Child Pugh score
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Child Pugh score criteria scoring interpretation clinical use
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Child-Pugh Score (Child-Turcotte-Pugh / CTP Score)
Background
The Child-Pugh score (also called the Child-Turcotte-Pugh or CTP score) was originally developed to predict surgical mortality in patients with cirrhosis. It assesses the severity of chronic liver disease and portal hypertension using five clinical and laboratory parameters, each scored 1-3 points, giving a total range of 5-15.
Scoring Criteria
| Parameter | 1 point | 2 points | 3 points |
|---|---|---|---|
| Ascites | Absent | Slight | Moderate |
| Bilirubin (mg/dL) | ≤ 2 | 2-3 | > 3 |
| Albumin (g/dL) | > 3.5 | 2.8-3.5 | < 2.8 |
| INR | < 1.7 | 1.8-2.3 | > 2.3 |
| Hepatic Encephalopathy | None | Grade 1-2 | Grade 3-4 |
- Symptom to Diagnosis, 4th ed. - Table 19-5
Classification
| Total Score | Child Class | Interpretation |
|---|---|---|
| 5-6 | A | Compensated cirrhosis - well-functioning liver |
| 7-9 | B | Significantly compromised liver function |
| 10-15 | C | Decompensated cirrhosis |
Operative Mortality
| Child Class | Early retrospective data | More recent laparoscopic data |
|---|---|---|
| A | 10% (some report 2-10%) | ~2% |
| B | 30% (12-31%) | ~12% |
| C | 73-82% | ~12-82% |
- Miller's Anesthesia, 10th ed., p. 1537-1538
Key surgical implications:
- Class A: Generally safe for elective surgery (when no thrombocytopenia or clinically significant portal hypertension)
- Class B and C: Elective surgery generally not recommended
- After abdominal surgery: Class A ~10% mortality, Class B ~30%, Class C ~70-80%
1-Year and 2-Year Survival
| Child Class | 1-year survival | 2-year survival |
|---|---|---|
| A | ~100% | 85% |
| B | ~80% | 60% |
| C | ~45% | 35% |
Clinical Uses
- Prognosis of cirrhosis - estimates survival and disease trajectory
- Surgical risk stratification - predicts perioperative morbidity/mortality
- Drug dosing - manufacturers use Child-Pugh class to define hepatic impairment categories for pharmacokinetic dose adjustments (e.g., caspofungin dose reduction in Class B)
- Liver transplant candidacy - historically used prior to widespread adoption of MELD
Limitations
- Subjective parameters - grading of ascites and encephalopathy varies between observers
- No etiology weighting - doesn't account for cause of cirrhosis or type of surgery
- Limited differentiation at extremes - e.g., a patient with INR 6 and bilirubin 14 can score the same as one with INR 2.3 and bilirubin 4.0
- Supplanted for transplant allocation - the MELD score (uses INR, creatinine, bilirubin ± sodium) is now preferred for organ allocation due to better prognostic accuracy and fewer subjective components
- Sabiston Textbook of Surgery, 21st ed., p. 113-119
CTP vs. MELD - Quick Comparison
| Feature | CTP | MELD |
|---|---|---|
| Variables | Albumin, bilirubin, INR, ascites, encephalopathy | INR, creatinine, bilirubin (± Na) |
| Objective? | Partially (ascites/encephalopathy subjective) | Fully objective |
| Used for | Surgical risk, drug dosing, clinical guidance | Transplant allocation, surgical risk |
| Advantage | Includes clinical signs (ascites, encephalopathy) | Better for severe portal hypertension with preserved synthetic function |
In patients with severe portal hypertension but preserved hepatic synthetic function, the CTP may actually be more informative than MELD. - Sabiston Textbook of Surgery
Bottom line: The Child-Pugh score remains widely used in clinical practice - especially for drug dosing decisions and quick surgical risk assessment - even though MELD/MELD-Na has largely replaced it for liver transplant prioritization.
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