The albumin‐bilirubin grade uncovers the prognostic relationship between hepatic reserve and immune dysfunction in HIV‐associated hepatocellular carcinoma

Abstract

Hepatocellular carcinoma (HCC) is a leading cause of liver-related mortality in people living with HIV, where co-infection with hepatotropic viruses accelerates the course of chronic liver disease. To evaluate whether the albumin-bilirubin (ALBI) grade, a more accurate marker of liver dysfunction in HCC, might identify patients with progressive liver dysfunction in the context of HIV/hepatitis co-infection. Using uni- and multi-variable analyses, we studied the albumin-bilirubin grade as a predictor of overall survival (OS) in a large, multi-center cohort of patients with HIV-associated HCC recruited from 44 centres in 9 countries within the Liver Cancer in HIV study group. Patients who underwent liver transplantation were excluded. A total of 387 patients, predominantly HCV co-infected (78%) with balanced representation of all Barcelona Clinic Liver Cancer (BCLC) stages (A=33%, B=18%, C=37%, D=12%) were recruited. At HCC diagnosis, 84% had been on anti-retrovirals for a median duration of 8.8years. The albumin-bilirubin grade identified significant differences in median survival of 97months for grade 1 (95% CI 13-180months), 17months for grade 2 (95% CI 11-22months) and 6months for grade 3 (95% CI 4-9months, P<.001). A more advanced albumin-bilirubin grade correlated with lower CD4 counts (464/373/288 cells/mm3 for grades 1/2/3) and higher HIV viraemia (3.337/8.701/61.845 copies/mL for grades 1/2/3, P<.001). In this large, multi-center retrospective study, the albumin-bilirubin grade highlights the interplay between liver reserve and immune dysfunction as prognostic determinants in HIV-associated HCC.