The Child-Pugh score (Pugh RN et al., 1973) is a classic prognostic scale for cirrhosis. It incorporates 5 parameters: total bilirubin, albumin, INR (or PT), presence of ascites, and grade of hepatic encephalopathy. Each parameter is scored 1-3 points, for a total of 5-15.
Classification: class A (5-6 points) - compensated cirrhosis, one-year survival ~95%, low operative risk; class B (7-9) - subcompensated, survival ~80%, moderate risk; class C (10-15) - decompensated, survival 45%, high operative risk.
The score is used to assess cirrhosis severity, guide management (medical therapy, endoscopic interventions, transplantation), and estimate operative risk before elective surgery. AASLD/EASL guidelines include Child-Pugh as a standard tool. Its main competitor is MELD, which is used for liver transplant allocation.
When to use
Established diagnosis of liver cirrhosis - severity stratification.
Decision to start specific therapy (beta-blockers for esophageal varices, lactulose for encephalopathy).
Preoperative risk assessment before elective procedures (particularly liver resection).
Outcome prediction and referral to a transplant specialist (class C - priority candidate).
Parameters in detail
Total bilirubin
Total bilirubin: < 34 µmol/L (1), 34-51 (2), > 51 (3). In primary biliary cholangitis the thresholds are higher (< 68/68-170/> 170).
Serum albumin
Albumin: > 35 g/L (1), 28-35 (2), < 28 (3).
INR (prothrombin time)
INR: < 1.7 (1), 1.7-2.2 (2), > 2.3 (3).
Ascites
Ascites: none (1), controlled with diuretics (2), refractory (3).
Hepatic encephalopathy
Encephalopathy (West Haven): none (1), grade I-II (2), grade III-IV (3).
Clinical example
Case
A 56-year-old man with HCV-related liver cirrhosis. Bilirubin 65 µmol/L, albumin 26 g/L, INR 1.9, refractory ascites, episodes of grade I-II encephalopathy.
Class C - decompensated cirrhosis, one-year survival 45%. Management: lactulose to control encephalopathy, diuretics (spironolactone + furosemide) with reassessment if refractory (TIPS or serial paracentesis), spontaneous bacterial peritonitis prophylaxis (norfloxacin), HCC screening (ultrasound + AFP every 6 months), referral to a transplant center. MELD should be calculated in parallel.
Limitations and cautions
Ascites and encephalopathy grading is subjective - two clinicians may assign different scores.
Does not finely discriminate within class C - the difference between MELD 15 and 30 is substantial.
Does not account for renal function - a critical factor in cirrhosis (which MELD includes).
Not validated for acute liver failure - King's College Hospital criteria are used there.
Frequently asked questions
Child-Pugh vs MELD - which is better?
For transplant allocation, MELD is preferred (more objective, no subjective components). For clinical assessment and patient discussion, Child-Pugh is more intuitive.
Can it be used in a patient without cirrhosis?
No. The score is validated specifically for cirrhosis. Other criteria (King's College, MELD) apply in acute liver failure.
Does the class change with alcohol abstinence?
Yes, in alcohol-related cirrhosis, abstinence can lead to improvement by 1 class within 3-6 months. This is critical for transplant listing decisions.
How often should it be recalculated?
Every 3-6 months in compensated patients, and at every hospitalization or episode of decompensation.
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Aleksandr A. Aulov
Physician, internal medicine, Sechenov School — independent medical education platform.
Calculators are compiled from the original publications and current clinical guidelines. Interpretation thresholds follow the source study unless stated otherwise.
This calculator is intended for healthcare professionals. Do not use it for self-diagnosis or self-treatment. Management decisions are made by the treating clinician based on the full clinical picture of the individual patient.
Last clinical review: April 28, 2026 ·
Author: Aleksandr A. Aulov,
MD, internal medicine ·
Primary source: Pugh RN et al. Br J Surg 1973; 60(8): 646-649