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Page 4 of 17 Marasco et al. Hepatoma Res 2020;6:32 I http://dx.doi.org/10.20517/2394-5079.2019.54

Table 1. Studies evaluating ALBI score in predicting PHLF
Authors Country Population Etiology Outcome Nr. cases ALBI cut-off AUROC
Toyoda et al. [38] , 2016 Asia/Europe 1,148 Mixed Death N/A -2.60 N/A
Wang et al. [39] , 2016 China 1,242 85% HBV PHLF 166 -2.77 0·723
Ke et al. [40] , 2016 China 372 80% HBV Postoperative complications 166 N/A 0.721
Andreatos et al. [41] , 2017 USA 2,659 N/A PHLF 149 -2.60/-1.39 N/A
Li et al. [42] , 2017 China 491 83% HBV Postoperative complications 270 -2.45 0.647
Russolillo et al. [43] , 2019 Italy 400 40% HCV Overall morbidity, 176 -2.60/-1.39 N/A
PHLF 82
Božin et al. [44] , 2018 Croatia 38 84% ALD Death 24 N/A N/A
[5]
Zhang et al. , 2018 China 338 82% HBV PHLF 26 -2.44 0.782
Zou et al. [37] , 2018 China 473 85% HBV PHLF 50 -2.303 0.745
Mai et al. [45] , 2019 China 1,055 HBV PHLF 151 -2.77 0.717
ALBI: Albumin-bilirubin; ALD: alcoholic liver disease; HBV: hepatitis B virus; HCV: hepatitis C virus; N/A: not available; PHLF: post-
hepatectomy liver failure

initially proposed as an alternative to the Child-Pugh score, which has some limitations, such as the inclusion
of non-objective parameters (ascites, encephalopathy). However, the ALBI score was also able to predict the
[33]
severity and long-term prognosis of patients with chronic liver disease . In particular, it was found to be
[34]
a reliable prognostic tool in assessing short-term outcomes in hepatic decompensation , in predicting in-
[35]
hospital mortality in patients with acute upper gastrointestinal bleeding and as a prognostic factor in HCC
[36]
patients . The ALBI score is based on serum levels of albumin and total bilirubin and can be calculated
through the following formula: (log10 bilirubin [µmol/L] × 0.66) + (albumin [g/L] × -0.0852). It was further
[32]
categorized into three different grades: grade 3 (> - 1.39), grade 2 (> - 2.60 to ≤ - 1.39), and grade 1 (≤ - 2.60) .
[5]
The ALBI grade was also a significant prognostic factor for PHLF in HCC patients . In a comparative
[37]
study , the ALBI score showed superior predictive value of PHLF over the Child-Pugh score, MELD score
and ICG R15. The area under the ROC curve (AUC) of the ALBI score (AUC 0.745) for predicting PHLF
was significantly higher than that of the Child-Pugh score (AUC 0.665), MELD score (AUC 0.649) and ICG
R15 (AUC 0.668). With a cut-off value of the ALBI score of -2.303, it was possible to reach a sensitivity of
[37]
[24]
77.3% and a specificity of 64.0% for predicting PHLF . Another group associated the ALBI score with
spleen thickness (ST) as a surrogate of portal hypertension. In this study, they compared the predictive
ability of ALBI/ST with FIB-4 and APRI and found that ALBI/ST had a higher diagnostic accuracy for PHLF
than FIB-4 and APRI. The AUC for the ALBI/ST ratio (AUC = 0.774, P < 0.001) was larger than that of FIB-4
(AUC = 0.696, P < 0.001), APRI (AUC = 0.697, P < 0.001), ALBI (AUC = 0.701, P < 0.001), and ST (AUC =
[24]
0.710, P < 0.001) . Also, in this study, multivariate analysis in the minor hepatectomy subgroup revealed
that age, Child-Pugh score and ALBI/ST and Child-Pugh score, FIB-4, and ALBI/ST were significant
[5]
predictors of PHLF in the APRI and FIB-4 models respectively. However, a study conducted by Zhang et al.
showed that the ALBI grade was a good predictor of overall survival in BCLC stage 0/A patients but not in
other BCLC stages. Thus, it is possible to conclude that the novel ALBI score is certainly one of the most
validated scores for predicting PHLF, as described in Table 1 [5,33,45,37-44] .

Indocyanine Green Retention Test
The clearance of indocyanine green (ICG) is a test used to assess liver excretory function quantitatively.
ICG is a water-soluble fluorescent dye, which totally binds to albumin and β-lipoprotein in the blood and is
exclusively taken up by hepatocytes and excreted unmodified in bile, without entero-hepatic circulation [46,47] .
Thus, its clearance depends on several factors: hepatic blood flow, the function of the hepatocytes and
biliary excretion [46,47] . However, this test takes time and is uncomfortable for patients. Thus, a faster sampling
method was subsequently introduced, the ICG 15-min retention test (ICG‐r15), consisting of an injection
of an ICG bolus and peripheral venous blood sampling every 5 min for 20 min [48,49] . In the last few decades,
a noninvasive ICG measurement by spectrophotometry, called LiMON® (Pulsion Medical System, Munich,