A Novel Preoperative Score Predicts Posthepatectomy Liver Failure in Hepatocellular Carcinoma: Comparison with Traditional Risk Scores

Abstract

Background: Posthepatectomy liver failure (PHLF) remains one of the most serious and potentially lethal adverse events after surgical resection for hepatocellular carcinoma (HCC). Conventional evaluation frameworks are often inadequate for predicting PHLF in the setting of operative stress, and no unified model currently integrates coagulation competence, hepatocellular injury, and underlying functional reserve. Objectives: This study aimed to identify independent preoperative predictors of PHLF in patients with HCC, develop an integrated multidimensional predictive tool, and benchmark its accuracy against currently used scoring systems to strengthen preoperative risk stratification. Methods: Records were retrospectively collected from 228 patients with histopathologically confirmed HCC who underwent partial hepatectomy between June 2022 and June 2025. The cohort was randomly divided into a training cohort (n = 159) and a test cohort (n = 69). Candidate predictors were screened using least absolute shrinkage and selection operator (LASSO) regression, and a predictive equation was derived using multivariable logistic regression. The model was evaluated using the area under the receiver operating characteristic curve (AUC-ROC), calibration plots, and decision curve analysis (DCA). Results: The overall PHLF rate was 25.4%. Three variables—prothrombin time (PT), De Ritis ratio (DRR), and albumin-bilirubin (ALBI) score—were retained as independent determinants and collectively constituted the proposed PT-ALBI-DRR (PAD) score: (0.736 × PT + 1.441 × DRR + 1.535 × ALBI). The PAD score demonstrated strong discriminative performance, with AUC values of 0.838 in the training cohort and 0.816 in the test cohort, outperforming seven established indices: Child-Pugh, FIB-4, ALBI, MELD, ALBI-FIB4, PALBI, and APRI. Calibration showed close agreement between predicted and observed event rates, and DCA confirmed a greater net clinical benefit compared with conventional alternatives. Conclusions: By jointly quantifying baseline hepatic reserve, acute synthetic performance, and mitochondrial injury, the PAD score addresses the limitations of existing tools. Its simplicity and low cost make it a practical instrument for preoperative risk stratification and may support surgical planning and individualized perioperative care.