1About the Child-Pugh Score
The Child-Pugh score (formally the Child-Turcotte-Pugh or CTP score) is a validated clinical scoring system used to assess the severity of chronic liver disease — primarily cirrhosis — and estimate short-term prognosis. It was originally developed in 1964 by Child and Turcotte to predict survival after portocaval shunt surgery, and later modified by Pugh in 1973, who replaced the nutritional status criterion with prothrombin time (now expressed as INR), giving the scoring system its current form.
The score evaluates five clinical and laboratory parameters, each scored 1–3 points based on severity: serum bilirubin, serum albumin, INR, degree of ascites, and the grade of hepatic encephalopathy. The total score (minimum 5, maximum 15) classifies patients into Class A, B, or C, each with distinct prognostic implications.
Child-Pugh Classification — Survival & Operative Risk
Class A (score 5–6): Well-compensated cirrhosis. One-year survival approximately 100%, two-year survival approximately 85%. Operative mortality for major abdominal surgery is around 10%. These patients generally tolerate elective surgery and can undergo hepatic resection if residual liver volume is adequate.
Class B (score 7–9): Significant functional compromise. One-year survival approximately 80%, two-year approximately 60%. Operative mortality rises to around 30%. Elective major surgery should be approached with caution; risk-benefit analysis is essential. These patients may benefit from pre-operative optimisation (diuretic control of ascites, lactulose for encephalopathy, nutritional support).
Class C (score 10–15): Decompensated cirrhosis. One-year survival approximately 45%, two-year approximately 35%. Operative mortality is approximately 82% — elective surgery is generally contraindicated. Class C patients should be referred for liver transplant evaluation. Emergency surgery, when unavoidable, carries extremely high mortality and requires ICU-level perioperative care.
Child-Pugh Score vs MELD Score
The Child-Pugh score and the MELD score (Model for End-Stage Liver Disease) are the two most widely used tools in hepatology practice. They serve complementary rather than competing purposes:
| Feature | Child-Pugh | MELD / MELD-Na |
|---|---|---|
| Parameters | Bilirubin, albumin, INR, ascites, encephalopathy | Bilirubin, creatinine, INR, sodium (MELD-Na) |
| Objectivity | Partly subjective (ascites, encephalopathy grading) | Fully objective / laboratory-based |
| Best use | Surgical risk stratification, drug dosing, bedside staging | Transplant waitlist prioritization (UNOS / NOTTO) |
| Transplant listing | Class C triggers referral; not used for prioritisation | MELD ≥ 15 used for waitlist; MELD ≥ 25 = high priority |
| Creatinine required | No — practical in resource-limited settings | Yes — reflects renal function / hepatorenal syndrome |
| Score range | 5–15 (3 classes) | 6–40 (continuous; higher = worse) |
In Indian hepatology practice, both scores are routinely used together. Child-Pugh is simpler to calculate at the bedside and is particularly useful for surgical risk assessment and determining eligibility for hepatic resection or TIPS (transjugular intrahepatic portosystemic shunt).
PBC / PSC Bilirubin Modification
In cholestatic liver diseases — primarily Primary Biliary Cholangitis (PBC) and Primary Sclerosing Cholangitis (PSC) — serum bilirubin is disproportionately elevated relative to overall liver synthetic function. Using standard bilirubin cut-offs in these conditions would artificially inflate the Child-Pugh score and overestimate disease severity. The modified thresholds are: 1 point (<4 mg/dL), 2 points (4–10 mg/dL), 3 points (>10 mg/dL). Enable the PBC/PSC toggle in the calculator above when assessing patients with cholestatic liver disease.
Limitations
Despite its widespread use, the Child-Pugh score has several recognised limitations: the grading of ascites and hepatic encephalopathy involves clinical subjectivity and observer variability; serum albumin can be reduced by non-hepatic conditions (malnutrition, nephrotic syndrome, protein-losing enteropathy); and INR values may be affected by anticoagulant therapy. Additionally, the score does not directly account for renal function (a key predictor in hepatorenal syndrome) or for the dynamic trajectory of liver disease. MELD or MELD-Na address some — but not all — of these limitations.
2Frequently Asked Questions
What is the Child-Pugh score and what is it used for?
What is the difference between Child-Pugh Class A, B, and C?
Class B (score 7–9): Significant functional impairment. 1-year survival ~80%, 2-year ~60%, operative mortality ~30%. Requires careful surgical risk-benefit analysis.
Class C (score 10–15): Decompensated cirrhosis. 1-year survival ~45%, 2-year ~35%, operative mortality ~82%. Elective surgery generally contraindicated; prompt transplant referral indicated.
What is the difference between Child-Pugh score and MELD score?
Is there a different Child-Pugh bilirubin cut-off for PBC and PSC?
What are the West Haven criteria for hepatic encephalopathy grading?
Grade 0: No symptoms; normal psychomotor testing may show subtle deficits (covert HE).
Grade 1: Mild confusion, euphoria or depression, slowed thinking, impaired arithmetic, sleep disturbance.
Grade 2: Lethargy, moderate confusion, personality change, inappropriate behaviour, slurred speech.
Grade 3: Somnolent but arousable, severe confusion, gross disorientation, bizarre behaviour.
Grade 4: Coma — unresponsive to painful stimuli.
For Child-Pugh scoring: Grade 0 = 1 point; Grade 1–2 = 2 points; Grade 3–4 = 3 points.