Child-Pugh score

Severity of chronic liver disease / cirrhosis (class A, B, C)

Sources last checked: 2026-10-13

Child-Pugh score

Severity of chronic liver disease / cirrhosis (class A, B, C)

Total bilirubin

Serum albumin

INR (or prothrombin time prolongation)

Ascites

Hepatic encephalopathy

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Pugh 1973 used prothrombin-time prolongation; the INR cut-offs are the widely used later adaptation. In primary biliary cholangitis / sclerosing cholangitis higher bilirubin cut-offs (68 / 170 µmol/L; 4 / 10 mg/dL) were proposed. Ascites and encephalopathy grading is subjective.

Source: Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973;60(8):646-649.Open

Interpretation

Class A (5–6) — well-compensated	Child-Pugh A.
Class B (7–9) — significant functional compromise	Child-Pugh B.
Class C (10–15) — decompensated	Child-Pugh C.

What is the Child-Pugh score?

The Child-Pugh score grades the severity of chronic liver disease from bilirubin, albumin, coagulation, ascites and encephalopathy into classes A, B and C. It is Pugh's 1973 modification of the Child-Turcotte classification, originally used to predict the outcome of oesophageal transection for variceal bleeding, and remains standard in hepatology and drug dosing.

When to use it

Staging cirrhosis at diagnosis and follow-up
Drug dosing: many product labels give dose adjustments by Child-Pugh class
Assessing operative risk and eligibility for treatments such as TIPS or HCC therapy

When not to use it

Transplant prioritisation — use MELD-based scores (Eurotransplant: reMELD-Na)
Acute liver failure, where the score was not designed

How it is calculated

Criterion	Points
Total bilirubin
< 34 µmol/L (< 2 mg/dL)	1
34–50 µmol/L (2–3 mg/dL)	2
> 50 µmol/L (> 3 mg/dL)	3
Serum albumin
> 35 g/L (> 3.5 g/dL)	1
28–35 g/L (2.8–3.5 g/dL)	2
< 28 g/L (< 2.8 g/dL)	3
INR (or prothrombin time prolongation)
INR < 1.7 (PT prolonged < 4 s)	1
INR 1.7–2.3 (PT prolonged 4–6 s)	2
INR > 2.3 (PT prolonged > 6 s)	3
Ascites
None	1
Mild / controlled with diuretics	2
Moderate to severe / refractory	3
Hepatic encephalopathy
None	1
Grade 1–2 (or controlled with treatment)	2
Grade 3–4 (or refractory)	3

Clinical pearls and limitations

Pugh 1973 used prothrombin-time prolongation; the INR cut-offs are the widely used later adaptation. In primary biliary cholangitis / sclerosing cholangitis higher bilirubin cut-offs (68 / 170 µmol/L; 4 / 10 mg/dL) were proposed. Ascites and encephalopathy grading is subjective.
Class A 5–6, B 7–9, C 10–15 points.
The INR cut-offs (< 1.7, 1.7–2.3, > 2.3) replace Pugh's original prothrombin-time prolongation in seconds.
In cholestatic disease (PBC/PSC) higher bilirubin thresholds (68 / 170 µmol/L) were proposed.
Albumin can be influenced by infusions and the INR by vitamin K antagonists.

Frequently asked questions

What are the Child-Pugh classes?

Class A = 5–6 points (well-compensated), class B = 7–9 (significant functional compromise), class C = 10–15 (decompensated).

What bilirubin values are used in Child-Pugh in µmol/L?

Below 34 µmol/L scores 1, 34–50 µmol/L scores 2 and above 50 µmol/L scores 3 (about 2 and 3 mg/dL).

Child-Pugh or MELD?

Child-Pugh is used for clinical staging and drug dosing; MELD-type scores are more objective and are used for transplant allocation.

Evidence and guidelines

Primary source: Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973;60(8):646-649.

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