Abstract
Outcomes in hepatocellular carcinoma (HCC) depend on tumor biology and hepatic functional reserve. The albumin-bilirubin (ALBI) grade, developed by Johnson et al. in a Japanese cohort undergoing resection or sorafenib, quantifies hepatic reserve. We aimed to validate ALBI in a large, predominantly noncirrhotic Indian surgical cohort selected by conventional preoperative work-up (Child-Turcotte-Pugh score, Barcelona Clinic Liver Cancer (BCLC) and Hong Kong Liver Cancer (HKLC) staging, future liver remnant), to assess its incremental value for patient selection. The aim of the study is to evaluate preoperative ALBI grade as a predictor of survival and postoperative complications after curative hepatectomy for HCC. This retrospective study included 333 patients undergoing curative-intent hepatectomy for HCC at a tertiary cancer center in India (2010-2023). ALBI grade was calculated from preoperative ALBI. Primary endpoint: overall survival (OS). Secondary endpoints: posthepatectomy liver failure (PHLF), bile leak (PHBL), major complications (Clavien-Dindo ≥ IIIa), 6-month mortality, and recurrence-free survival (RFS). Multivariable logistic and Cox regression assessed ALBI as an independent predictor, with sensitivity analysis excluding the small, unstable ALBI grade 3 subgroup. ALBI grade distribution: grade 1 (54.4%), grade 2 (44.1%), grade 3 (1.5%). PHLF rose from 3.3% to 4.1% and 40% across grades (P = 0.019); bile leak, 2.2%, 7.5%, and 40% (P = 0.002); 6-month mortality, 9.9%, 12.9%, and 60% (P = 0.013). Median OS declined from 96.5 to 59.4 to 4.0 months across grades (log-rank P = 0.013). ALBI independently predicted 6-month mortality (adjusted odds ratio [OR]: 8.94, P = 0.020) and OS (grade 2: adjusted hazard ratio [HR]: 1.64, P = 0.005). RFS showed a borderline association in the primary analysis (grade 2: adjusted HR: 1.39, P = 0.024), reaching significance on grades 1-2 sensitivity analysis (log-rank P = 0.049). ALBI retained prognostic significance despite surgeons tailoring resection extent to hepatic reserve. Preoperative ALBI grade independently predicts survival, liver-specific complications, and early mortality after HCC hepatectomy, offering clinically accessible risk stratification complementary to tumor staging and supporting its integration into preoperative assessment and surgical decision-making.