What is Child-Pugh Class C?

Child-Pugh Class C (score 10–15) represents decompensated cirrhosis with an estimated 1-year survival of approximately 45% and 2-year survival of 35% without liver transplantation. It indicates significant hepatic decompensation and typically warrants transplant evaluation.

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

Child-Pugh uses five variables (three laboratory values: bilirubin, albumin and INR; two clinical assessments: ascites and encephalopathy) and classifies patients into classes A, B, C. MELD uses three purely objective laboratory values (INR, bilirubin, creatinine) and generates a continuous numeric score. MELD is now preferred for transplant prioritisation due to better predictive accuracy and reproducibility, but Child-Pugh is still widely used for surgical risk stratification and simple clinical staging.

Child-Pugh Score calculator

How to use it

1
5 domains. Bilirubin, albumin, INR, ascites, encephalopathy — each scored 1–3.
2
Class A (5–6). Good function. Class B (7–9): moderate. Class C (10–15): poor.
3
Use PBC bilirubin ranges. For primary biliary cholangitis, different bilirubin thresholds apply.

When to use it

Use in patients with known or suspected liver cirrhosis for staging, prognosis, surgical risk assessment, and guiding management decisions. Class C cirrhosis typically warrants transplant evaluation.

Surgical risk in cirrhosis: Child-Pugh A: mortality ~10%. B: ~30%. C: ~80% for major abdominal surgery.
Drug dosing: Many hepatically-metabolised drugs: half-dose in Child-Pugh B; avoid in C.
Screening for HCC: Child-Pugh A/B: 6-monthly USS + AFP. Child-Pugh C not transplant-listed: limited benefit.

About the score

The Child-Pugh score (originally the Child-Turcotte-Pugh score) is a widely used clinical grading system for the severity of chronic liver disease and cirrhosis. It combines five variables — serum bilirubin, serum albumin, prothrombin time/INR, ascites severity, and hepatic encephalopathy grade — to classify patients into three categories: Class A (well-compensated), Class B (significant functional compromise), and Class C (decompensated cirrhosis). Despite being partially superseded by MELD for transplant prioritisation, Child-Pugh remains valuable for assessing surgical risk, prognosis in non-transplant settings, and as a simple bedside classification system.

Scoring criteria

Bilirubin (µmol/L)<34=1, 34–50=2, >50=3: 1–3
Albumin (g/L)>35=1, 28–35=2, <28=3: 1–3
Prothrombin time (seconds prolonged) or INR<4s / INR<1.7=1; 4–6s / 1.7–2.3=2; >6s / >2.3=3: 1–3
AscitesNone=1, Mild (controlled)=2, Moderate–severe (refractory)=3: 1–3
Hepatic encephalopathy (grade)None=1, Grade I–II=2, Grade III–IV=3: 1–3

Score interpretation

5–6 (Class A)Well-compensated cirrhosis1-year survival ~100%; 2-year ~85%; standard surgical risk
7–9 (Class B)Significant impairment1-year survival ~80%; 2-year ~60%; high surgical risk
10–15 (Class C)Decompensated cirrhosis1-year survival ~45%; 2-year ~35%; transplant evaluation warranted

Guideline recommendation

EASL Clinical Practice Guidelines on Decompensated Cirrhosis (2018): Child-Pugh Class C cirrhosis indicates decompensated disease with poor prognosis and warrants referral for transplant evaluation. Child-Pugh is also the standard tool for assessing operative risk in cirrhotic patients requiring surgery.

Clinical pearls

Child-Pugh Class C (score 10–15) with no contraindications to transplantation should prompt urgent hepatology referral.
Ascites and encephalopathy components are subjective — ensure consistent assessment within the clinical team.
Patients with Child-Pugh B/C undergoing elective surgery carry 30-day mortality risks of 30% and 80% respectively; avoid elective surgery in Class C.
MELD score is preferred for transplant waitlist prioritisation; Child-Pugh remains useful for surgical risk assessment and simple staging.

Limitations

Two subjective components (ascites, encephalopathy) reduce reproducibility between observers.
Less accurate than MELD for predicting short-term mortality in acute settings.
Does not incorporate renal function, which independently predicts outcomes in cirrhosis.

Child-Pugh Score for Cirrhosis