About the Child-Pugh Score
The Child-Pugh score (also called Child-Turcotte-Pugh or CTP) was originally developed by Child and Turcotte in 1964 and modified by Pugh in 1973 to assess the prognosis of patients with cirrhosis and guide surgical risk estimation, particularly for portosystemic shunt surgery. It classifies hepatic reserve into three categories — Class A (well-compensated), Class B (significant functional compromise), and Class C (decompensated).
The score incorporates five parameters that together reflect the two principal functions of the liver most relevant to clinical outcomes: synthetic function (assessed by albumin and prothrombin time/INR) and excretory/detoxifying function (assessed by bilirubin). The subjective parameters — ascites and hepatic encephalopathy — provide clinical context about portal hypertension and hepatic encephalopathy burden that laboratory values alone cannot fully capture. This blend of objective and clinical assessment is both the strength and a limitation of the Child-Pugh score: it integrates a broader clinical picture than MELD, but introduces inter-observer variability.
Despite being developed more than 50 years ago, the Child-Pugh score remains clinically relevant and widely used in surgical risk stratification, oncology treatment decisions, staging for hepatocellular carcinoma (particularly within the Barcelona Clinic Liver Cancer [BCLC] algorithm), and prognostication in cirrhosis across multiple etiologies including alcoholic liver disease, viral hepatitis, and metabolic-associated steatohepatitis (MASH). While MELD-Na has replaced Child-Pugh for organ allocation purposes, the two tools are complementary and often used together in comprehensive hepatology assessments.
How to Use This Calculator
Select the appropriate point value for each of the five parameters based on your patient's current clinical status and most recent laboratory results. Total bilirubin and albumin are entered as tiered ranges rather than exact values. For INR, use the most recently available prothrombin time expressed as INR. For ascites, grade the clinical severity after current medical management (i.e., on diuretics): absent, mild/controlled, or refractory/tense. For encephalopathy, use the West Haven criteria to grade severity — absent, mild-to-moderate (Grades I–II), or severe (Grades III–IV) — reflecting the patient's baseline state, not an acute precipitant episode.
All five parameters must be selected for the score to calculate. The result displays Child-Pugh class, estimated 1- and 2-year survival, and perioperative mortality, along with clinical guidance for each class.
Scoring Criteria
| Parameter | 1 Point | 2 Points | 3 Points |
|---|---|---|---|
| Bilirubin | <2 mg/dL | 2–3 mg/dL | >3 mg/dL |
| Albumin | >3.5 g/dL | 2.8–3.5 g/dL | <2.8 g/dL |
| INR | <1.7 | 1.7–2.3 | >2.3 |
| Ascites | None | Mild | Mod–Severe |
| Encephalopathy | None | Grade I–II | Grade III–IV |
Interpretation Guide: Child-Pugh Classification
| Class | Score | 1-Yr Survival | 2-Yr Survival | Perioperative Mortality |
|---|---|---|---|---|
| A | 5–6 | 100% | 85% | 10% |
| B | 7–9 | 81% | 57% | 30% |
| C | 10–15 | 45% | 35% | 82% |
Class A patients have well-compensated cirrhosis and generally tolerate most surgical procedures. The 10% perioperative mortality figure applies primarily to major abdominal surgery; minor procedures carry substantially lower risk. Standard surveillance (endoscopy every 1–3 years, 6-monthly hepatocellular carcinoma screening with ultrasound ± AFP) is appropriate.
Class B patients have clinically significant hepatic dysfunction. Elective surgery carries substantially elevated risk, and the decision to proceed requires careful multidisciplinary assessment including hepatology and anesthesia. Optimization of ascites, nutrition, and coagulopathy before any planned procedure is essential. Transplant evaluation should be initiated if not already underway.
Class C patients have decompensated cirrhosis. Elective surgery is generally contraindicated due to very high perioperative mortality (above 80% for major surgery). The clinical priority is transplant evaluation. Palliative interventions and goals-of-care discussions are appropriate in patients who are not transplant candidates.
Child-Pugh vs MELD
The MELD score replaced Child-Pugh for organ allocation due to its fully objective (laboratory-only) inputs and better prediction of short-term mortality. However, Child-Pugh remains clinically valuable for surgical risk assessment, hepatocellular carcinoma staging (Barcelona Clinic Liver Cancer criteria), and decisions about treatment tolerability (e.g., chemotherapy, procedures). Use both in clinical practice for complementary information.
Limitations & Considerations
Subjective components: Ascites grading and encephalopathy grading are inherently observer-dependent. Studies have documented substantial inter-observer variability in Child-Pugh scoring — particularly for ascites, which can be difficult to distinguish clinically between "mild/controlled" and "moderate/refractory" categories. Wherever possible, ascites should be graded after imaging confirmation and assessment of response to current diuretic therapy.
Arbitrary thresholds: The cutoffs for bilirubin and albumin are fixed and do not reflect the continuous relationship between these values and prognosis. A patient with albumin of 3.6 g/dL (scored 1 point) is scored identically to a patient with albumin of 4.5 g/dL, despite meaningfully different clinical situations. Conversely, patients just above a threshold boundary may have scores that change substantially with small laboratory fluctuations.
Not validated for transplant allocation: Child-Pugh should not be used as the primary tool for organ allocation decisions. MELD-Na is the appropriate score for UNOS/OPTN transplant allocation. Child-Pugh is most appropriate for surgical risk stratification, oncology treatment eligibility decisions, and overall prognosis communication.
Etiology and treatment response: Survival estimates are derived from pooled cirrhosis cohorts and do not account for differences in survival by etiology (viral vs. alcoholic vs. metabolic), presence of portal hypertension complications, or response to treatments (direct-acting antivirals for HCV, alcohol abstinence). A patient with Child-Pugh B due to active alcohol use may improve dramatically to Class A with sustained sobriety.
References
Pugh RN, et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60(8):646–649.
Child CG, Turcotte JG. Surgery and portal hypertension. Major Probl Clin Surg. 1964;1:1–85.
Kamath PS, Kim WR. The model for end-stage liver disease (MELD). Hepatology. 2007;45(3):797–805.
Forner A, Reig M, Bruix J. Hepatocellular carcinoma. Lancet. 2018;391(10127):1301–1314. (BCLC algorithm incorporating Child-Pugh class)