Assessment of Severity of Liver Disease Before Surgery

Cirrhotic patients have a great risk for increased morbidity and mortality rather than the normal population after undergoing surgical procedures.(1) High mortality rates were reported among patients with liver cirrhosis as high as 67 % after surgical interventions. (2) This high surgical risk occurs is contributing to the pathophysiology of the diseased liver itself and to the presence of contributing factors, such as coagulopathy, poor nutritional status, adaptive immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction, which all predisposing to poor outcomes. Preoperative optimization after risk stratification and careful management are mandatory before surgery.(1) The challenge is to assess the surgical risks before deciding whether the procedure will be carried out safely or should be delayed until the patient underwent liver transplantation, or it should be avoided completely, and so early involvement of an experienced surgical and medical team is important.(1) The degree of hepatic dysfunction is one of the most risk factors for post-operative mortality and complication, other factors are considered as non-hepatic comorbidities, type of surgical procedures and the expertise of the managing team.(3) Various score systems are being used in clinical practice, for assessment of prognosis among cirrhotic patients such as the Child-Turcotte score, Model for End stage Liver Disease (MELD), . However, these scoring systems have several limitations in their prognostic implications. Although CTP scoring is easily applicable at bedside, the interpretation of ascites and encephalopathy is subjective in nature and equal point allocation of all variables make its results unstable.(4, 5) Also, the wide reference ranges for grading cirrhosis and its complications, such as ascites, bleeding, spontaneous bacterial peritonitis (SBP), and hepato-pulmonary syndrome, restricts the predictive accuracy of the MELD score. This raises a need for evaluating other potential biomarkers to strengthen prognostication and severity of cirrhosis (3).

Recently, the albumin-to-bilirubin (ALBI) score has emerged to evaluate severity of liver disease in hepatocellular carcinoma (HCC) (5) The ALBI is a new and simple score, easily calculated at bedside without having to use subjective determinants such as ascites and encephalopathy and because the ALB and TB levels are indicators of liver function, and can reflect the synthesis and metabolic function of the liver , so Its prognostic role in various liver diseases has recently been validated in several studies where it was found to be superior to CTP and MELD in assessing severity of liver disease.(4, 6, 7)

In general, ALBI grades 1, 2, and 3 correspond to Child-Pugh A, B, and C, respectively, and it was reported that the ALBI grade is more accurate in prediction of postoperative liver failure than the Child-Pugh grade. However, the Child-Pugh grade itself is a relatively rough grading system and was not intended for the prediction of liver failure after hepatectomy .(8)