Child-Pugh Score Calculator

Background.

Drug labels, pre-operative assessments and hepatology clinic letters often sum up a person's cirrhosis in a single letter: Child-Pugh A, B or C. The letter comes from five findings, each worth one to three points. Three are blood tests (total bilirubin, serum albumin and the INR) and two are clinical judgements: how much ascites there is, and whether hepatic encephalopathy is present and how severe it is. The points add to a total between 5 and 15, and the total sets the class: 5 or 6 is class A, 7 to 9 is class B, 10 to 15 is class C. The grade describes how severe established liver disease is; it does not diagnose cirrhosis, choose a treatment or set a drug dose.

Every component's points appear beside the total so the class can be checked line by line, and that matters because the bands are coarse. A bilirubin of 3.0 mg/dL earns 2 points while 3.1 earns 3; an albumin of 2.8 g/dL earns 2 while 2.7 earns 3. One tenth on a single lab value, or a change in how the ascites is described in the notes, can move a patient across a class boundary, and the breakdown shows at once which component did it.

The system comes from Pugh and colleagues' 1973 paper on oesophageal transection for bleeding varices, which adapted an earlier grading by Child and Turcotte and put prothrombin time in place of nutritional status. Modern tables, including the one used here, express clotting as the INR. The score's age shows in two ways. Each laboratory value stops at three steps, so a bilirubin of 4 mg/dL and one of 30 score the same. And two of the five inputs depend on how a clinician grades what they see at the bedside. Both limits help explain why the laboratory-only MELD score was developed later, and why the two are often reported together.

What is child-pugh score calculator?

The Child-Pugh score, also called the Child-Turcotte-Pugh score, grades how far chronic liver disease, usually cirrhosis, has progressed. Bilirubin reflects how well the liver clears the breakdown products of haemoglobin; albumin and the INR reflect how well it makes proteins, including clotting factors; ascites and encephalopathy are complications that appear as liver function fails and pressure in the portal circulation rises. Each finding scores 1 point when it is normal or close to it and up to 3 when it is severely abnormal, and the five scores carry equal weight. Higher totals mean worse function: class A at the low end, class C at the high end. Regulators and drug labels commonly describe hepatic impairment as mild, moderate or severe according to Child-Pugh class A, B or C.

How to use this calculator.

1. 01Enter total bilirubin in mg/dL, using the total figure rather than the direct (conjugated) fraction. If your report gives µmol/L, divide by 17.1 first: 51 µmol/L is about 3.0 mg/dL.
2. 02Enter serum albumin in g/dL. A result reported in g/L needs dividing by 10, so 29 g/L becomes 2.9.
3. 03Enter the INR from the same set of bloods. If the patient takes warfarin, the INR reflects the drug as much as the liver and will inflate this component.
4. 04Choose the ascites category recorded at clinical assessment: none; mild, or controlled with diuretics; or moderate to severe, or refractory to treatment.
5. 05Choose the hepatic encephalopathy grade documented on examination: none, grade I–II, or grade III–IV.
6. 06Read the total and the class shown beside it (5–6 is A, 7–9 is B, 10–15 is C), checking each points line before the class goes into a note.

The formula.

Total score = bilirubin points + albumin points + INR points + ascites points + encephalopathy points, each component scoring 1, 2 or 3. Bilirubin scores 1 below 2 mg/dL, 2 from 2 to 3 mg/dL inclusive, and 3 above 3 mg/dL (in SI units the cut-offs are 34.2 and 51.3 µmol/L). Albumin runs the other way, because a low value means poor synthesis: above 3.5 g/dL scores 1, 2.8 to 3.5 g/dL inclusive scores 2, and below 2.8 g/dL scores 3 (35 and 28 g/L). The INR scores 1 below 1.7, 2 from 1.7 to 2.3 inclusive, and 3 above 2.3. Exact boundary values fall in the middle band, so a bilirubin of exactly 2.0, an albumin of exactly 3.5 and an INR of exactly 2.3 each score 2. Ascites scores 1 when absent, 2 when mild or controlled and 3 when moderate to severe or refractory; encephalopathy scores 1 when absent, 2 for grade I–II and 3 for grade III–IV. The total runs from 5, when everything is normal, to 15. Totals of 5–6 are class A, 7–9 class B and 10–15 class C. Because every component is weighted equally, deep hepatic coma adds the same 3 points as an albumin of 2.7 g/dL. The bilirubin bands are the standard ones; the higher cut-offs some tables give for cholestatic disease such as primary biliary cholangitis are not applied.

A worked example.

Frequently asked questions.

References& sources.

1. [1]Pugh, R. N. H., et al. (1973). Transection of the oesophagus for bleeding oesophageal varices. British Journal of Surgery.
2. [2]Vilstrup, H., et al. (2014). Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by AASLD and EASL. Hepatology.
3. [3]American Association for the Study of Liver Diseases and European Association for the Study of the Liver (2014). Hepatic Encephalopathy in Chronic Liver Disease. AASLD PDF.
4. [4]European Association for the Study of the Liver (2018). EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. EASL PDF.
5. [5]European Association for the Study of the Liver (2018). EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. Journal of Hepatology.
6. [6]Farnsworth, N., Fagan, S. P., Berger, D. H., and Awad, S. S. (2004). Child-Turcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients. American Journal of Surgery, 188(5), 580-583.