Child Pugh Score Calculator

Child-Pugh Score: Formula, Variables, and Clinical Application

The Child-Pugh score (also called the Child-Pugh-Turcotte score) is a validated clinical scoring system used to assess the severity of liver cirrhosis, estimate short-term prognosis, and stratify surgical risk. Originally developed by Child and Turcotte in 1964 and later refined by Pugh RN et al. in their landmark 1973 British Journal of Surgery publication, the score remains a cornerstone tool in hepatology practice worldwide.

The Scoring Formula

The Child-Pugh score sums five independently scored clinical and laboratory parameters:

Total Score = P1 + P2 + P3 + P4 + P5

Each parameter receives a value of 1 (normal or mild abnormality), 2 (moderate abnormality), or 3 (severe abnormality), producing a total score ranging from 5 to 15. Higher scores indicate more advanced hepatic decompensation.

Scoring Each Variable

• Total Bilirubin (mg/dL): Less than 2.0 mg/dL scores 1 point; 2.0-3.0 mg/dL scores 2 points; greater than 3.0 mg/dL scores 3 points. Elevated bilirubin reflects impaired hepatic conjugation and excretion capacity.
• Serum Albumin (g/dL): Greater than 3.5 g/dL scores 1 point; 2.8-3.5 g/dL scores 2 points; less than 2.8 g/dL scores 3 points. Because albumin is synthesized exclusively in the liver, hypoalbuminemia serves as a sensitive marker of diminished hepatic synthetic function.
• INR (International Normalized Ratio): Less than 1.7 scores 1 point; 1.7-2.3 scores 2 points; greater than 2.3 scores 3 points. Prolonged prothrombin time reflects reduced synthesis of clotting factors I, II, V, VII, and X — all produced by hepatocytes.
• Ascites: Absent scores 1 point; mild ascites (controlled with diuretics) scores 2 points; moderate to severe or refractory ascites scores 3 points. Ascites signals portal hypertension and impaired oncotic pressure from low albumin.
• Hepatic Encephalopathy (West Haven Criteria): No encephalopathy scores 1 point; Grade I-II (mild confusion, asterixis) scores 2 points; Grade III-IV (marked confusion, stupor, or coma) scores 3 points. Encephalopathy indicates failure to clear ammonia and other neurotoxic metabolites.

Child-Pugh Classification and Survival Estimates

• Class A — 5 to 6 points: Well-compensated disease. Estimated 1-year survival approximately 100%; 2-year survival approximately 85%. Patients typically tolerate major surgery and standard drug dosing.
• Class B — 7 to 9 points: Significant functional compromise. Estimated 1-year survival approximately 80%; 2-year survival approximately 60%. Elective surgery carries moderate risk; drug dose reductions are often warranted.
• Class C — 10 to 15 points: Decompensated disease. Estimated 1-year survival approximately 45%; 2-year survival approximately 35%. Surgery is typically contraindicated except in life-threatening emergencies; liver transplant evaluation is strongly indicated.

Worked Clinical Example

A patient presents with: total bilirubin 2.5 mg/dL (2 points), serum albumin 3.0 g/dL (2 points), INR 1.9 (2 points), mild ascites controlled with spironolactone (2 points), and no hepatic encephalopathy (1 point). Total score = 2 + 2 + 2 + 2 + 1 = 9 points — Child-Pugh Class B. This patient carries moderate perioperative risk and warrants dose adjustments for hepatically metabolized medications.

Clinical Applications

• Surgical risk stratification: Anesthesiologists and surgeons use Child-Pugh class to estimate operative mortality before abdominal, cardiac, and orthopedic procedures in cirrhotic patients.
• Pharmaceutical dosing: FDA and EMA labeling for many drugs — including antifungals, antivirals, and targeted cancer therapies — specifies dose reductions or contraindications based on Child-Pugh Class B or C status.
• Liver transplant prioritization: Class C patients receive priority consideration for transplant listing, used alongside the MELD score per AASLD Practice Guidelines on Cirrhosis.
• Disease monitoring: Serial Child-Pugh scores track progression in hepatitis B, hepatitis C, alcoholic cirrhosis, and metabolic-associated steatohepatitis (MASH).

Limitations

The ascites and encephalopathy parameters involve subjective clinical judgment, introducing inter-observer variability. The score excludes renal function — a critical determinant in hepatorenal syndrome. Its ordinal scale limits precision compared to continuous models. According to StatPearls on NCBI Bookshelf, the MELD score has largely supplanted Child-Pugh for organ allocation in the United States, yet Child-Pugh retains indispensable value in surgical planning and pharmacokinetic dose-adjustment protocols globally.