The Combination of APRI and ALBI Facilitates Preoperative Risk Stratification for Patients Undergoing Liver Surgery After Neoadjuvant Chemotherapy

Ann Surg Oncol. 2019 Mar;26(3):791-799. doi: 10.1245/s10434-018-07125-6. Epub 2019 Jan 7.


Background: Neoadjuvant chemotherapy (NeoCTx) is performed for most patients with colorectal cancer liver metastases (CRCLM). However, chemotherapy-associated liver injury (CALI) has been associated with poor postoperative outcome. To date, however, no clinically applicable and noninvasive tool exists to assess CALI before liver resection.

Methods: Routine blood parameters were assessed in 339 patients before and after completion of NeoCTx and before surgery. The study assessed the prognostic potential of the aspartate aminotransferase (AST)-to-platelet ratio index (APRI), the albumin-bilirubin grade (ALBI), and their combinations. Furthermore, an independent multi-center validation cohort (n = 161) was included to confirm the findings concerning the prediction of postoperative outcome.

Results: Higher ALBI, APRI, and APRI + ALBI were found in patients with postoperative morbidity (P = 0.001, P = 0.064, P = 0.001, respectively), liver dysfunction (LD) (P = 0.009, P = 0.012, P < 0.001), or mortality (P = 0.037, P = 0.045, P = 0.016), and APRI + ALBI had the highest predictive potential for LD (area under the curve [AUC], 0.695). An increase in APRI + ALBI was observed during NeoCTx (P < 0.001). Patients with longer periods between NeoCTx and surgery showed a greater decrease in APRI + ALBI (P = 0.006) and a trend for decreased CALI at surgery. A cutoff for APRI + ALBI at - 2.46 before surgery was found to identify patients with CALI (P = 0.002) and patients at risk for a prolonged hospital stay (P = 0.001), intensive care (P < 0.001), morbidity (P < 0.001), LD (P < 0.001), and mortality (P = 0.021). Importantly, the study was able to confirm the predictive potential of APRI + ALBI for postoperative LD and mortality in a multicenter validation cohort.

Conclusion: Determination of APRI + ALBI before surgery enables identification of high-risk patients for liver resection. The combined score seems to dynamically reflect CALI. Thus, APRI + ALBI could be a clinically relevant tool for optimizing timing of surgery in CRCLM patients after NeoCTx.

MeSH terms

  • Aspartate Aminotransferases / blood*
  • Bilirubin / blood*
  • Colorectal Neoplasms / blood*
  • Colorectal Neoplasms / pathology
  • Colorectal Neoplasms / surgery
  • Follow-Up Studies
  • Hepatectomy / mortality*
  • Humans
  • Liver Neoplasms / blood*
  • Liver Neoplasms / secondary
  • Liver Neoplasms / surgery
  • Neoadjuvant Therapy
  • Platelet Count
  • Preoperative Care
  • Prognosis
  • Prospective Studies
  • ROC Curve
  • Risk Assessment / methods*
  • Risk Factors
  • Serum Albumin / analysis*
  • Survival Rate


  • Serum Albumin
  • Aspartate Aminotransferases
  • Bilirubin