Child-Pugh Score: A Vital Tool for Assessing Liver Disease Severity
The Child-Pugh score is an empiric scoring system that classifies patients with chronic liver disease into three classes (A-C) according to likelihood of survival, providing a rough estimate of liver function by categorizing patients as having compensated (class A) or decompensated (classes B and C) cirrhosis. 1
Components of the Child-Pugh Score
The Child-Pugh score incorporates five parameters:
Laboratory Parameters (Objective):
- Serum albumin
- Serum bilirubin
- Prothrombin time/INR
Clinical Parameters (Subjective):
- Hepatic encephalopathy
- Ascites
Scoring System
Each parameter is scored 1-3 points, with higher scores indicating worse function:
| Parameter | 1 point | 2 points | 3 points |
|---|---|---|---|
| Albumin (g/dL) | >3.5 | 2.8-3.5 | <2.8 |
| Bilirubin (mg/dL) | <2 | 2-3 | >3 |
| PT (seconds prolonged) or INR | <4 or <1.7 | 4-6 or 1.7-2.3 | >6 or >2.3 |
| Ascites | None | Mild/Controlled | Moderate-Severe/Refractory |
| Encephalopathy | None | Grade 1-2 | Grade 3-4 |
Classification and Interpretation
- Class A: 5-6 points (compensated cirrhosis)
- Class B: 7-9 points (moderate functional compromise)
- Class C: 10-15 points (decompensated cirrhosis)
This classification correlates with 1-year survival rates:
- Class A: 100%
- Class B: 80%
- Class C: 45%
Clinical Applications
The Child-Pugh score is used for:
- Assessing prognosis in cirrhotic patients
- Determining candidacy for liver transplantation
- Guiding treatment decisions for hepatocellular carcinoma
- Evaluating surgical risk in cirrhotic patients
- Predicting complications of portal hypertension
Advantages and Limitations
Advantages:
- Easy to perform at bedside
- Includes both laboratory and clinical parameters
- Well-established prognostic value
- Useful for long-term prognosis (1-5 years) 2
Limitations:
- Includes subjective assessments (ascites, encephalopathy)
- Does not include renal function (an important prognostic factor)
- Limited sensitivity for short-term mortality prediction
- Does not account for other important factors like portal hypertension
Comparison with MELD Score
The Model for End-Stage Liver Disease (MELD) score is an alternative scoring system that:
- Uses only objective laboratory values (bilirubin, creatinine, INR)
- Includes renal function assessment
- Better predicts short-term (3-month) mortality
- Is used for liver transplant allocation by UNOS
However, the Child-Pugh score remains valuable for clinical assessment at the bedside and for long-term prognostication 1, 2, 3.
Clinical Pearls
- A more recent version of the Child-Pugh score incorporates INR instead of prothrombin time 1
- The Child-Pugh score should be supplemented with assessment for portal hypertension (varices, splenomegaly, thrombocytopenia) 1
- In some settings, modified versions of the Child-Pugh score (adding creatinine) perform similarly to MELD 4
- The Child-Pugh score remains a cornerstone of liver disease assessment despite newer scoring systems 3
Remember that while the Child-Pugh score is valuable for overall assessment of liver function, treatment decisions should consider additional factors specific to the clinical scenario and underlying liver disease etiology.