The Child-Pugh score: Prognosis in chronic liver disease and cirrhosis [Classics Series]

Classics Series, Landmark Trials in Medicine

1. The Child-Pugh score consists of five clinical features and is used to assess the prognosis of chronic liver disease and cirrhosis.

2. The Child-Pugh score was originally developed in 1973 to predict surgical outcomes in patients presenting with bleeding esophageal varices.

3. The score is used with the Model for End-Stage Liver Disease (MELD) to determine priority for liver transplantation.

Original Date of Publication: August 1973

Study Rundown: Originally developed in 1973, the Child-Pugh score was used to estimate the risk of operative mortality in patients with bleeding esophageal varices. It has since been modified, refined, and become a widely used tool to assess prognosis in patients with chronic liver disease and cirrhosis. The score considers five factors, three of which assess the synthetic function of the liver (i.e., total bilirubin level, serum albumin, and international normalized ratio, or INR) and two of which are based on clinical assessment (i.e., degree of ascites and degree of hepatic encephalopathy). 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.

Please click to read study in British Journal of Surgery

In-Depth [case series study]: This study, originally published in 1973 in the British Journal of Surgery, sought to determine whether clinical features could help predict surgical outcomes in patients with esophageal varices. A total of 38 consecutive cases of bleeding esophageal varices requiring surgery were included in the study. The severity of liver disease was assessed in each patient based on five clinical features: 1) total bilirubin level, 2) serum albumin, 3) prothrombin time (now measured as the INR), 4) the degree of ascites, and 5) the grade of hepatic encephalopathy. The total point score was then used to determine the patient’s Child-Pugh class. Class A patients (n=7) experienced a 29% operative mortality rate, while Class B (n=13) and Class C (n=18) patients had operative mortality rates of 38% and 88%, respectively. Since its publication, the Child-Pugh score has undergone modifications and is currently used to assess the severity and prognosis of chronic liver disease and cirrhosis. Moreover, it is often used together with the MELD to determine the priority for liver transplantation. The currently used Child-Pugh scoring system has been outlined below.

 

Factor

1 point

2 points

3 points

Total bilirubin (μmol/L)

<34

34-50

>50

Serum albumin (g/L)

>35

28-35

<28

PT INR

<1.7

1.71-2.30

>2.30

Ascites

None

Mild

Moderate to Severe

Hepatic encephalopathy

None

Grade I-II (or suppressed with medication)

Grade III-IV (or refractory)

 

Class A

Class B

Class C

Total points

5-6

7-9

10-15

1-year survival

100%

80%

45%

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