Hepatocellular carcinoma (HCC) is the sixth most common malignancy and the fourth leading cause of cancer-related death worldwide. Hepatectomy is the most effective treatment for early-stage HCC patients, and selective intermediate-stage and advanced-stage HCC patients with resectable tumors and moderate liver function. Advances surgical techniques and management have greatly improved the safety and postoperative outcomes over the past few decades; however, the International Study Group of Liver Surgery (ISGLS) grade B/C posthepatectomy liver failure (PHLF) remains a serious complication, which is a predominant cause of postoperative mortality.[5, 6]
Incidence of PHLF as reported in literature widely ranges from 1.2%-32% attributing to diverse etiological and pathogenic liver characteristics and surgical procedures.[6, 7] Independent risk factors of PHLF can be grouped into three categories[5, 8]: 1) Patient-related factors including age, sex, comorbidities such as malnutrition, diabetes mellitus, cardiopulmonary, renal or cerebral dysfunction; 2) liver disease-related factors including hepatitis B/C, steatosis, cholangitis, alcoholic liver disease and cirrhosis; 3) surgery-related factors including future liver remnant volume (FLRV), excessive intraoperative blood loss, prolonged operation time, and ischemia-reperfusion injury resulting from Pringle’s manoeuver manipulation. In particular, as a major cause to promote decompensate liver cirrhosis and dysfunction, chronic hepatitis B is highly prevalent and associated with 70%-90% of HCC cases in the Asia-Pacific region.
Accurate prediction of PHLF is of primary concern for determining the feasibility of hepatectomy for HCC.[5, 8] Child-Pugh grade, model for end-stage liver disease (MELD), albumin–bilirubin (ALBI),[12, 13] platelet-albumin-bilirubin (PALBI) and aspartate aminotransferase to platelet ratio index (APRI) are commonly conventional scores used for evaluating PHLF, nevertheless their predictive performance remains controversial due to inherent limitations. Child-pugh grade is the most widely used for evaluating compensate liver function and has been incorporated into surgical treatment algorithms. However, subjective and unquantifiable variables usually complicate Child-pugh grade: serum bilirubin level of 55 µmol/L has the same influence on Child-pugh grade as 550 µmol/L due to arbitrary thresholds for continuous variables; there is no clear guideline for distinguishing mild or moderate ascites, and the influence of diuretic therapy on grading ascites remains unclear; sedatives therapy frequently mislead encephalopathy. MELD was developed to evaluate acute liver failure mortality risk and rank candidates for transplantation,[16, 17] which was also good at determining increased PHLF morbidity and mortality risk when a MELD score > 8 on postoperative day 5. However, MELD has a poor performance at preoperative predicting PHLF.[5, 6, 11] ALBI statistical eliminates subjective observation and assesses liver function and overall survival compared favorably with Child-pugh grade in four geographical and etiological HCC patient groups. A preoperative ALBI score predicting PHLF was more accurately than Child-pugh grade, MELD and indocyanine green retention at 15 minutes (ICG-15).[12, 13] However, when patients with hyperbilirubinemia were divide into the ALBI grade 3, patients with obstructive jaundice may have better liver function and prognosis than patients with jaundice caused by decompensate liver dysfunction, which significantly misleading the grading of ALBI.[19, 20] Blood platelet (PLT) counts as a surrogate marker of portal hypertension was added to ALBI to develop the PALBI, which predicting survival in HCC patients across treatment modalities including hepatectomy was better than ALBI and MELD. Nonetheless, further research is necessary as few studies have been done evaluating use of PALBI for predicting PHLF. APRI is noninvasive and reliable for evaluating liver fibrosis and cirrhosis,[21, 22] meanwhile a preoperative APRI score ≥ 10 have a high risk of PHLF in HCC patients. However, APRI only includes two quantitative variables and has no ceiling effect. In general, these conventional scores were primarily designed for assessing liver function or other purposes rather than predicting PHLF. Moreover, when they were used for predicting PHLF none of these scores comprehensively considers patient-related, liver-related, and surgical-related risk factors.
As an evidence-based model, nomogram has been proposed as an alternative tool for therapy risk individualized estimation in clinical application.[23, 24] This study aimed to establish a nomogram to predict grade B/C PHLF risk for HBV-HCC patients.