Predicting Post-Hepatectomy Liver Failure in HCC Patients: A Review of Liver Function Assessment Based on Laboratory Tests Scores

Predicting post-hepatectomy liver failure using a nomogram based on portal vein width, inflammatory indices, and the albumin-bilirubin score

BACKGROUND

Post-hepatectomy liver failure (PHLF) after liver resection is one of the main complications causing postoperative death in patients with hepatocellular carcinoma (HCC). It is crucial to help clinicians identify potential high-risk PHLF patients as early as possible through preoperative evaluation.

AIM

To identify risk factors for PHLF and develop a prediction model.

METHODS

This study included 248 patients with HCC at The Second Affiliated Hospital of Air Force Medical University between January 2014 and December 2023; these patients were divided into a training group (n = 164) and a validation group (n = 84) via random sampling. The independent variables for the occurrence of PHLF were identified by univariate and multivariate analyses and visualized as nomograms. Ultimately, comparisons were made with traditional models via receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA).

RESULTS

In this study, portal vein width [odds ratio (OR) = 1.603, 95%CI: 1.288-1.994, P ≤ 0.001], the preoperative neutrophil-to-lymphocyte ratio (NLR) (OR = 1.495, 95%CI: 1.126-1.984, P = 0.005), and the albumin-bilirubin (ALBI) score (OR = 8.868, 95%CI: 2.144-36.678, P = 0.003) were independent risk factors for PHLF. A nomogram prediction model was developed using these factors. ROC and DCA analyses revealed that the predictive efficacy and clinical value of this model were better than those of traditional models.

CONCLUSION

A new Nomogram model for predicting PHLF in HCC patients was successfully established based on portal vein width, the NLR, and the ALBI score, which outperforms the traditional model.

Five-Year Prospective Follow-Up of Patients with Hepatitis C Virus Infection Treated with Direct-Acting Antiviral Agents

Purpose

The research intended to present prospective data on the long-term prognosis of individuals with hepatitis C virus (HCV) infection who received direct-acting antiviral agent (DAA) treatment.

Patients and Methods

Patients who received DAA treatment at Tianjin Third Central Hospital and Tianjin Second People's Hospital were prospectively enrolled and subsequently underwent a longitudinal follow-up. This research monitored occurrences of virological relapse, hepatocellular carcinoma (HCC), mortality, and liver disease progression. The annualized incidence rates (AIRs), cumulative incidence rates of adverse events and risk factors were investigated. Changes in liver stiffness measurement (LSM), aspartate aminotransferase-to-platelet ratio index (APRI) score, fibrosis-4 (FIB-4) index, as well as the albumin-bilirubin (ALBI) scores were also documented.

Results

A total of 862 individuals were followed up for 4.86 (P25, P75; 4.48, 5.48) years. The proportion of all participants with undetectable HCV-RNA exceeded 98% at all follow-up time points. Patients experienced virological relapse, HCC, death and disease progression with a cumulative AIRs of 1.03% (95% confidence interval [CI] 0.6-1.5), 1.76% (95% CI 1.2-2.3), 1.51% (95% CI 1.0-2.0), and 5.81% (95% CI 4.8-6.8), respectively. Cirrhotic patients were at a heightened risk of virological relapse (adjusted hazard ratio [aHR] 3.20, 95% CI 1.59-9.75; p = 0.016), HCC (aHR 6.57, 95% CI 2.66-16.28; p < 0.0001), and unfavorable prognosis (aHR 6.93, 95% CI 2.56-18.74; p < 0.0001). Additionally, patients with diabetes faced an elevated risk of HCC (aHR 2.33, 95% CI 1.05-5.15; p = 0.038) and poor prognosis (aHR 2.72, 95% CI 1.13-6.55; p = 0.026). Furthermore, liver stiffness measurement (LSM) exhibited a significant decrease compared to baseline. Additionally, patients in the cirrhosis group showed reductions in APRI score, FIB-4 index and ALBI score to different degrees.

Conclusion

Cirrhotic patients exhibited increased susceptibility to virological relapse, HCC, unfavorable prognosis, and liver disease progression following DAA treatment. Consequently, it is imperative to implement a rigorous monitoring protocol for all cirrhotic patients after DAA treatment.

Hepatobiliary scintigraphy and liver function changes in patients with hepatocellular carcinoma treated with 166Ho-radioembolization : HBS in HCC treated with holmium-166

BACKGROUND

To study the feasibility of hepatobiliary scintigraphy (HBS) to improve selection and planning of patients with hepatocellular carcinoma (HCC) treated with holmium-166 (166Ho)-microspheres radioembolization.

