Printed on 3/17/2026
For informational purposes only. This is not medical advice.
The Child-Pugh score (also known as the Child-Turcotte-Pugh score) classifies the severity of chronic liver disease and cirrhosis. It combines five clinical and laboratory parameters — total bilirubin, serum albumin, INR, ascites, and hepatic encephalopathy — to classify patients into Class A (well-compensated), B (significant compromise), or C (decompensated). It is widely used for surgical risk assessment and prognosis in cirrhosis.
Formula: Child-Pugh = Bilirubin(1–3) + Albumin(1–3) + INR(1–3) + Ascites(1–3) + Encephalopathy(1–3)
Obtain recent bilirubin, albumin, and INR. These should be from the past few days and reflect the patient's current hepatic synthetic function.
Evaluate for ascites (none, mild/controlled, moderate-severe) and hepatic encephalopathy grade (none, grade I-II, grade III-IV).
Sum the five scores (5-15 total). Class A (5-6): compensated. Class B (7-9): significant compromise. Class C (10-15): decompensated with high surgical risk.
Surgeons, anesthesiologists
Assess whether a cirrhotic patient can safely undergo elective surgery. Class C patients have ~50-80% perioperative mortality for abdominal surgery.
Hepatologists, palliative care
Communicate disease severity to patients and families. Class correlates with survival: A ~100%, B ~81%, C ~45% at 1 year.
Interventional radiologists, hepatologists
Evaluate candidacy for transjugular intrahepatic portosystemic shunt. Child-Pugh B/C patients have higher post-TIPS encephalopathy risk.
Researchers, study coordinators
Stratify patients by disease severity for hepatology research. Child-Pugh class is a common inclusion/exclusion criterion.
Pharmacists, prescribing physicians
Many drugs require dose adjustment in hepatic impairment. Prescribing information often references Child-Pugh class for dosing recommendations.
Hepatology clinics
Track Child-Pugh class over time to monitor disease progression or improvement with treatment (e.g., after alcohol cessation, HCV cure).
The transition from A to B marks decompensation onset. Class A patients generally tolerate procedures well; Class B/C require careful risk-benefit analysis. Watch for patients with 6 vs. 7 points.
Different examiners may grade these differently. Use standardized definitions: mild ascites = detectable only on imaging or shifting dullness; moderate = obvious on exam; severe = tense ascites. Document your grading.
Diuretics can control ascites (scoring 2 vs. 3). Lactulose can control encephalopathy (scoring 2 vs. 3). A patient on medications may score lower than their true disease severity without treatment.
Use Child-Pugh for surgical risk and prognosis; use [MELD](/tools/meld-score) for transplant prioritization. They capture different aspects: MELD is purely lab-based; Child-Pugh includes clinical assessment.
HCC can kill patients with well-preserved liver function. A Class A patient with HCC may have worse prognosis than their Child-Pugh suggests. Consider HCC separately.
If a patient is on warfarin, INR doesn't reflect hepatic synthetic function. Some experts use a baseline INR of 1.0 or estimate what INR would be off warfarin.
Low albumin isn't solely hepatic; malnutrition, nephrotic syndrome, and inflammation also lower albumin. Consider the clinical context when interpreting.
Perioperative mortality for Class C abdominal surgery approaches 50-80%. Most surgeons decline elective procedures. Emergency surgery has even higher mortality but may be unavoidable.
A patient progressing from A to B, or B to C, has clinically meaningful decompensation. This progression should trigger intensified management and transplant evaluation if appropriate.
Primary biliary cholangitis and primary sclerosing cholangitis may have disproportionately high bilirubin relative to synthetic function. Some modified scoring systems exist but aren't widely used.
Child-Pugh originated from Child and Turcotte (1964) for surgical risk assessment, modified by Pugh (1973). It remains the most widely used cirrhosis classification system. Survival estimates are from the original studies and subsequent validations. Perioperative mortality data is compiled from multiple surgical series.
The Child-Pugh score ranges from 5 to 15 and classifies patients into three classes. Class A (5–6 points) indicates well-compensated cirrhosis with approximately 100% one-year survival and low operative risk. Class B (7–9 points) indicates significant functional compromise with approximately 81% one-year survival and moderate surgical risk. Class C (10–15 points) indicates decompensated cirrhosis with approximately 45% one-year survival and very high operative risk.
The classification helps predict perioperative mortality: Class A patients generally tolerate surgery well, Class B patients have increased but potentially acceptable surgical risk depending on the procedure, and Class C patients have prohibitively high mortality for most elective surgeries (approaching 50–80% for abdominal operations). The score also guides management decisions regarding variceal prophylaxis, transplant referral timing, and overall prognosis.
Use the Child-Pugh score to classify the severity of chronic liver disease in patients with known or suspected cirrhosis. It is particularly valuable for preoperative risk assessment — surgeons and anesthesiologists rely on it to determine whether a cirrhotic patient can safely undergo elective surgery. Class C patients are generally considered too high-risk for most elective procedures.
The score is also used to guide clinical management decisions, such as determining whether to initiate primary prophylaxis for variceal bleeding, assessing the timing of liver transplant referral, and as an entry criterion or stratification variable in clinical research. It provides a quick bedside assessment that combines laboratory data with clinical findings.
The Child-Pugh score includes two subjective components — ascites severity and hepatic encephalopathy grade — which can vary between examiners and are influenced by treatment. A patient on diuretics with controlled ascites and one on lactulose with controlled encephalopathy may score differently depending on how the examiner interprets their current status. This subjectivity reduces inter-rater reliability compared to purely objective scores like [MELD](/tools/meld-score).
The score classifies patients into only three broad categories, which limits its ability to differentiate within groups. Two patients both classified as Class B (one with 7 points and another with 9 points) may have meaningfully different prognoses. The continuous [MELD score](/tools/meld-score) provides finer discrimination and is preferred for transplant allocation.
The score does not account for several important factors in liver disease, including the presence of hepatocellular carcinoma, portal vein thrombosis, hepatorenal syndrome, or the specific etiology of cirrhosis. It was originally developed for predicting surgical risk and may be less accurate for other prognostic applications.
Disclaimer: This tool is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about your health.
Calculate the MELD and MELD-Na scores to assess liver disease severity and transplant priority. Uses bilirubin, INR, creatinine, and sodium.
ClinicalCalculate estimated glomerular filtration rate (eGFR) using the CKD-EPI 2021 race-free equation. Free kidney function assessment with CKD staging from serum creatinine.