Can Child-Pugh Score Be Used in HCC?
Yes, the Child-Pugh score can and should be used in hepatocellular carcinoma (HCC) as it is a fundamental component of the BCLC staging system and essential for treatment selection, but it has significant limitations in patients with good hepatic reserve (Child-Pugh A) where the ALBI grade provides superior prognostic discrimination. 1
Role in HCC Staging and Treatment Selection
The Child-Pugh score is embedded in the Barcelona Clinic Liver Cancer (BCLC) staging system, which is the most widely endorsed classification system for HCC management. 1, 2 The BCLC system integrates three critical variables: tumor burden, liver function (assessed by Child-Pugh), and performance status to guide treatment allocation. 1, 2
Child-Pugh classification determines eligibility for curative and palliative therapies:
- Child-Pugh A patients are candidates for resection, ablation, transplantation, TACE, and systemic therapy 1, 2
- Child-Pugh B patients (score 7-9) may receive TACE if score ≤7 without ascites, but are generally excluded from resection and systemic therapy trials 2
- Child-Pugh C patients (score 10-15) should receive best supportive care only, with median survival <4 months, unless tumor meets Milan criteria for transplantation 2
Critical Limitations in HCC
Poor Discrimination in Compensated Cirrhosis
The most significant limitation is that Child-Pugh fails to adequately stratify patients with Child-Pugh A disease, who now comprise nearly 80% of newly diagnosed HCC cases. 1, 3 The 2025 EASL guidelines explicitly acknowledge that Child-Pugh has "limited predictive power" and includes subjective variables (ascites detected by imaging) that impair clinical applicability. 1
The ALBI grade outperforms Child-Pugh in multiple domains:
- Predicting postoperative liver failure: ALBI has superior discriminatory ability (AUC 0.723 vs 0.607 for Child-Pugh, P<0.001) 4
- Stratifying overall survival: ALBI grade subdivides Child-Pugh A patients into two distinct prognostic groups (P<0.001), while Child-Pugh cannot further stratify ALBI grade 2 patients 5
- Long-term outcomes: Time-dependent ROC analysis demonstrates ALBI maintains better discriminatory ability than Child-Pugh, especially for long-term survival prediction 5
Subjective Components and Missing Variables
Child-Pugh includes subjective assessments (ascites grading, encephalopathy) that introduce variability. 1, 6 More critically, it does not capture clinically significant portal hypertension—a key contraindication to resection—which must be assessed separately through esophagogastric varices, splenomegaly, thrombocytopenia <100×10³/µL, or hepatic venous pressure gradient >10 mmHg. 1, 2
Practical Algorithm for Liver Function Assessment in HCC
Step 1: Calculate Child-Pugh score (bilirubin, albumin, INR, ascites, encephalopathy) to determine broad treatment eligibility 6, 2
Step 2: If Child-Pugh A, calculate ALBI grade to refine prognostic stratification:
- ALBI grade 1: Best hepatic reserve, proceed with planned therapy 5, 4
- ALBI grade 2: Subdivide using modified ALBI (mALBI 2a vs 2b) for more granular risk assessment 3
Step 3: Assess for portal hypertension regardless of Child-Pugh score, as this independently predicts poor surgical outcomes 1, 2
Step 4: For surgical candidates, consider ICG-R15 testing with cutoffs <20-25% for major hepatectomy and <30-35% for segmentectomy 7
Common Pitfalls to Avoid
Do not rely solely on Child-Pugh A designation to proceed with aggressive therapy. Nearly half of Child-Pugh A patients have ALBI grade 2 disease with significantly worse outcomes than ALBI grade 1 patients (5-year survival 0% vs 35.5%, P<0.001). 5
Do not assume Child-Pugh B patients are uniform. Child-Pugh B7 without ascites may tolerate TACE, while B8-9 or any B with ascites should not receive locoregional therapy due to high risk of acute liver failure. 2
Do not use Child-Pugh alone for surgical planning. The presence of clinically significant portal hypertension (HVPG >10 mmHg) is an absolute contraindication to resection regardless of Child-Pugh A status, as it dramatically increases postoperative liver failure risk. 1, 2
Evidence Quality and Guideline Consensus
The 2025 EASL guidelines explicitly state that while Child-Pugh remains part of the BCLC system, "there is room for further refinement of prognosis evaluation" and acknowledge that ALBI grade provides "improved model for liver functional estimation." 1 Multiple high-quality studies from 2016-2020 consistently demonstrate ALBI's superiority in HCC-specific outcomes. 5, 4, 3
The current consensus is to use Child-Pugh for initial treatment allocation per BCLC staging, but supplement with ALBI grade for refined prognostication, especially in Child-Pugh A patients. 1, 5