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Child-Pugh Score for Cirrhosis Mortality

Calculators  Gastrointestinal
Child-Pugh Score is a widely used tool to assess prognosis in patients with chronic liver disease and cirrhosis. The score is used with the Model for End-Stage Liver Disease (MELD) to determine priority for liver transplantation.
Bilirubin (Total)
<2 mg/dL (<34.2 µmol/L) 1
2-3 mg/dL (34.2-51.3 µmol/L) 2
>3 mg/dL (>51.3 µmol/L) 3
Albumin
>3.5 g/dL (>35 g/L) 1
2.8-3.5 g/dL (28-35 g/L) 2
<2.8 g/dL (<28 g/L) 3
INR
<1.7 1
1.7-2.2 2
>2.2 3
Ascites
Absent 1
Minor 2
Common 3
Encephalopathy
See encephalopathy grades in Evidence > Facts & Figures
No Encephalopathy 1
Grade 1-2 2
Grade 3-4 3
Result:

Background

Measured Factor
Child Pugh Score
Measured Factor Disease
  • Liver cirrhosis
  • Chronic liver disease
Measured Factor Detail
The score considers five factors. Three of the factors assess the synthetic function of the liver, which include total bilirubin level, serum albumin, and international normalized ratio(INR). 

Following list gives the score calculation for these three factors:
                                                                                                                                                                                                                                                                                                                                                                                                                              Bilirubin(total)
< 2 mg/dL: Score 1
2-3 mg/dL: Score 2
> 3 mg/dL: Score 3

Albumin
> 3.5 g/dL: Score 1
2.8-3.5 g/dL: Score 2
< 2.8 g/dL: Score 3

INR
< 1.7: Score 1
1.7-2.2: Score 2
> 2.2: Score 3

Presence of Ascites
The fourth factor is presence of ascites. Following are the scores assigned for presence of ascites:
Absent: Score 1
Minor: Score 2
Common: Score 3

Encephalopathy Grades
The final and fifth factor is degree of hepatic encephalopathy. Following are the scores assigned for degree of heptic encephalopathy:
Grade 0, normal consciousness, personality, neurological examination, electroencephalogram: Score 1
Grade 1, restless, sleep disturbed, irritable/agitated, tremor, impaired handwriting, 5 cps waves: Score 2
Grade 2, lethargic, time-disoriented, inappropriate, asterixis, ataxia, slow triphasic waves: Score 2
Grade 3, somnolent, stuporous, place-disoriented, hyperactive reflexes, rigidity, slower waves: Score 3
Grade 4, unrousable coma, no personality/behavior, decerebrate, slow 2-3 cps delta activity: Score 3
Speciality
Hepatologist
Body System
Gastrointestinal
Measured Factor High Impact
  • Liver cirrhosis
  • Chronic liver disease

Result Interpretation

Ranges Ranges
  • Critical Low: 0
  • Critical High: 1
  • Normal: 0
  • Normal Adult Male: 0
  • Normal Adult Female: 0
  • Normal Pediatric: 0
  • Normal Neonate Female: 0
  • Normal Geriatric Male: 0
  • Normal Geriatric Female: 0
Result High Conditions
  • Chronic liver disease
  • Cirrhosis
Test Limitations
Critics of the Child-Pugh score have noted its reliance on clinical assessment, which may result in inconsistency in scoring. Others have suggested that its broad classifications of disease are impractical when determining priority for liver transplantation; nevertheless, it remains widely used. The Model for End-Stage Liver Disease (MELD) is a newer scoring system that has been developed to address some of the concerns with the Child-Pugh score, and the two systems are often used in conjunction to determine liver transplantation priority.

