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Multicenter Study
. 2021 Jan 8;5(1):zraa043.
doi: 10.1093/bjsopen/zraa043.

Combined APRI/ALBI score to predict mortality after hepatic resection

P Starlinger  1 , D S Ubl  2 , H Hackl  3 , J Starlinger  4 , D M Nagorney  1 , R L Smoot  1 , E B Habermann  2 , S P Cleary  1
Affiliations
Multicenter Study

Combined APRI/ALBI score to predict mortality after hepatic resection

P Starlinger et al. BJS Open. .

Abstract
in English, Spanish

Background: Aspartate aminotransferase/platelet ratio index (APRI) and albumin-bilirubin grade (ALBI) are validated prognostic indices implicated as predictors of postoperative liver dysfunction after hepatic resection. The aim of this study was to evaluate the relevance of the combined APRI/ALBI score for postoperative clinically meaningful outcomes.

Methods: Patients undergoing hepatectomy were included from the American College of Surgeons National Surgical Quality Improvement Program database. The association between APRI/ALBI score and postoperative grade C liver dysfunction, liver dysfunction-associated and overall 30-day mortality was assessed.

Results: A total of 12 055 patients undergoing hepatic resection from 2014 to 2017 with preoperative blood values and detailed 30-day postoperative outcomes were included (exploration cohort: January 2014 to December 2016; validation cohort: 2017). In the exploration cohort (8538 patients), the combination of both scores (APRI/ALBI) was significantly associated with postoperative grade C liver dysfunction, 30-day mortality, and liver dysfunction-associated 30-day mortality, and was superior to either score alone. The association with postoperative 30-day mortality was confirmed in multivariable analysis. A predictive model was generated using the exploration cohort. The predicted incidence of events closely followed the observed incidence in the validation cohort (3517 patients). Subgroup analyses of tumour types were used to generate disease-specific risk models to assess risk in different clinical scenarios. These findings informed development of a smartphone application (https://tellaprialbi.37binary.com).

Conclusion: The predictive potential of the combined APRI/ALBI score for clinically relevant outcomes such as mortality was demonstrated. An evidence-based smartphone application will allow clinical translation and facilitation of risk assessment before hepatic resection using routine laboratory parameters.

Antecedentes: El índice de relación aspartato aminotransferasa/plaquetas (aspartate aminotransferase/platelet ratio index, APRI) y grado de albúmina-bilirrubina (albumin-bilirubin grade, ALBI) son índices pronóstico validados implicados como predictores de disfunción hepática postoperatoria (liver dysfunction, LD) después de una resección hepática. El objetivo de este estudio fue evaluar la relevancia de la puntuación combinada APRI/ALBI respecto los resultados postoperatorios clínicamente significativos.

Métodos:

 : Los pacientes sometidos a hepatectomía se incluyeron en la base de datos del American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Se evaluó la asociación de APRI/LBI con LD grado C postoperatorio, así como con LD asociada y mortalidad global a los 30 días.

Resultados:

 : Se incluyeron 12.055 pacientes sometidos a resección hepática entre 2014 y 2017 con valores sanguíneos preoperatorios y resultados postoperatorios detallados a los 30 días (cohorte de exploración: 01/2014-12/2016; cohorte de validación: 2017). En la cohorte de exploración (n = 8.538), la combinación de ambas puntuaciones (APRI/ALBI) se asoció significativamente con LD grado C postoperatorio, mortalidad a 30 días, mortalidad asociada a LD a los 30 días y fue superior a cualquiera de las puntuaciones por separado. La asociación con la mortalidad postoperatoria a los 30 días se confirmó mediante el análisis multivariable. Se generó un modelo predictivo utilizando la cohorte de exploración. La incidencia anticipada de eventos se ajustó a la incidencia observada en la cohorte de validación (n = 3.517). Se utilizaron análisis de subgrupos de tipos de tumores a fin de generar modelos de riesgo específicos de la enfermedad para evaluar el riesgo en diferentes escenarios clínicos. Estos hallazgos permitieron el desarrollo de una aplicación para teléfonos inteligentes (https://tellaprialbi.37binary.com).

