Albumin-Bilirubin Score: An accurate Predictor of Hepatic Decompensation in High-Risk Patients Undergoing Transarterial Chemoembolization for Hepatocellular Carcinoma
Patient selection is a critical component within the decision paradigm in patients with hepatocellular carcinoma. Most interventional radiologists use total bilirubin values and Child-Turcotte-Pugh (CP) scores to aid in decision making. In fact, CP scores are one of four factors that comprise the Barcelona Clinic Liver Cancer (BCLC) classification, along with tumor extension, physical status, and cancer-related symptoms. However, the CP score was originally created to predict mortality following surgery in the cirrhotic population. Under BCLC recommendations, any CP class C patient is recommended for best supportive care, relegating a significant number of patients without a treatment option.
The albumin-bilirubin (ALBI) grade was created in 2015 as a purely objective assessment of underlying liver function. The goal of this study from the Stanford group was to identify predictors of acute-on-chronic liver failure (ACLF) following chemoembolization (TACE) and evaluating the use of ALBI grade as a predictor of ACLF in the high risk patients. The study evaluated patients with a CP score greater than or equal to 8 who underwent TACE. Patients were treated with both conventional TACE and drug-eluting-bead TACE. ALBI grades were designated as grade 1 if ≤ -2.60, grade 2 if > -2.60 but ≤ -1.39, and grade 3 if > -1.39. ACLF was reported at 30 days and 90 days following TACE using the chronic liver failure-sequential organ failure assessment algorithm.
ACLF occurred within 30 days in 8% of cases, with an additional 5% between 30 and 90 days. Significant predictors of ACLF or worsening ascites or encephalopathy at 90 days included bilirubin, albumin, and ALBI grade. ALBI score was the only remaining statistically significant variable following multivariate regression analysis. The authors concluded that TACe can be performed safely in patients with moderate to severe liver dysfunction and that ALBI score can help determine risk stratification.
Figure 2. Prediction curve from logistic regression model for ACLF at 90 days using ALBI scores showing the risk of ACLF is negligible for ALBI scores < -1.5, increases minimally when the ALBI score reaches -1.39 (ABLI grade 3), and increases rapidly as the ALBI score nears 0.
ALBI Score = (log10 bilirubin x 0.66) + (albumin x -0.085)
Bilirubin is in µmol/L and albumin in g/L.
In the past three years, ALBI score has drawn a fair amount of attention within the interventional oncology world as a purely objective scale for predicting survival within cirrhotics with hepatocellular carcinoma. Patients with moderate and severe liver dysfunction and hepatocellular carcinoma have proven to be a challenging patient population. Following the BCLC algorithm, any patient with CP class C liver dysfunction is deemed terminal with recommendation for best supportive care. This study demonstrates the role of the ALBI score in aiding interventional radiologists in selecting which CP C patients are safe to TACE, with risk of ACLF increasing only when the ALBI score > -1. With using ALBI to determine which high risk patients have unacceptable morbidity and mortality risks following TACE, a significant population of CP C patients could now be offered treatment confidently. The impact would include improving overall survival with potential to down-stage patients to become transplant candidates or keep them transplant eligible. This paper adds to the existing literature supporting the use of ALBI score in not only survival prediction, but also risk stratification for ACLF and thus tumor board decision making and patient counseling.
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Mohmammed M, Khalaf M, Liang T, et al. Albumin-Bilirubin Score: An Accurate Predictor of Hepatic Decompensation in High-Risk Patients Undergoing Transarterial Chemoembolization for Hepatocellular Carcinoma. J Vasc Interv Radiol. 2018; 29: 1527-1534.
David M Mauro, MD
Department of Radiology
Vascular and Interventional Radiology
University of North Carolina