Studies

Study Validation 1
The study was designed to evaluate whether Child-Pugh score discriminates a prognosis of the Child-Pugh A patients who underwent hepatic resection for hepatocellular carcinoma. 361 patients with Child-Pugh A who underwent curative hepatectomy were divided into 2 groups: Child-Pugh score 5 points group (CPS5) and Child-Pugh score 6 points group (CPS6) were compared. The results of the study indicated that Overall survival rates (1/2/5 years of the CPS5 and CPS6 groups were 90.9%/82.5%/62.4% and 80.6%/68.0%/47.6%, respectively) and disease-free survival rates (67.6%/51.8%/30.1% and 36.9%/16.0%/5.9%, respectively) showed that the CPS5 group was significantly better than the CPS6 group. The study concluded that the overall survival and disease-free survival in Child-Pugh A showed quite a difference between the CPS5 and CPS6 groups. However, CPS5 and CPS6 may be a useful prognostic marker of hepatocellular carcinoma patients with hepatic resection.
References: 2
Study Validation 2
A retrospective study was conducted to compare the performance of Child-Pugh and Model for End-Stage Liver Diseases (MELD) scores for predicting the in-hospital mortality of acute upper gastrointestinal bleeding (UGIB) in patients with liver cirrhosis. A total of 145 patients with a diagnosis of liver cirrhosis and acute UGIB were retrospectively analyzed. The demonstrated that the discriminative ability was not significant different between the two scoring systems (P=0.7241). In conclusion, Child-Pugh and MELD scores were similar for predicting the in-hospital mortality of acute UGIB in cirrhotic patients.
References: 3
Study Validation 3
The purpose of this study was to evaluate liver function after high-dose liver stereotactic body radiation therapy (SBRT) in the treatment of metastatic and primary malignancies of the liver using the Child-Pugh score classification system. retrospective analysis of 46 patients treated with SBRT for metastatic and primary malignancies of the liver. Patient, disease, prior treatment, and SBRT dosimetric factors were analyzed to correlate with decline in Child-Pugh class after liver SBRT. Seven patients (15%) received adjuvant chemotherapy or targeted therapy. Twenty-nine patients (63%) experienced an intrahepatic recurrence after treatment. Ten patients (22%) experienced a decline in Child-Pugh class at a median of 1.6 months (range, 0.2-6 months). Eighty percent experienced a one-category decline. Only the V20, V25, V30, and V50 were correlated with decline in Child-Pugh class on univariate analysis, with V25 being most significant (P = .027). A V25 >32% was associated with a 42% incidence of Child-Pugh class decline compared with 9% for V25 ≤32 (P = .029). For primary liver malignancies, a V25 >36% was associated with a 4-fold increase in the incidence of Child-Pugh class decline (60% vs 15%, P = .021).The study concluded that approximately one-quarter of patients experience a decline in Child-Pugh class after high-dose liver SBRT.
References: 4
Study Additional 1
This study aimed to compare the value of the  albumin-bilirubin (ALBI) grade ALBI score with Child-Pugh score, model for end-stage liver disease (MELD) score and indocyanine green (ICG) R15 in predicting posthepatectomy liver failure (PHLF). The values of the Child-Pugh score, MELD score, ICG R15 and ALBI score in predicting PHLF were evaluated. A total of 473 HCC patients were enrolled. The ALBI score was identified as an independent predictor of PHLF. The AUCs for the Child-Pugh score, MELD score, ICG R15 and ALBI score in predicting PHLF were 0.665, 0.649, 0.668, and 0.745 respectively. Multivariable analyses revealed that the ALBI score was an independent predictor of PHLF regardless of the hepatectomy subgroups, but the Child-Pugh score and MELD score were not significant predictors of PHLF both in major and minor hepatectomy subgroups, and ICG R15 was only a significant predictor of PHLF in minor hepatectomy subgroup. The study concluded that the ALBI score showed superior predictive value of PHLF over Child-Pugh score, MELD score and ICG R15.
References: 5
Study Additional 2
A multicenter study retrospectively analyzed data from Child-Pugh B-HCC patients naïve to systemic therapies, treated with MC or best supportive care (BSC). Propensity score was generated including: extrahepatic spread; macrovascular invasion; performance status, alpha fetoprotein > 400 ng/ml, Child- Pugh score [B7 vs. B8-9]. Median overall survival was 7.5 [95% CI: 3.733-11.267]in MC-patients and 5.1 months [95% CI: 4.098-6.102] in the BSC group (p = 0.013). In patients treated with MC, median progression-free survival was 4.5 months (95% CI: 2.5-6.5). The univariate unweighted Cox regression showed a 42% reduction in death risk for patients on MC (95%CI: 0.370-0.906; p = 0.017). After weighting for potential confounders, death risk remained essentially unaltered. In the MC group, 12 patients (34.3%) experienced at least one adverse event, the most common of which were: fatigue (17.1%), hand-foot syndrome (8.5%), thrombocytopenia (8.5%), and neutropenia (5.7%). The study shows that MC seems a safe option for Child-Pugh B-HCC patients.
References: 6
Study Additional 3
This study aimed to investigate vitamin D levels and their relationship with disease advancement in these patients. Vitamin D levels were checked in 125 chronic liver disease patients. The patients were classified in three stages according to Child-Pugh score: A, B and C. The relationship of vitamin D levels with Child-Pugh score and other variables in the study was assessed by the contingency coefficient. The results of the study suggested that Vitamin D levels were notably related to Child-Pugh class (contingency coefficient = 0.5, p <0.05). On univariate and multinomial regression analyses, age, female sex, MELD and Child-Pugh class were predictors of low vitamin D levels. Age, model of end-stage liver disease score and Child-Pugh score were negatively correlated to vitamin D levels (p <0.05).  The study concluded that Vitamin D levels should be routinely checked in patients with advanced liver cirrhosis (Child-Pugh class B and C) and this deficiency must be addressed in a timely manner to improve general well-being of cirrhotic patients.
References: 7

