Child-Pugh Classification for Liver Disease
The Child-Pugh classification is a validated bedside scoring system that stratifies patients with cirrhosis into three prognostic classes (A, B, or C) based on five clinical and laboratory parameters: encephalopathy, ascites, bilirubin, albumin, and prothrombin time/INR. 1
Scoring Components
The Child-Pugh score assigns 1-3 points for each of five parameters, with total scores ranging from 5-15 points 2:
Laboratory Parameters
- Bilirubin: <2 mg/dL (1 point), 2-3 mg/dL (2 points), >3 mg/dL (3 points) 2
- Albumin: >3.5 g/dL (1 point), 2.8-3.5 g/dL (2 points), <2.8 g/dL (3 points) 2
- Prothrombin time/INR: <4 seconds or INR <1.7 (1 point), 4-6 seconds or INR 1.7-2.3 (2 points), >6 seconds or INR >2.3 (3 points) 2
Clinical Parameters
- Encephalopathy: None (1 point), Grade 1-2 (2 points), Grade 3-4 (3 points) 2
- Ascites: Absent (1 point), Slight (2 points), Moderate to severe (3 points) 2
Classification and Prognosis
Patients are classified into three distinct prognostic categories based on total score 1:
- Class A (5-6 points): Compensated cirrhosis with 90% 5-year survival 2
- Class B (7-9 points): Decompensated cirrhosis with 80% 5-year survival 2
- Class C (10-15 points): Advanced decompensated cirrhosis with >33% mortality within 1 year 2
The classification effectively separates patients into groups with significantly different median survivals and survival curves (p <0.0001) 3.
Clinical Applications
Treatment Decision-Making
The Child-Pugh score directly guides therapeutic interventions and determines eligibility for major procedures 1:
- Class A patients: Candidates for surgical resection, liver transplantation, and aggressive interventions 1
- Class B patients: Selected favorable Class B patients may be considered for specific treatments; unfavorable Class B patients should receive palliative approaches 1
- Class C patients: Should receive only supportive care unless on transplant waiting list, given poor anticipated survival 1
Hepatocellular Carcinoma Management
The score is essential for HCC treatment planning, as it assesses hepatic functional reserve in patients where tumor burden and liver function both impact prognosis 1. The NCCN guidelines specifically incorporate Child-Pugh classification to stratify HCC patients for resection, transplantation, or palliative therapy 1.
Perioperative Risk Assessment
Child-Pugh classification predicts perioperative mortality and helps determine surgical candidacy, particularly for hepatectomy in cirrhotic patients 1, 2.
Advantages and Limitations
Key Advantages
- Simplicity: Can be calculated at bedside without complex formulas 1, 3
- Availability: Uses widely available laboratory tests and clinical assessments 3
- Validation: Well-established with decades of clinical use and validation 3
- Clinical parameters: Incorporates subjective but clinically relevant findings (ascites, encephalopathy) 1
Important Limitations
The Child-Pugh score has several critical shortcomings that must be recognized 1, 2:
- Subjective components: Grading of ascites and encephalopathy introduces inter-observer variability 2
- No renal function assessment: Does not include creatinine, an established prognostic marker in liver disease 1
- Limited dynamic range: Categorizes continuous variables into only three groups, reducing discriminatory power 2
- Ceiling effect: Most patients cluster in Class A (score 5-6), limiting prognostic granularity in compensated cirrhosis 2
Comparison with MELD Score
The MELD score (using bilirubin, creatinine, and INR) provides more objective assessment and better predicts short-term mortality 1:
- MELD includes renal function (creatinine), which Child-Pugh lacks 1
- MELD uses continuous variables without arbitrary cutoffs 1
- MELD is the standard for liver transplant allocation in the United States 1
- It remains unclear whether MELD is superior to Child-Pugh for predicting survival in non-transplant cirrhosis patients 1
Critical Clinical Pearls
Portal hypertension assessment should always accompany Child-Pugh scoring 1. Look for esophagogastric varices, splenomegaly, abdominal collaterals, and thrombocytopenia, as these findings significantly impact prognosis independent of the Child-Pugh score 1.
A 2-point worsening in Child-Pugh score or progression from Class A to Class B accurately indicates deteriorating health status and increased mortality risk 2. This makes the score useful for monitoring disease progression over time.
Development of decompensating events (ascites, variceal bleeding, hepatorenal syndrome) dramatically worsens prognosis, with 5-year survival dropping to 20-50% regardless of initial Child-Pugh class 2.
Current Role in Practice
Despite ongoing debate about whether to abandon Child-Pugh classification 4, it remains widely used in clinical practice, particularly for HCC staging systems (BCLC classification) and treatment algorithms 1. The AASLD continues to recommend Child-Pugh classification over MELD for HCC management contexts 1, primarily because it is more commonly used in this setting and incorporates clinical parameters relevant to treatment tolerance.