A Nomogram For Prediction Of Post-hepatectomy Liver Failure In Patients With Hepatocellular Carcinoma

ObjectiveTo identify risk factors for post-hepatectomy liver failure(PHLF)in patients with hepatocellular carcinoma(HCC),and to generate a nomogram in predicting PHLF.To illustrate the case of PHLF and provide the basis to assess the risks of PHLF.MethodsWe retrospectively reviewed 665 patients with HCC who underwent hepatectomy in two academic institutions in China.Patients from the Second Affiliated Hospital of Zhejiang University School of Medicine were used as the training cohort(n = 325)while patients from Eastern Hepatobiliary Surgery Hospital were used as the validation cohort(n = 340).Only patients who underwent hepatectomy(R0 or R1 resection)and had histopathologically-confirmed HCC according to the European Association for the Study of the Liver(EASL)criteria were included.Univariate logistic regression was used for screening risk factors of PHLF,multifactor regression analysis was used to screen independet risk factors.A predictive nomogram was established based on the independent risk factors and compared with existing models.Receiver operating characteristic(ROC)curves and the corresponding area under the curve(AUC)were used to assess how the predictive model performed on the test data.Results1.The PHLF rate was 8.3%(n = 27)in the training cohort and 7.1%(n = 24)in the externally validated cohort;2.Univariate analysis showed that CSPH,serum alkaline phosphatase(ALP),serum gamma-glutamyl transpeptidase(GGT),serum total bilirubin(TB),serum albumin(ALB),serum creatinine(CRE),intraoperative hemorrhage,extent of resection and FLR ratio were significantly associated with PHLF;3.The multifactor regression finally had 4 entry regression model,which were clinical signs of portal hypertension(P = 0.023),serum TB(P = 0.001),serum CRE(P = 0.039)and intraoperative hemorrhage(P = 0.015)。 A predictive nomogram was established based on the independent risk factors and compared with existing models;4.Based on the risk estimated by the nomogram,the patients could be separated into three risk groups : 1)a low-risk group(total points < 60.6 and predicted PHLF rate < 10%),with a predicted mean risk of PHLF of 7.71%(95% CI: 7.36-8.57);2)an intermediate-risk group(total points 60.6-80.3 and predicted PHLF rate 10%-30%),with predicted mean risk of PHLF of 18%(95% CI: 16.64-19.35);and 3)a high-risk group(total points > 80.3 and predicted PHLF rate >30%),with predicted mean risk of 50.81% PHLF of(95% CI: 39.89-61.73).The observed PHLF rates were more or less equal to the predicted mean risks.Conclusions1.PHLF is closely related to clinical signs of portal hypertension(P = 0.023),serum TB(P = 0.001),serum CRE(P = 0.039)and intraoperative hemorrhage(P =0.015);2.We present a novel prediction nomogram of PHLF based on four essential independent prognostic factors.This proposed nomogram showed satisfactory performance,with an AUC of 0.906 and was externally validated.It can be a convenient tool for facilitating decisions regarding the post-hepatectomy treatment approach;3.Specific management strategies can be established according to the risks.We suggest early use of hepatinica,close observation and intensive care should be planned after surgery especially in the intermediate-and high-risk groups.