RESULTS

Thirty-one patients with HCC were included and treated with 166Ho- radioembolization as part of a prospective phase 2 study. Twenty-seven patients were eligible for analysis, 67% had a cirrhotic liver morphology on imaging, 70% had multifocal disease and 51% had bilobar disease. None of the patients had clinical signs of liver decompensation (Child Pugh ≤ B7, median MELD 9 or ALBI - 2.55). Global and regional hepatic function was based on manual delineation of HBS using 200 MBq 99mTc-mebrofenine, acquired during screening and approximately three months after 166Ho-radioembolization, referred to as liver clearance rate (LCR). In line with LCR at baseline, a significant correlation was found between LCR and lab results, including bilirubin, albumin, ALT, MELD-score, and ALBI-score (p < 0.05) during follow-up. HBS showed a significant decrease in median LCR (-16%; p = 0.0017) and volume (-17%; p = 0.0027) in the treated liver, without a significant increase in the non-treated liver. Median relative change in overall LCR in non-cirrhotics was 0% (range - 23-33%), in cirrhotics - 10% (range - 40 - 19%; p = 0.40).

CONCLUSION

HBS showed that hepatic function and volume significantly decreased in parts of the liver treated with 166Ho-microspheres radioembolization in patients with HCC. Cirrhotic patients do not seem to have the capacity to increase hepatic function in the treated part of the liver.

TRIAL REGISTRATION

Registry name: Clinicaltrials.gov.

TRIAL NUMBER

NCT03379844. Date of registration: 21 November 2017. Trial URL: https://clinicaltrials.gov/study/NCT03379844?cond=hcc&term=hepar primary&rank=1#study-overview .

Liver Resection for Hepatocellular Carcinoma: Recent Advances

Hepatocellular carcinoma (HCC) represents a significant global health burden. Surgery remains a cornerstone in the curative treatment of HCC, and recent years have witnessed notable advancements aimed at refining surgical techniques and improving patient outcomes. This review presents a detailed examination of the recent innovations in HCC surgery, highlighting key developments in both surgical approaches and adjunctive therapies. Advanced imaging technologies have revolutionized preoperative assessment, enabling precise tumour localization and delineation of vascular anatomy. The use of three-dimensional rendering has significantly augmented surgical planning, facilitating more accurate and margin-free resections. The advent of laparoscopic and robotic-assisted surgical techniques has ushered in an era of minimal access surgery, offering patients the benefits of shorter hospital stays and faster recovery times, while enabling equivalent oncological outcomes. Intraoperative innovations such as intraoperative ultrasound (IOUS) and fluorescence-guided surgery have emerged as valuable adjuncts, allowing real-time assessment of tumour extent and aiding in parenchyma preservation. The integration of multimodal therapies, including neoadjuvant and adjuvant strategies, has allowed for 'bio-selection' and shown the potential to optimize patient outcomes. With the advent of augmented reality and artificial intelligence (AI), the future holds immense potential and may represent significant strides towards optimizing patient outcomes and refining the standard of care.

Predictors of Post-Hepatectomy Liver Failure in Klatskin Tumors: The Role of Preoperative Glucose, Future Liver Remnant to Spleen Ratio, and Early Bilirubin Monitoring

Background: Post-hepatectomy liver failure (PHLF) is a serious complication following hepatic resection for Klatskin tumors, significantly affecting patient prognosis. Identifying reliable preoperative and early postoperative predictors of PHLF can help optimize patient outcomes and guide surgical planning. Method: We conducted a retrospective review of 34 patients who underwent hemi-hepatectomy for extrahepatic cholangiocarcinoma at Kosin University Gospel Hospital between April 2019 and April 2024, and at Chonnam National University Hwasun Hospital between September 2017 and April 2024. Demographics, laboratory data, and volumetric measurements including spleen volume, were analyzed to assess their roles in predicting PHLF. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed to evaluate the predictive value of these factors. Results: Elevated preoperative glucose levels and reduced future liver remnant to spleen ratio (FLR/SV) were significantly associated with an increased risk of PHLF. Additionally, elevated postoperative day 1 total bilirubin (POD 1 TB) was identified as a key postoperative predictor of PHLF. Multivariable analysis confirmed the significance of these factors, with FLR/SV, preoperative glucose, and POD 1 TB demonstrating good discriminative ability in ROC analysis, with AUC values of 0.779, 0.782, and 0.786 respectively. Conclusion: Preoperative glucose control, evaluation of FLR/SV, and early postoperative monitoring of TB are useful for improving outcomes in patients undergoing major hepatectomy for Klatskin tumors.

