Child-Pugh Score Calculator

Bilirubin (mg/dL)

Albumin (g/dL)

INR (or use PT below)

Ascites

Hepatic Encephalopathy

Quick reference: Bilirubin <2=1pt, 2–3=2pt, >3=3pt • Albumin >3.5=1pt, 2.8–3.5=2pt, <2.8=3pt • INR <1.7=1pt, 1.7–2.3=2pt, >2.3=3pt

Scoring Criteria

Parameter	1 point	2 points	3 points
Bilirubin (mg/dL)	< 2.0	2.0–3.0	> 3.0
Albumin (g/dL)	> 3.5	2.8–3.5	< 2.8
INR	< 1.7	1.7–2.3	> 2.3
Ascites	None	Mild (diuretic-responsive)	Moderate–severe or refractory
Encephalopathy	None	Grade I–II	Grade III–IV

Total score = sum of 5 parameters. Range: 5–15 points. Some centres use PT prolongation instead of INR: <4s=1pt, 4–6s=2pt, >6s=3pt.

Interpretation

Score	Class	Disease State	1-Year Survival	2-Year Survival
5–6	A	Well-compensated	~100%	~85%
7–9	B	Significant functional compromise	~81%	~57%
10–15	C	Decompensated cirrhosis	~45%	~35%

Surgical Risk (Cirrhotic Patients)

Class	Estimated Operative Mortality	Recommendation
A	5–10%	Elective surgery acceptable with optimisation
B	25–30%	High risk — consider only if unavoidable; optimise first
C	60–80%	Surgery contraindicated except life-saving emergency

Clinical Application

Originally developed by Child and Turcotte (1964) and modified by Pugh (1973) to predict perioperative mortality in patients with cirrhosis undergoing porto-caval shunt surgery. It remains the most widely used clinical classification of liver disease severity in surgical and anaesthetic planning.

Surgical risk stratification: Standard tool for assessing fitness for elective surgery in cirrhotic patients, used alongside MELD for major hepatic and non-hepatic procedures
Hepatocellular carcinoma: BCLC staging and most HCC treatment algorithms require Child-Pugh classification — Class C generally excludes resection, ablation, and TACE
Primary biliary cholangitis & PSC: Used alongside disease-specific scores for transplant timing decisions
HVPG-guided therapy: Child-Pugh class informs risk of variceal bleeding in cirrhotic patients and guides prophylaxis
Drug dosing: Medication prescribing in hepatic impairment commonly references Child-Pugh class (A/B/C) for dose adjustments

Limitations

Subjective parameters (ascites and encephalopathy) introduce inter-observer variability
Ceiling effect — Class C covers a wide range of severity (score 10–15)
Less precise than MELD for predicting 90-day mortality on the transplant waiting list
Albumin and bilirubin affected by factors other than liver function (inflammation, haemolysis, nutritional state)
Does not incorporate renal function (creatinine/sodium), which strongly predicts outcomes in cirrhosis
PT/INR can be affected by vitamin K deficiency and anticoagulant use

References

Child CG, Turcotte JG. Surgery and portal hypertension. In: The Liver and Portal Hypertension. Philadelphia: Saunders; 1964. pp 50–64.
Pugh RN, et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60(8):646–649.
Garrison RN, et al. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Ann Surg. 1984;199(6):648–655.
de Franchis R, et al. Baveno VII — Renewing consensus in portal hypertension. J Hepatol. 2022;76(4):959–974.
Reissfelder C, et al. The EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma. J Hepatol. 2018;69(1):182–236.

Child-Pugh Score