Child-Pugh score: A key assessment of liver function

Liver cancer, especially hepatocellular carcinoma (HCC), often develops on the background of chronic liver disease and cirrhosis. Therefore, when planning therapy for patients with HCC, it is not enough to assess only the stage of the tumor, but also the functional status of the liver. The Child-Pugh score plays a key role in this, a simple but extremely important clinical scale that helps determine the prognosis and make therapeutic decisions.

What is the Child-Pugh score?

The Child-Pugh (Child-Turcotte-Pugh, CTP) score is a system that assesses the degree of liver function impairment, most often in patients with cirrhosis, but also in those with HCC. It was developed to predict postoperative mortality in liver surgery, but today it has a much wider application, especially in oncology.

Parameters it assesses

The Child-Pugh score is based on five clinical-biochemical parameters:

Parameter	Points: 1	Points: 2	Points: 3
Albumin (g/L)	>35	28–35	<28
Bilirubin (μmol/L)	<34	34–50	>50
INR / Protrombin time	<1,7 / <4s	1,7–2,3 / 4–6s	>2,3 / >6s
Ascites	Not present	Mild (controlled)	Severe (uncontrolled)
Hepatic encelopathy	Not present	Stage I–II	Stage III–IV

The sum of the points classifies the patient into:

• Child-Pugh A (5–6 points) – compensated cirrhosis, good liver function

• Child-Pugh B (7–9 points) – moderate impairment

• Child-Pugh C (10–15 points) – decompensated cirrhosis, poor liver function

Why is it important in liver cancer?

In HCC, the choice of therapy depends not only on the stage of the tumor, but also on the Child-Pugh score, as it determines how well the liver is able to tolerate certain therapies:

• Surgery (liver resection) and local ablative methods (radiofrequency ablation, microwave ablation) are mainly performed in patients with Child-Pugh A.

• Transarterial chemoembolization (TACE) is also most often used in Child-Pugh A, and sometimes in carefully selected patients with Child-Pugh B.

• Systemic therapy, such as atezolizumab + bevacizumab, sorafenib, lenvatinib or immunotherapy, is mainly used in patients with preserved liver function (Child-Pugh A), while in Child-Pugh B the application is limited and requires an individual approach.

• Child-Pugh C patients are generally not candidates for active oncological treatment and are primarily focused on palliative care and symptomatic treatment.

Figure 1. A patient with ascites. Ascites can lead to abdominal distension with resultant pain and difficulty eating. The degree of ascites is important for calculating the Child-Pugh score.

Alternative scales - ALBI score

Recently, the ALBI score (Albumin-Bilirubin) has been used, which excludes subjective parameters (ascites and encephalopathy) and is based exclusively on laboratory values. However, the Child-Pugh score remains the gold standard in everyday clinical practice.

Conclusion

The Child-Pugh score is a simple and extremely useful scale that allows for an objective assessment of liver function in patients with HCC. Its application is crucial in choosing the optimal therapeutic strategy and provides valuable prognostic insight. In any oncological approach to a patient with liver cancer, assessment of liver function must be as important as assessment of tumor stage.