Online interpretable dynamic prediction models for clinically significant posthepatectomy liver failure based on machine learning algorithms: a retrospective cohort study

BACKGROUND

Posthepatectomy liver failure (PHLF) is the leading cause of mortality in patients undergoing hepatectomy. However, practical models for accurately predicting the risk of PHLF are lacking. This study aimed to develop precise prediction models for clinically significant PHLF.

METHODS

A total of 226 patients undergoing hepatectomy at a single center were recruited. The study outcome was clinically significant PHLF. Five preoperative and postoperative machine learning (ML) models were developed and compared with four clinical scores, namely, the MELD, FIB-4, ALBI, and APRI scores. The robustness of the developed ML models was internally validated using fivefold cross-validation (CV) by calculating the average of the evaluation metrics and was externally validated on an independent temporal dataset, including the area under the curve (AUC) and the area under the precision-recall curve (AUPRC). SHapley Additive exPlanations analysis was performed to interpret the best performance model.

RESULTS

Clinically significant PHLF was observed in 23 of 226 patients (10.2%). The variables in the preoperative model included creatinine, total bilirubin, and Child-Pugh grade. In addition to the above factors, the extent of resection was also a key variable for the postoperative model. The preoperative and postoperative artificial neural network (ANN) models exhibited excellent performance, with mean AUCs of 0.766 and 0.851, respectively, and mean AUPRC values of 0.441 and 0.645, whereas the MELD, FIB-4, ALBI, and APRI scores reached AUCs of 0.714, 0.498, 0.536, and 0.551, respectively, and AUPRC values of 0.204, 0.111, 0.128, and 0.163, respectively. In addition, the AUCs of the preoperative and postoperative ANN models were 0.720 and 0.731, respectively, and the AUPRC values were 0.380 and 0.408, respectively, on the temporal dataset.

CONCLUSION

Our online interpretable dynamic ML models outperformed common clinical scores and could function as a clinical decision support tool to identify patients at high risk of PHLF preoperatively and postoperatively.

Optimizing Prognostic Precision in Hepatocellular Carcinoma: Integrating PWR with ALBI and PALPI Scores

BACKGROUND

Enhancing prognostication in Hepatocellular Carcinoma (HCC) remains an unmet need, especially in patients with preserved liver function. This study aimed to integrate the Platelet-to-White Blood Cell Ratio (PWR) with albumin-bilirubin (ALBI) and platelets-albumin-bilirubin (PALBI) scores for improved assessment of mortality and treatment responses in hepatocellular carcinoma (HCC) patients.

METHODS

In this prospective study, 262 patients with hepatocellular carcinoma (HCC) were included, with basic data collected and followed up for one year or until death. All prognostic scores were calculated by integrating the PWR with the ALBI and PALBI scores, examining their relationship with treatment responses and mortality rates.

RESULTS

The patients were mainly males (69.5%), aged 59.6 ± 8.09 years. The predictive power of the integrated PALBI+PWR score at different time points 1 (P 0.004), 3 months, and 6 months (P 0.004) overpowered all other scores. However, late at the 12-month follow-up, ALBI score had reported superiority on PALPI+PWR (AUC 0.631, 0.617), respectively. Regression analyses confirmed the high performance of PALBI+PWR factors in influencing treatment response (P 0.009-OR 0.562 (0.365 - 0.867)). Regarding mortality prediction, PALPI+PWR proved the highest efficacy in regression analysis (P <0.001) OR (2.451 (1.555 - 3.862).

CONCLUSION

Integrating PWR with the PALBI score enhances prognostic precision in patients with HCC, offering improved predictive power for treatment responses and mortality in the early stages of HCC with preserved liver function.

Interaction between the albumin-bilirubin score and nutritional risk index in the prediction of post-hepatectomy liver failure

BACKGROUND

Post-hepatectomy liver failure (PHLF) is the most common postoperative complication and the leading cause of death after hepatectomy. The albumin-bilirubin (ALBI) score and nutritional risk index (NRI) have been shown to assess end-stage liver disease and predict PHLF and patient survival. We hypothesized that the ALBI score and NRI interact in the prediction of PHLF.

