ALBI grade: Evidence for an improved model for liver functional estimation in patients with hepatocellular carcinoma

Abstract

Hepatocellular carcinoma (HCC) usually arises in the context of a chronically damaged liver. Liver functional estimation is of paramount importance in clinical decision making. The Child-Pugh score (CPS) can be used to categorise patients into 3 classes (A to C) based on the severity of liver functional impairment according to 5 parameters (albumin, bilirubin, prothrombin time, presence of ascites and hepatic encephalopathy). The albumin-bilirubin (ALBI) grade has emerged as an alternative, reproducible and objective measure of liver functional reserve in patients with HCC, defining worsening liver impairment across 3 grades (I to III). The ALBI score can identify different subgroups of patients with different prognoses across the diverse Barcelona Clinic Liver Cancer stages and CP classes, making it an appealing clinical predictor. In patients treated with potentially curative approaches (resection, transplantation, radiofrequency ablation, microwave ablation), ALBI grade has been shown to correlate with survival, tumour relapse, and post-hepatectomy liver failure. ALBI grade also predicts survival, toxicity and post-procedural liver failure in patients treated with transarterial chemoembolisation, radioembolisation, external beam radiotherapy as well as multi-kinase inhibitors (sorafenib, lenvatinib, cabozantinib, regorafenib) and immune checkpoint inhibitor therapy. In this review, we summarise the body of evidence surrounding the role of ALBI grade as a biomarker capable of optimising patient selection and therapeutic sequencing in HCC.

Keywords: ALBI, albumin-bilirubin; APRI, aspartate aminotransferase to platelet count index; BCLC, Barcelona Clinic Liver Cancer; CLD, chronic liver disease; CPS, Child-Pugh score; Child-Pugh; HCC; HCC, hepatocellular carcinoma; ICIs, immune checkpoint inhibitors; LT, liver transplantation; MELD, model for end-stage liver disease; ORR, objective response rate; OS, overall survival; PHLF, post-hepatectomy liver failure; RFS, recurrence-free survival; TACE, transarterial chemoembolisation; TARE, transarterial radioembolisation; cirrhosis; liver function; mAb, monoclonal antibody; prognosis.

Fig. 1

Utility of the ALBI grade across BCLC stages and therapeutic modalities for HCC. ALBI, albumin-bilirubin; BCLC, Barcelona Clinic Liver Cancer; CP, Child-Pugh; ORR, objective response rate; OS, overall survival; PFS, progression-free survival; PPS, post-progression survival; SIRT, selective internal radiation therapy; TACE, transarterial chemoembolisation; TARE, transarterial radioembolization.