The Child-Pugh score is the classic bedside grading of liver dysfunction in cirrhosis. It is quick to add up and widely quoted, but it carries a few historical quirks and real limitations that are worth knowing before you rely on it. This guide covers where it came from, how each item is scored, what the classes mean, and how it compares with MELD.
Origin
Pugh and colleagues published the table in the British Journal of Surgery in 1973. They modified the earlier Child and Turcotte grading for patients having oesophageal transection for bleeding varices: they dropped nutritional status and added prothrombin time. Child and Turcotte first used the grades to estimate operative risk; the classes are now used more widely to describe how well the liver is working.
The five items
Each item scores 1, 2 or 3 points, so the total runs from 5 to 15.
| Item | 1 point | 2 points | 3 points |
|---|---|---|---|
| Hepatic encephalopathy | None | Grade 1-2 | Grade 3-4 |
| Ascites | None | Slight | Moderate to severe |
| Bilirubin | Under 2 mg/dL (under 34 µmol/L) | 2-3 mg/dL (34-50 µmol/L) | Over 3 mg/dL (over 50 µmol/L) |
| Albumin | Over 3.5 g/dL (over 35 g/L) | 2.8-3.5 g/dL (28-35 g/L) | Under 2.8 g/dL (under 28 g/L) |
| INR | Under 1.7 | 1.7-2.3 | Over 2.3 |
Prothrombin time or INR?
Pugh's original table scored clotting as seconds of prothrombin time prolongation over control: 1 to 4, 4 to 6, and over 6 seconds. Prothrombin time in seconds differs between laboratories, so most current versions score the INR instead, with under 1.7, 1.7 to 2.3 and over 2.3 as the cut-offs. If you compare a modern score with an old paper, check which one was used.
Unit conversions
Bilirubin in mg/dL multiplied by 17.1 gives µmol/L, so the 2 and 3 mg/dL cut-offs are about 34 and 51 µmol/L, usually rounded to 34 and 50. Albumin in g/dL multiplied by 10 gives g/L.
Classes A, B and C
- Class A, 5 or 6 points: well-compensated cirrhosis.
- Class B, 7 to 9 points: moderate dysfunction. It is sometimes reported by its exact score, as B7, B8 or B9.
- Class C, 10 to 15 points: severe dysfunction.
Blind spots
- Two subjective items. Ascites and encephalopathy are graded by clinical judgement, so two clinicians can score the same patient differently, and treatment can lower both grades.
- INR is imperfect. It varies between laboratories and does not fully reflect clotting in cirrhosis.
- Albumin moves for other reasons. It falls with poor nutrition and rises with infused albumin.
- Ceiling effect. Each item tops out at 3 points, so a very high bilirubin or INR adds no more to the score.
- No kidney function. Creatinine is not part of Child-Pugh, while it is part of MELD.
Child-Pugh or MELD?
Child-Pugh adds points for five items, two of them clinical grades, and gives a class from A to C. MELD is calculated from three lab values (bilirubin, creatinine and INR) and is used to rank candidates for liver transplant. A 2016 meta-analysis of 119 studies by Peng and colleagues found the two scores had similar prognostic value in most settings, with differences in some groups, such as patients in intensive care or having surgery.
Calculator
AskMed, an AI medical reference app for clinicians, has a Child-Pugh calculator that scores INR, accepts bilirubin in mg/dL or µmol/L and albumin in g/dL or g/L, and shows the class with the original table and sources. It runs in your browser and does not send or store what you enter: Child-Pugh calculator.
Sources
- Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60(8):646-649.
- Peng Y, Qi X, Guo X. Child-Pugh versus MELD score for the assessment of prognosis in liver cirrhosis: a systematic review and meta-analysis of observational studies. Medicine (Baltimore). 2016;95(8):e2877.