AIM

To analyze the interaction between the ALBI score and NRI in PHLF in patients with hepatocellular carcinoma.

METHODS

This retrospective study included 186 patients who underwent hepatectomy for hepatocellular carcinoma at the Affiliated Hospital of Youjiang Medical University for Nationalities between January 2020 and July 2023. Data on patient characteristics and laboratory indices were collected from their medical records. Univariate and multivariate logistic regression were performed to determine the interaction effect between the ALBI score and NRI in PHLF.

RESULTS

Of the 186 patients included in the study, PHLF occurred in 44 (23.66%). After adjusting for confounders, multivariate logistic regression identified ALBI grade 2/3 [odds ratio (OR) = 73.713, 95% confidence interval (CI): 9.175-592.199] and NRI > 97.5 (OR = 58.990, 95%CI: 7.337-474.297) as risk factors for PHLF. No multiplicative interaction was observed between the ALBI score and NRI (OR = 0.357, 95%CI: 0.022-5.889). However, the risk of PHLF in patients with ALBI grade 2/3 and NRI < 97.5 was 101 times greater than that in patients with ALBI grade 1 and NRI ≥ 97.5 (95%CI: 56.445-523.839), indicating a significant additive interaction between the ALBI score and NRI in PHLF.

CONCLUSION

Both the ALBI score and NRI were risk factors for PHLF, and there was an additive interaction between the ALBI score and NRI in PHLF.

Significance of Prediction Models for Post-Hepatectomy Liver Failure Based on Type IV Collagen 7s Domain in Patients with Hepatocellular Carcinoma

Background: Previous studies have attempted to establish predictive models for post-hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC) undergoing liver resection. However, a versatile and useful predictive model for PHLF remains to be developed. Therefore, we aimed to develop predictive models for PHLF based on type IV collagen 7s domain (7s collagen) in patients with HCC. Methods: We retrospectively collected data from 972 patients with HCC who had undergone initial curative liver resection between February 2000 and December 2020 at our hospital. Multivariate logistic regression analysis using a restricted cubic spline was performed to evaluate the effect of 7s collagen on the incidence of PHLF. A nomogram was developed based on 7s collagen. Results: PHLF grades B or C were identified in 104 patients (11%): 98 (10%) and 6 (1%) PHLF grades B and C, respectively. Multivariate logistic regression analysis revealed that the preoperative serum level of 7s collagen was significantly associated with a proportional increase in the risk of PHLF, which was confirmed in both laparoscopic and open liver resections. A nomogram was developed based on 7s collagen, with a concordance index of 0.768. The inclusion of 7s collagen values in the predictive model increased the predictive accuracy. Conclusion: The findings highlight the efficacy of the serum level of 7s collagen as a predictive factor for PHLF. Our novel nomogram using 7s collagen may be useful for predicting the risk of PHLF.

Predictive factors of 90-day mortality after curative hepatic resection for hepatocellular carcinoma: a western single-center observational study

PURPOSE

The aim of this study was to identify predictive risk factors associated with 90-day mortality after hepatic resection (HR) in hepatocellular carcinoma (HCC).

METHODS

All patients undergoing elective resection for HCC from a single- institutional and prospectively maintained database were included. Multivariate regression analysis was conducted to identify pre- and intraoperative as well as histopathological predictive factors of 90-day mortality after elective HR.

RESULTS

Between August 2004 and October 2021, 196 patients were enrolled (148 male /48 female). The median age of the study cohort was 68.5 years (range19-84 years). The rate of major hepatectomy (≥ 3 segments) was 43.88%. Multivariate analysis revealed patient age ≥ 70 years [HR 2.798; (95% CI 1.263-6.198); p = 0.011], preoperative chronic renal insufficiency [HR 3.673; (95% CI 1.598-8.443); p = 0.002], Child-Pugh Score [HR 2.240; (95% CI 1.188-4.224); p = 0.013], V-Stage [HR 2.420; (95% CI 1.187-4.936); p = 0.015], and resected segments ≥ 3 [HR 4.700; (95% 1.926-11.467); p = 0.001] as the major significant determinants of the 90-day mortality.

CONCLUSION

Advanced patient age, pre-existing chronic renal insufficiency, Child-Pugh Score, extended hepatic resection, and vascular tumor involvement were identified as significant predictive factors of 90-day mortality. Proper patient selection and adjustment of treatment strategies could potentially reduce short-term mortality.

