# What is my Child-Pugh class?

Adds up the Child-Pugh score (Pugh 1973) for chronic liver disease from bilirubin, albumin, INR, ascites, and encephalopathy, in US or SI units, and shows class A, B, or C.

- Page: https://www.acalculator.org/health/child-pugh-calculator
- JSON spec: https://www.acalculator.org/health/child-pugh-calculator.json
- Version: 9dc229662a40

## Default answer

Example with the default inputs (Lab units US, Bilirubin (mg/dL) 1.5, Albumin (g/dL) 3.2, INR 1.4, Ascites Mild, Encephalopathy None, PBC or PSC No): The Child-Pugh score is 7 (Class B).

## Inputs

| Key | Label | Description |
| --- | --- | --- |
| units | Lab units | US units (bilirubin mg/dL, albumin g/dL) or SI units (bilirubin µmol/L, albumin g/L). |
| bili | Bilirubin (mg/dL) | Total serum bilirubin, in mg/dL. |
| biliSi | Bilirubin (µmol/L) | Total serum bilirubin, in µmol/L. |
| alb | Albumin (g/dL) | Serum albumin, in g/dL. |
| albSi | Albumin (g/L) | Serum albumin, in g/L. |
| inr | INR | International normalized ratio of the prothrombin time. |
| ascites | Ascites | Fluid in the belly: none, mild (or controlled with medicine), or moderate to severe. |
| enceph | Encephalopathy | Hepatic encephalopathy (confusion from liver disease): none, grade 1 to 2, or grade 3 to 4. |
| cholestatic | PBC or PSC | Primary biliary cholangitis or primary sclerosing cholangitis, which use higher bilirubin bands. |

## Outputs

| Key | Label | Description |
| --- | --- | --- |
| score | Child-Pugh score | The total of the five items, 5 to 15. |
| childClass | Class | Class A (5 to 6), B (7 to 9), or C (10 to 15). |
| parts | Points per item | The points for each of the five items. |

## Method

Score = points for bilirubin + albumin + INR + ascites + encephalopathy, each 1 to 3; class A 5 to 6, B 7 to 9, C 10 to 15.

## Assumptions

- Bands are applied in the unit you pick: bilirubin under 2, 2 to 3, over 3 mg/dL (under 34, 34 to 50, over 50 µmol/L); PBC and PSC under 4, 4 to 10, over 10 mg/dL (under 68, 68 to 170, over 170 µmol/L).
- Albumin over 3.5, 2.8 to 3.5, under 2.8 g/dL (over 35, 28 to 35, under 28 g/L). INR under 1.7, 1.7 to 2.3, over 2.3. A value on a band edge scores the middle band.
- INR stands in for the prothrombin time prolongation of the 1973 paper (1 to 4, 4 to 6, over 6 seconds).

## Worked examples

1. units = us, bili = 1.5, alb = 3.2, inr = 1.4, ascites = mild, enceph = none, cholestatic = no gives score = 7, childClass = Class B, parts = bilirubin 1, albumin 2, INR 1, ascites 2, encephalopathy 1. Source: Pugh et al., Br J Surg 1973 point table: 1 + 2 + 1 + 2 + 1 = 7, class B.
2. units = us, bili = 1, alb = 4, inr = 1, ascites = none, enceph = none, cholestatic = no gives score = 5, childClass = Class A. Source: Pugh et al. 1973: every item scores 1, total 5, class A ().
3. units = si, biliSi = 60, albSi = 25, inr = 2.5, ascites = severe, enceph = severe, cholestatic = no gives score = 15, childClass = Class C. Source: Pugh et al. 1973 SI bands: bilirubin over 50 µmol/L 3, albumin under 28 g/L 3, INR over 2.3 3, 3, 3 = 15 ().
4. units = us, bili = 3, alb = 3.5, inr = 1.7, ascites = none, enceph = mild, cholestatic = no gives score = 9, childClass = Class B, parts = bilirubin 2, albumin 2, INR 2, ascites 1, encephalopathy 2. Source: Pugh et al. 1973: bilirubin 3.0, albumin 3.5, and INR 1.7 sit on band edges and score 2 each.
5. units = us, bili = 5, alb = 3.6, inr = 1.2, ascites = none, enceph = none, cholestatic = yes gives score = 6, childClass = Class A, parts = bilirubin 2, albumin 1, INR 1, ascites 1, encephalopathy 1.

## FAQ

### What is the Child-Pugh score?

The Child-Pugh score (also Child-Turcotte-Pugh) grades how severe chronic liver disease, usually cirrhosis, is. Child and Turcotte proposed it in 1964, and Pugh and others revised it in 1973. Five items each score 1 to 3 points, for a total of 5 to 15.

### What do the Child-Pugh classes mean?

Class A (5 to 6 points) is well-compensated disease, class B (7 to 9) is significant loss of liver function, and class C (10 to 15) is decompensated disease. The class helps clinicians judge the outlook, the risk of surgery, and how the liver may handle some medicines.

### What is the difference between Child-Pugh and MELD?

MELD uses only lab values and is used to rank patients for a liver transplant in the US. Child-Pugh also includes two clinical signs (ascites and encephalopathy) that a clinician judges. Many clinicians look at both.

### Why is INR used instead of prothrombin time?

The 1973 paper scored the prothrombin time in seconds above normal (1 to 4, 4 to 6, over 6). Seconds vary between labs, so most tables now use the INR bands under 1.7, 1.7 to 2.3, and over 2.3.

### Why are there different bilirubin bands for PBC and PSC?

In primary biliary cholangitis and primary sclerosing cholangitis, bilirubin rises early in the disease, so the usual bands would overstate severity. Tables for these conditions use under 4, 4 to 10, and over 10 mg/dL.

## Sources

- Pugh RNH, 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. https://doi.org/10.1002/bjs.1800600817
- Child CG, Turcotte JG. Surgery and portal hypertension. In: Child CG, ed. The Liver and Portal Hypertension. Philadelphia: Saunders; 1964:50-64.
- Tsoris A, Marlar CA. Use of the Child Pugh score in liver disease. StatPearls. StatPearls Publishing; updated 2023. https://www.ncbi.nlm.nih.gov/books/NBK542308/ (INR bands, PBC and PSC bilirubin bands)