Child-Pugh Score Calculator — Cirrhosis Severity Classification
The Child-Pugh score (also known as the Child-Turcotte-Pugh score) is a widely used clinical tool for assessing the severity of liver cirrhosis and predicting prognosis. It classifies patients into Class A (well-compensated), B (significant functional compromise), or C (decompensated disease) based on five clinical and laboratory parameters.
About
The Child-Pugh score was originally developed by Child and Turcotte in 1964 for assessing surgical risk in patients undergoing portacaval shunt surgery, later modified by Pugh et al. in 1973 to replace the subjective nutritional status assessment with prothrombin time/INR. The score combines five variables: total bilirubin, serum albumin, INR (or prothrombin time), ascites severity, and hepatic encephalopathy grade. Each variable is scored from 1 to 3, yielding a total score of 5 (best prognosis) to 15 (worst prognosis). The score is used in clinical practice for prognostication in cirrhosis, guiding treatment decisions such as elective surgery risk assessment, variceal bleeding management, and determination of liver transplant urgency. It is also a component of the MELD score and remains a key tool in liver disease assessment despite the development of more refined scoring systems.
Formula
Child-Pugh = Bilirubin score (1-3) + Albumin score (1-3) + INR score (1-3) + Ascites score (1-3) + Encephalopathy score (1-3)
The Child-Pugh score is calculated by summing the points assigned to each of five clinical and laboratory variables. Each variable is scored 1, 2, or 3 based on predefined thresholds. Bilirubin: <2 mg/dL = 1, 2-3 mg/dL = 2, >3 mg/dL = 3. Albumin: >3.5 g/dL = 1, 2.8-3.5 g/dL = 2, <2.8 g/dL = 3. INR: <1.7 = 1, 1.7-2.3 = 2, >2.3 = 3. Ascites: None = 1, Mild-Moderate (diuretic-responsive) = 2, Severe/Tense (diuretic-refractory) = 3. Encephalopathy: None = 1, Grade I-II (mild, controlled with lactulose) = 2, Grade III-IV (severe, obtundation or coma) = 3. The total score (5-15) determines the Child-Pugh class: Class A (5-6, well-compensated, 100% 1-year survival), Class B (7-9, significant compromise, 80% 1-year survival), Class C (10-15, decompensated, 45% 1-year survival). The score is used to predict surgical risk in cirrhotic patients, guide transplant timing, and assess prognosis in acute variceal bleeding. Important caveats: In patients with primary biliary cholangitis (PBC) or primary sclerosing cholangitis (PSC), the bilirubin thresholds are adjusted upward (bilirubin <4 mg/dL = 1, 4-10 = 2, >10 = 3) due to the predominant cholestatic picture.
Score Interpretation
The Child-Pugh score is one of the most established clinical tools in hepatology, used for over five decades to assess cirrhosis severity and predict outcomes. Despite the development of the MELD score for transplant allocation, Child-Pugh remains widely used in clinical practice for its simplicity and clinical applicability. Key applications include: (1) Predicting surgical risk in cirrhotic patients — Class A patients tolerate surgery well, Class B requires careful preoperative optimization, and Class C has prohibitively high surgical risk; (2) Guiding variceal bleeding management — the score predicts rebleeding risk and guides prophylaxis; (3) Assessing candidacy and urgency for liver transplantation; (4) Determining prognosis in acute decompensation. The score has been validated in multiple populations including alcoholic cirrhosis, viral hepatitis cirrhosis, and NAFLD-related cirrhosis. Limitations include ceiling and floor effects (as it uses ordinal rather than continuous scoring), subjective assessment of ascites and encephalopathy, and lack of discrimination among patients at the extremes of disease severity. The modified Child-Pugh score for PBC/PSC adjusts bilirubin thresholds to account for the cholestatic nature of these diseases.
Child-Pugh Class A — Well-compensated — 5–6
Child-Pugh A (5-6). Well-compensated cirrhosis. 100% 1-year survival.
Management: Continue routine liver disease management. Monitor liver function every 6 months. Screen for varices and HCC. Avoid alcohol and hepatotoxic medications.
Child-Pugh Class B — Significant compromise — 7–9
Child-Pugh B (7-9). Significant functional compromise. 80% 1-year survival.
Management: Monitor liver function every 3 months. Consider liver transplant evaluation. Manage ascites, encephalopathy, and varices. Restrict sodium.
Child-Pugh Class C — Decompensated — 10–15
Child-Pugh C (10-15). Decompensated cirrhosis. 45% 1-year survival.
Management: Urgent liver transplant evaluation. Aggressive management of complications. ICU-level monitoring if acutely decompensated. Palliative care if not transplant candidate.
Reference Ranges
| Population | Normal Range | Notes |
|---|---|---|
| Patients with cirrhosis | 5-15 points (Class A: 5-6, B: 7-9, C: 10-15) | Higher score = more severe disease. Class A: 100%, B: 80%, C: 45% 1-year survival. |
Dr. Mahmoud El-Sayed
Dr. Mahmoud is an endocrinology consultant with expertise in metabolic liver disease assessment.
View medical review board & editorial policy →Example Calculation
A 55-year-old man with decompensated alcoholic cirrhosis presents with new-onset ascites requiring large-volume paracentesis, and mild hepatic encephalopathy (Grade II) controlled with lactulose. Labs: total bilirubin 4.8 mg/dL (>3 → 3 points), albumin 2.4 g/dL (<2.8 → 3 points), INR 1.9 (1.7-2.3 → 2 points). Ascites: severe/tense requiring frequent paracentesis (3 points). Encephalopathy: Grade II, controlled with lactulose (2 points). Total score = 3 + 3 + 2 + 3 + 2 = 13. Child-Pugh Class C (decompensated disease, 45% 1-year survival). This patient should undergo urgent liver transplant evaluation, aggressive management of ascites and encephalopathy, and ICU-level monitoring for acute decompensation events.
Related Conditions
Related Medications
Common Mistakes
Using standard bilirubin thresholds for patients with PBC or PSC
For PBC and PSC, use adjusted thresholds: bilirubin <4 mg/dL = 1, 4-10 = 2, >10 = 3, as these patients have predominant cholestasis with higher baseline bilirubin.
Relying solely on Child-Pugh for transplant allocation without MELD
Child-Pugh is valuable for clinical prognostication, but MELD/MELD-Na is the standard score for liver transplant allocation in most regions. Use both scores complementarily.
Not accounting for subjective variability in ascites and encephalopathy assessment
Ascites should be assessed by physical examination and/or ultrasound. Encephalopathy grading should use standardized West Haven criteria. Consider interobserver variability when interpreting results.
Frequently Asked Questions
What is the difference between Child-Pugh and MELD scores?
Can Child-Pugh be used in acute liver failure?
How is ascites graded in the Child-Pugh score?
References
- Pugh RN, Murray-Lyon IM, Dawson JL, et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60(8):646-649. PubMed
- Child CG, Turcotte JG. Surgery and portal hypertension. Major Probl Clin Surg. 1964;1:1-85.
- Infante-Rivard C, Esnaola S, Villeneuve JP. Clinical and statistical validity of conventional prognostic factors in predicting short-term survival among cirrhotics. Hepatology. 1987;7(4):660-664. PubMed
- Fattovich G, Giustina G, Degos F, et al. Morbidity and mortality in compensated cirrhosis type C: a retrospective follow-up study of 384 patients. Gastroenterology. 1997;112(2):463-472. PubMed
- European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the Management of Patients with Decompensated Cirrhosis. J Hepatol. 2018;69(2):406-460. PubMed