Probiotics are beneficial for liver cirrhosis: a systematic review and meta-analysis of randomized control trials

Introduction

Gut dysbiosis may play a pivotal role in the pathogenesis of cirrhosis and the severity of complications. Numerous studies have investigated the probiotics as treatments for cirrhosis. However, there is still a lack of definitive evidence confirming the beneficial effects of probiotics on cirrhosis.

Methods

Databases including PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched for randomized controlled trials that compared the effects of probiotic intervention and control treatments, including placebo, no treatment, and active control, on cirrhosis, published from inception to February 2024. Outcomes included hepatic encephalopathy (HE) reversal, safety and tolerability of probiotics, liver function, quality of life, and other cirrhotic-related outcomes. A meta-analysis was conducted to synthesize evidence.

Results

Thirty studies were included. The quantitative synthesis results showed that compared with the control group, probiotics significantly reverse minimal hepatic encephalopathy (MHE) (risk ratio [RR] 1.54, 95% confidence interval [CI] 1.03 to 2.32) and improve HE (RR 1.94, 95% CI 1.24 to 3.06). Additionally, probiotics demonstrated higher safety and tolerability by causing a lower incidence of serious adverse events (RR 0.71, 95% CI 0.58 to 0.87). Probiotics could potentially improve liver function by reducing the Model for End-Stage Liver Disease (MELD) scores (standardized mean difference [SMD] -0.57, 95% CI -0.85 to -0.30), and displayed favorable changes in quality of life (SMD 0.51, 95% CI 0.27 to 0.75) and gut flora (SMD 1.67, 95% CI 1.28 to 2.06).

Conclusion

This systematic review and meta-analysis offers compelling evidence that probiotics are beneficial for cirrhosis by demonstrating reversal of HE, potential for liver function improvements, enhancements in quality of life, and regulation of gut dysbiosis. Furthermore, the apparent safety profile suggests that probiotics are a promising intervention for treating cirrhosis.

Clinical trial registration number

CRD42023478380.

Predicting Safe Liver Resection Volume for Major Hepatectomy Using Artificial Intelligence

(1) Background: Advancements in the field of liver surgery have led to a critical need for precise estimations of preoperative liver function to prevent post-hepatectomy liver failure (PHLF), a significant cause of morbidity and mortality. This study introduces a novel application of artificial intelligence (AI) in determining safe resection volumes according to a patient's liver function in major hepatectomies. (2) Methods: We incorporated a deep learning approach, incorporating a unique liver-specific loss function, to analyze patient characteristics, laboratory data, and liver volumetry from computed tomography scans of 52 patients. Our approach was evaluated against existing machine and deep learning techniques. (3) Results: Our approach achieved 68.8% accuracy in predicting safe resection volumes, demonstrating superior performance over traditional models. Furthermore, it significantly reduced the mean absolute error in under-predicted volumes to 23.72, indicating a more precise estimation of safe resection limits. These findings highlight the potential of integrating AI into surgical planning for liver resections. (4) Conclusion: By providing more accurate predictions of safe resection volumes, our method aims to minimize the risk of PHLF, thereby improving clinical outcomes for patients undergoing hepatectomy.

Peri-interventional LiMAx test for liver ablation - A feasibility study

BACKGROUND

Local ablation is an important treatment for liver cancer in cases of cirrhosis. Liver failure may occur after ablation, especially in advanced liver diseases. Currently, there is no standardization for peri-interventional risk assessment. The liver maximum capacity test (LiMAx) is used to assess functional liver capacity, but there is a lack of exploration of its use in this context.

OBJECTIVE

The aim of this study was to retrospectively evaluate the usefulness of peri-interventional LiMAx measurements in patients with primary or secondary liver cancer who underwent ablation treatment.

METHODS

A LiMAx test was performed at 24 hours pre- and postablation in 49 patients. Blood parameters were collected to determine liver function using MELD and ALBI scores. The results of the LiMAx test were related with these scores and to critical postintervention LiMAx values.

RESULTS

LiMAx values correlated strongly with MELD and ALBI scores before the intervention and reflected the change in liver function, as shown by an increase in scores after the intervention. Notably, LiMAx values decreased during the intervention. AUC analysis for patients at risk of reaching a critical liver level after the intervention showed a cutoff value of 186μg/kg/h.

CONCLUSIONS

The LiMAx test may be a valuable tool in liver ablation for both peri-interventional monitoring of liver function and preintervention risk assessment.