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  • Writer's pictureNicholas Murtha

An APRI+ALBI Based Multivariable Model as Preoperative Predictor for Posthepatectomy Liver Failure



An APRI+ALBI Based Multivariable Model as Preoperative Predictor for Posthepatectomy Liver Failure

October 21, 2023

HEIDELBERG, GERMANY – On October 20, 2023, the article, “An APRI+ALBI Based Multivariable Model as Preoperative Predictor for Posthepatectomy Liver Failure,” a research collaboration led by Dr Patrick Starlinger (MD)(PHD) and of which Liver Surgery Research was a part of, was published. This manuscript was published by the peer reviewed and open access journal, Annals Of Surgery; which has an impact factor of 9.0. Authors include: Jonas Santol MD, Sarang Kim, Lindsey A Gregory, Ruth Baumgartner MD, Anastasia Murtha-Lemekhova MD, Emrullah Birgin MD, Severin Gloor MD, Eva Braunwarth MD, Markus Ammann MD, Johannes Starlinger MD, David Pereyra MD, Daphni Ammon MD, Marijana Ninkovic MD, Anna E Kern, Benedikt Rumpf MD, Gregor Ortmayr MD, Yannic Herrmann, Yawen Dong MD, Felix X Huber, Jeremias Weninger, Cornelius A Thiels DO MBA, Susanne G Warner MD, Rory L Smoot MD, Mark J Truty MD, Michael L Kendrick MD, David N Nagorney MD, Sean P Cleary MD, Guido Beldi MD, Nuh N Rahbari MD, Katrin Hoffmann MD MBA, Stefan Gilg MD PHD , Alice Assinger PHD, Thomas Gruenberger MD, Hubert Hackl PHD, Patrick Starlinger MD PHD


Objective and background: Clinically significant posthepatectomy liver failure (PHLF B+C) remains the main cause of mortality after major hepatic resection. This study aimed to establish an APRI+ALBI, aspartate aminotransferase to platelet ratio (APRI) combined with albumin-bilirubin grade (ALBI), based multivariable model (MVM) to predict PHLF and compare its performance to indocyanine green clearance (ICG-R15 or ICG-PDR) and albumin-ICG evaluation (ALICE).

Methods: 12,056 patients from the National Surgical Quality Improvement Program (NSQIP) database were used to generate a MVM to predict PHLF B+C. The model was determined using stepwise backwards elimination. Performance of the model was tested using receiver operating characteristic curve analysis and validated in an international cohort of 2,525 patients. In 620 patients, the APRI+ALBI MVM, trained in the NSQIP cohort, was compared with MVM's based on other liver function tests (ICG clearance, ALICE) by comparing the areas under the curve (AUC).

Results: A MVM including APRI+ALBI, age, sex, tumor type and extent of resection was found to predict PHLF B+C with an AUC of 0.77, with comparable performance in the validation cohort (AUC 0.74). In direct comparison with other MVM's based on more expensive and time-consuming liver function tests (ICG clearance, ALICE), the APRI+ALBI MVM demonstrated equal predictive potential for PHLF B+C. A smartphone application for calculation of the APRI+ALBI MVM was designed.

Conclusion: Risk assessment via the APRI+ALBI MVM for PHLF B+C increases preoperative predictive accuracy and represents an universally available and cost-effective risk assessment prior to hepatectomy, facilitated by a freely available smartphone app.

About Liver Surgery Research

Liver Surgery Research (LSR) is a medical research group, located at Heidelberg University in Heidelberg, Germany. LSR specializes in research investigating liver regeneration after hepatectomy (liver resection) and post-hepatectomy liver failure, HCC development and treatment (especially in the context of MAFLD [metabolically associated fatty liver disease]), and rare liver lesions and diseases. LSR is the founder and leader of the RELIVE (RarE LIVEr) Initiative; a multidisciplinary project to establish evidence-based therapies for rare liver diseases. LSR is currently working on over 10 research projects and has over 100 peer reviewed published authorships. To learn more about Liver Surgery Research, visit


Nicholas Murtha

Communications Manager

Liver Surgery Research at Heidelberg University


Santol, J., Kim, S., Gregory, L. A., Baumgartner, R., Murtha-Lemekhova, A., Birgin, E., Gloor, S., Braunwarth, E., Ammann, M., Starlinger, J., Pereyra, D., Ammon, D., Ninkovic, M., Kern, A. E., Rumpf, B., Ortmayr, G., Herrmann, Y., Dong, Y., Huber, F. X., Weninger, J., … Starlinger, P. (2023). An APRI+ALBI Based Multivariable Model as Preoperative Predictor for Posthepatectomy Liver Failure. Annals of surgery, 10.1097/SLA.0000000000006127. Advance online publication.

PMID: 37860868 DOI: 10.1097/SLA.0000000000006127

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