Development and Validation of a Nomogram Based on Noninvasive Liver Reserve and Fibrosis (PALBI and FIB-4) Model to Predict Posthepatectomy Liver Failure Grade B-C in Patients with Hepatocellular Carcinoma

Abstract

Hepatectomy is currently one of the most effective treatments for hepatocellular carcinoma (HCC). However, postoperative liver failure (PHLF) is a serious complication and the leading cause of mortality in patients with HCC after hepatectomy. This study attempted to develop a novel nomogram based on noninvasive liver reserve and fibrosis models, platelet-albumin-bilirubin grade (PALBI) and fibrosis-4 index (FIB-4), able to predict PHLF grade B-C. This was a single-centre retrospective study of 574 patients with HCC undergoing hepatectomy between 2014 and 2018. The independent risk factors of PHLF were screened using univariate and multivariate logistic regression analyses. Multivariate logistic regression was performed using the training set, and the nomogram was developed and visualised. The utility of the model was evaluated in a validation set using the receiver operating characteristic (ROC) curve. A total of 574 HCC patients were included (383 in the training set and 191 for the validation set) and included PHLF grade B-C complications of 14.8, 15.4, and 13.6%, respectively. Overall, cirrhosis ( P < 0.026 , OR = 2.296, 95% confidence interval (CI) 1.1.02–4.786), major hepatectomy ( P = 0.031 , OR = 2.211, 95% CI 1.077–4.542), ascites ( P = 0.014 , OR = 3.588, 95% 1.299–9.913), intraoperative blood loss ( P < 0.001 , OR = 4.683, 95% CI 2.281–9.616), PALBI score >−2.53 (, OR = 3.609, 95% CI 1.486–8.764), and FIB-4 score ≥1.45 ( P < 0.001 , OR = 5.267, 95% CI 2.077–13.351) were identified as independent risk factors associated with PHLF grade B-C in the training set. The areas under the ROC curves for the nomogram model in predicting PHLF grade B-C were significant for both the training and validation sets (0.832 vs 0.803). The proposed nomogram predicted PHLF grade B-C among patients with HCC with a better prognostic accuracy than other currently available fibrosis and noninvasive liver reserve models.

Albumin‐bilirubin score is superior to platelet‐albumin‐bilirubin score and model for end‐state liver disease sodium for predicting posthepatectomy liver failure

“…In China, Lu et al 15 also demonstrated greater accuracy for predicting overall survival with PALBI than ALBI for their entire cohort of 2038 patients with HCC (AUC: 0.693 vs. 0.683, respectively) and subgroup of patients who received major liver resection (AUC: 0.677 vs. 0.646, respectively). To predict severe PHLF, Zhong et al 17 reported a greater AUC for PALBI compared to ALBI (AUC: 0.731 vs. 0.673). However, Pang et al 20 found ALBI to be more accurate in predicting OS than PALBI.…”

“…For example, I‐PALBI included platelet crit (percentage volume occupied by platelets in blood) instead of platelet level, in addition to albumin and bilirubin levels, which was reported to have a greater discriminatory power in predicting PHLF (AUC = 0.72) over both PALBI and ALBI 19 . A nomogram was designed by combining multiple models (e.g., PALBI and Fibrosis Index‐4 [utilizes aspartate transaminase, alanine aminotransferase, and platelet level]) in predicting severe PHLF in patients with HCC with excellent accuracy (AUC > 0.8) 17 . Unfortunately, some of these models are unable to be recreated with data from NSQIP due to unavailable variables.…”

“…The platelet‐albumin‐bilirubin (PALBI) scoring system was recently established, which incorporates platelet count in addition to albumin and bilirubin to account for portal hypertension 15–19 . The discriminatory power of the PALBI score to predict postoperative complications after hepatic resection over other conventional scoring systems remains unclear.…”

“…The discriminatory power of the PALBI score to predict postoperative complications after hepatic resection over other conventional scoring systems remains unclear. While some data report no significant difference between the ALBI and PALBI scores in predicting severe PHLF, 16,19 others suggest the PALBI score is superior 15,17,18,20 . In addition, the majority of published studies on PALBI as a predictor for survival and severe PHLF were conducted in institutions outside the United States.…”

A Novel Nomogram for Predicting Postoperative Liver Failure After Major Hepatectomy for Hepatocellular Carcinoma

“…Recently, a few predictive models have been established for PHLF in HCC patients and showed certain predictive ability (15)(16)(17)(18)(19). However, most of these models incorporated both preand postoperative predictors which might reduce the validity of preoperative prediction.…”