Conclusión:

 : Se demostró el potencial predictivo de la puntuación combinada APRI/ALBI para parámetros de resultados clínicamente relevantes, tales como la mortalidad. Una aplicación de teléfono inteligente basada en la evidencia permite la traducción clínica y facilita la evaluación de riesgos antes de la resección hepática utilizando parámetros de laboratorio de rutina.

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Figures

Fig. 1
Fig. 1
Receiver operating characteristic (ROC) curves comparing predictive ability of APRI and ALBI scores, individually or in combination, in relation to clinical outcomes after hepatic resection a Postoperative grade C liver dysfunction (LD), b postoperative 30-day mortality, and c LD-associated 30-day mortality. Areas under the curve: a aspartate aminotransferase/platelet ratio index (APRI) 0.662, albumin–bilirubin grade (ALBI) 0.659, APRI/ALBI 0.689; b APRI 0.679, ALBI 0.704, APRI/ALBI 0.728; c APRI 0.697, ALBI 0.704, APRI/ALBI 0.735.
Fig. 2
Fig. 2
Model generation for individualized prediction of postoperative outcome Given the continuous non-linear relationship between combined aspartate aminotransferase/platelet ratio index/albumin–bilirubin grade (APRI/ALBI) score and clinical outcomes, generalized additive models with smoothing splines were used, as illustrated for a postoperative grade C liver dysfunction (LD), b postoperative 30-day mortality, and c LD-associated 30-day mortality. Shaded areas represent 95 per cent confidence intervals. Based on the respective model, the combined APRI/ALBI score was grouped into deciles and individual risk for each outcome is shown in the lower panels. Number of patients in each decile is also shown.
Fig. 3
Fig. 3
Assessment of prediction models in validation cohort Model-based predicted incidence by aminotransferase/platelet ratio index/albumin–bilirubin grade (APRI/ALBI) score decile of a postoperative grade C liver dysfunction LD, b postoperative 30-day mortality, and c LD-associated 30-day mortality, compared with actual incidence in the validation cohort.
Fig. 4
Fig. 4
Receiver operating characteristic (ROC) curves comparing predictive power of combined APRI/ALBI score and MELD score for postoperative outcomes a Postoperative grade C liver dysfunction (LD), b postoperative 30-day mortality, and c LD-associated 30-day mortality. Areas under the curve: a aspartate aminotransferase/platelet ratio index (APRI) 0.640, albumin–bilirubin grade (ALBI) 0.655, APRI/ALBI 0.678, Model for End-Stage Liver Disease (MELD) 0.637; b APRI 0.647, ALBI 0.684, APRI/ALBI 0.700, MELD 0.633; c APRI, 0.651, ALBI 0.689, APRI/ALBI 0.710; MELD 0.630. For clarity, only curves for APRI/ALBI and MELD scores are shown.
Fig. 5
Fig. 5
Bubble plot illustrating association between combined APRI/ALBI score and postoperative 30-day mortality in patient subgroups Incidence and individual risk of postoperative 30-day mortality (percentage probability) is shown in relation to combined aspartate aminotransferase/platelet ratio index/albumin–bilirubin grade (APRI/ALBI) score deciles for several patient and surgical subgroups. The change from green to red indicates a gradual increase in risk, with red indicating a higher risk of postoperative 30-day mortality. Increased bubble size reflects large number of patients.
Fig. 6
Fig. 6
Subgroup model generation for individualized prediction of postoperative 30-day mortality Generalized additive models with smoothing splines were used, as illustrated for postoperative 30-day mortality in patient subgroups: a major resection, b minor resection, c perihilar cholangiocarcinoma (CCA), d metastatic disease to the liver, e hepatocellular carcinoma (HCC), and f CCA. Shaded areas represent 95 per cent confidence intervals. Based on the respective model, the combined aspartate aminotransferase/platelet ratio index/albumin–bilirubin grade (APRI/ALBI) score was grouped into deciles and individual risk for each subgroup is shown in the lower panel. Number of patients in each decile is also shown.
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