Authors

Charles G. Child
MD
Former chairman and Professor emeritus department of surgery at University of Michigan, University of Michigan and Emory University
Research Interests: Active researcher in areas of portal hypertension and other hepatic and gastrointestinal diseases
https://www.lib.umich.edu/faculty-history/faculty/charles-g-child-iii/memoir

References

  1. Child CG, Turcotte JG. Surgery and portal hypertension. In: The liver and portal hypertension. Edited by CG Child. Philadelphia: Saunders 1964:50-64.
  2. Okajima C, Arii S, Tanaka S, Matsumura S, Ban D, Ochiai T, Irie T, Kudo A, Nakamura N, Tanabe M. Prognostic role of Child-Pugh score 5 and 6 in hepatocellular carcinoma patients who underwent curative hepatic resection. Am J Surg. 2015 Jan;209(1):199-205.
  3. Peng Y, Qi X, Dai J, Li H, Guo X.Child-Pugh versus MELD score for predicting the in-hospital mortality of acute upper gastrointestinal bleeding in liver cirrhosis.Int J Clin Exp Med. 2015 Jan 15;8(1):751-7. eCollection 2015.
  4. Dyk P, Weiner A, Badiyan S, Myerson R, Parikh P, Olsen J.Effect of high-dose stereotactic body radiation therapy on liver function in the treatment of primary and metastatic liver malignancies using the Child-Pugh score classification system. Pract Radiat Oncol. 2015 May-Jun;5(3):176-82.
  5. Zou H, Yang X, Li QL, Zhou QX, Xiong L, Wen Y. A Comparative Study of Albumin-Bilirubin Score with Child-Pugh Score, Model for End-Stage Liver Disease Score and Indocyanine Green R15 in Predicting Posthepatectomy Liver Failure for Hepatocellular Carcinoma Patients. Dig Dis. 2018;36(3):236-243.
  6. De Lorenzo S, Tovoli F, Barbera MA, Garuti F, Palloni A, Frega G, Garajovà I, Rizzo A, Trevisani F, Brandi G. Metronomic capecitabine vs. best supportive care in Child-Pugh B hepatocellular carcinoma: a proof of concept. Sci Rep. 2018 Jul 3;8(1):9997.
  7. Jamil Z, Arif S, Khan A, Durrani AA, Yaqoob N. Vitamin D Deficiency and Its Relationship with Child-Pugh Class in Patients with Chronic Liver Disease. J Clin Transl Hepatol. 2018 Jun 28;6(2):135-140.