risk of drug accumulation and toxicity.'} When encountering this scenario in child pugh score calculations, users should verify that their input values fall within the expected range for the formula to produce meaningful results. Out-of-range inputs can lead to mathematically valid but practically meaningless outputs that do not reflect real-world conditions.
| Parameter | 1 Point | 2 Points | 3 Points |
|---|---|---|---|
| Bilirubin (mg/dL) | < 2 | 2–3 | > 3 |
| Albumin (g/dL) | > 3.5 | 2.8–3.5 | < 2.8 |
| INR | < 1.7 | 1.7–2.3 | > 2.3 |
| Ascites | None | Mild/controlled | Moderate-severe/refractory |
| Encephalopathy | None | Grade 1–2 | Grade 3–4 |
| Class A (5–6 pts) | 10% surgical mortality | 1-yr survival ~100% | Good hepatic reserve |
| Class B (7–9 pts) | 30% surgical mortality | 1-yr survival ~81% | Significant impairment |
| Class C (10–15 pts) | 75% surgical mortality | 1-yr survival ~45% | Decompensated cirrhosis |
What is the Child-Pugh score?
The Child-Pugh score is a 15-point scoring system assessing severity of chronic liver disease using five variables: serum bilirubin, serum albumin, INR or prothrombin time prolongation, degree of ascites, and degree of hepatic encephalopathy. It classifies patients as Class A (mild), B (moderate), or C (severe). In practice, this concept is central to child pugh score because it determines the core relationship between the input variables.
How does Child-Pugh differ from MELD?
Child-Pugh includes two subjective clinical parameters (ascites and encephalopathy grading) that can vary between observers, and it has a narrower score range (5–15). MELD uses only objective laboratory values and has a wider dynamic range, making it preferable for transplant allocation. MELD is used for organ prioritisation; Child-Pugh is widely used for hepatic reserve classification and surgical risk.
What surgical mortality does each Child-Pugh class predict?
Class A (5–6 points): approximately 10% surgical mortality. Class B (7–9 points): approximately 30% surgical mortality. Class C (10–15 points): approximately 75% surgical mortality. These estimates apply particularly to major abdominal surgery and portosystemic shunt procedures. This is an important consideration when working with child pugh score calculations in practical applications. The answer depends on the specific input values and the context in which the calculation is being applied.
Is the Child-Pugh score used for drug dosing?
Yes. Regulatory agencies and pharmaceutical manufacturers frequently use Child-Pugh classification (A, B, C) to define dose adjustments for drugs that are hepatically metabolised. Many drug labels state 'avoid in Child-Pugh C' or 'reduce dose in Child-Pugh B'. This is an important consideration when working with child pugh score calculations in practical applications. The answer depends on the specific input values and the context in which the calculation is being applied.
What are the limitations of the Child-Pugh score?
The subjective grading of ascites and encephalopathy creates inter-observer variability. The score does not incorporate renal function (a key mortality driver in cirrhosis), does not respond dynamically to rapid changes, and has a ceiling effect (cannot differentiate severity within Class C). These limitations led to MELD development. This is an important consideration when working with child pugh score calculations in practical applications.
Can the Child-Pugh score predict survival?
Yes. Class A is associated with 1-year survival of ~100% and 2-year survival of ~85%. Class B has ~81% 1-year and ~57% 2-year survival. Class C has ~45% 1-year and ~35% 2-year survival. These estimates vary significantly across published cohorts and should be interpreted alongside clinical context. This is an important consideration when working with child pugh score calculations in practical applications.
Does the score apply to primary biliary cholangitis?
Yes, but with modified bilirubin thresholds: 1 point for bilirubin <4 mg/dL, 2 points for 4–10 mg/dL, and 3 points for >10 mg/dL, because bilirubin naturally accumulates differently in cholestatic versus hepatocellular liver disease. This is an important consideration when working with child pugh score calculations in practical applications. The answer depends on the specific input values and the context in which the calculation is being applied.
How is ascites graded for the Child-Pugh score?
Ascites is graded as: absent (1 point), mild to moderate and responsive to diuretics (2 points), or severe/tense/refractory to diuretics (3 points). Grading is based on clinical examination, ultrasound findings, and the patient's response to diuretic therapy. The process involves applying the underlying formula systematically to the given inputs. Each variable in the calculation contributes to the final result, and understanding their individual roles helps ensure accurate application.
Pro Tip
When uncertain about ascites or encephalopathy grading, document your clinical findings in detail and consider using both a best-case and worst-case Child-Pugh score to communicate the uncertainty to surgical or transplant teams. This ensures safer decision-making at the borderline between classes.
Did you know?
The original Child-Turcotte score from 1964 used nutritional status instead of prothrombin time as one of its five parameters. When Pugh revised it in 1972 for his landmark study of oesophageal variceal surgery, he replaced nutritional status with prothrombin time, creating the Child-Pugh score still used today — over 50 years later.
References
- ›Child CG, Turcotte JG. Surgery and portal hypertension. The Liver and Portal Hypertension. 1964.
- ›Pugh RN et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973.
- ›AASLD Guidelines — Management of Cirrhosis and its Complications
- ›MDCalc — Child-Pugh Score for Cirrhosis Mortality
- ›European Association for the Study of the Liver (EASL) Clinical Practice Guidelines on Decompensated Cirrhosis