Prediction of Posthepatectomy Liver Failure with a Combination of Albumin-Bilirubin Score and Liver Resection Percentage

J Am Coll Surg. 2022 Feb 1;234(2):155-165. doi: 10.1097/XCS.0000000000000027.


Background: Posthepatectomy liver failure (PHLF) is a main cause of death after partial hepatectomy. The aim of this study was to develop a practical stratification system using the albumin-bilirubin (ALBI) score and liver resection percentage to predict severe PHLF and conduct safe hepatectomy.

Methods: Between January 2002 and March 2021, 361 hepatocellular carcinoma (HCC) patients who underwent partial hepatectomy were enrolled. Medical image analysis software was applied postoperatively to accurately simulate hepatectomy. The liver resection percentage was calculated as follows: (postoperatively reconstructed resected specimen volume [ml] - tumor volume [ml])/total functional liver volume (ml) × 100. Multivariate analysis was performed to identify risk factors for PHLF grade B/C. A heatmap for predicting grade B/C PHLF was generated by combining the ALBI score and liver resection percentage.

Results: Thirty-nine patients developed grade B/C PHLF; 2 of these patients (5.1%) died. Multivariate analysis demonstrated that a high ALBI score and high liver resection percentage were independent predictors of severe PHLF (odds ratio [OR], 8.68, p < 0.001; OR, 1.10, p < 0.001). With a threshold PHLF probability of 50% for the heatmap, hepatectomy was performed for 346 patients meeting our criteria (95.8%) and 325 patients meeting the Makuuchi criteria (90.0%). The positive predictive value and negative predictive value for severe PHLF were 91.6% and 66.7% for our system and 91.7% and 33.3% for the Makuuchi criteria.

Conclusion: Our stratification system could increase the number of hepatectomy candidates and is practical for deciding the surgical indications and determining the upper limit of the liver resection percentage corresponding to each patient's liver function reserve, which could prevent PHLF and yield better postoperative outcomes.

MeSH terms

  • Albumins
  • Bilirubin
  • Carcinoma, Hepatocellular* / pathology
  • Carcinoma, Hepatocellular* / surgery
  • Hepatectomy / adverse effects
  • Humans
  • Liver Failure* / diagnosis
  • Liver Failure* / etiology
  • Liver Neoplasms* / pathology
  • Postoperative Complications / diagnosis
  • Postoperative Complications / epidemiology
  • Postoperative Complications / etiology
  • Prognosis
  • Retrospective Studies


  • Albumins
  • Bilirubin