Understanding the Child-Pugh score

The Child-Turcotte-Pugh (CTP) score (or Child-Pugh score) was originally designed to assess the likelihood of mortality in patients with liver cirrhosis who were undergoing major abdominal surgery. It gives a general indication into how well the individual’s liver is functioning.

There are no validated scoring systems to determine the appropriate medication dosing in patients with liver cirrhosis. In clinical practice, factors such as individual patient characteristics, liver blood tests, pharmacokinetic principles combined with clinical judgement should be used to determine appropriate medicine dosing and drug use in patients with liver cirrhosis.

Questions to ask when giving medicines advice in liver impairment provides guidance on the background information and risk factors to consider when gathering information.

Newer scores like the Model for End-stage Liver disease (MELD) score or the MELD-Na score now supersede the Child-Pugh score in predicting the likelihood of mortality in patients with liver cirrhosis due to their better prognostic value.

Using the Child-Pugh score

The Child-Pugh grades A, B and C are sometimes referred to in the Summary of Product Characteristics (SmPC) when discussing medication dosing, contraindications or precautions.

The Child-Pugh grading scale relates to patients with liver cirrhosis. When this term is included in an SmPC, it is because the studies that support the information have been performed in patients with cirrhosis. Not all patients with liver dysfunction will have liver cirrhosis, and there may be other issues to consider.

Calculating a Child-Pugh Score

To calculate an individual’s Child-Pugh score five parameters are considered:

• total bilirubin,
• serum levels of albumin,
• International Normalized Ratio (INR),
• presence (and severity) of ascites and
• presence (and severity) of encephalopathy

Each of these parameters are assigned a score between 1 and 3, according to severity or degree of abnormality. The Child-Pugh score is the sum of all 5 parameter scores.

Patients with cirrhosis can have a Child-Pugh score of between 5 and 15.

Clinical Calculators

MDCalc is a free, online clinical calculator which can be used to calculate a patient’s Child-Pugh score (a free mobile application is also available for both Apple and Android).

BMJ Best Practice can also be used to calculate the Child-Pugh score.

Interpreting the Child-Pugh score

The sum of the five scores corresponds to a Child-Pugh grade of A, B or C.

Child-Pugh A (score 5 to 6)

A Child-Pugh score of 5 to 6 corresponds to a Child-Pugh grade of A and indicates a well-functioning liver (compensated cirrhosis).

Child-Pugh B (score 7 to 9)

A Child-Pugh score of 7 to 9 corresponds to a Child-Pugh grade of B and indicates significantly compromised liver function.

Child-Pugh C (score 10 to 15)

A Child-Pugh score of 10 to 15 corresponds to a Child-Pugh grade of C and indicates decompensation of the liver (decompensated cirrhosis).

The Child-Pugh score should be reassessed if the patient’s clinical condition improves or deteriorates.

Specific medicine examples

Using any medicines outside of their product licence constitutes off-label use.

Caspofungin

The caspofungin SmPC recommend a dose reduction in patients with Child-Pugh grade B cirrhosis.

No dose reduction is required in Child-Pugh grade A and it is not recommended for use in Child-Pugh grade C cirrhosis.

Letrozole

The letrozole SmPC recommends close supervision of patients with Child-Pugh grade C cirrhosis.

No dose adjustment is required for patients with Child-Pugh grade A or grade B cirrhosis.

Direct Oral Anticoagulants

The apixaban 5mg SmPC recommends caution in patients with Child-Pugh grade A or grade B cirrhosis.

The rivaroxaban 20mg SmPC contraindicates its use in patients with Child-Pugh grade B or grade C cirrhosis (with coagulopathy and relevant bleeding risk).

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