We reviewed with interest the recent publication by Ko et al., which demonstrated that a higher baseline albumin–bilirubin (ALBI) grade (≥ 2) independently predicts poorer long-term survival in patients with hepatocellular carcinoma (HCC) treated with transarterial chemoembolization (TACE), including those with preserved liver function classified as Child–Pugh A 1. The extended follow-up duration and comprehensive multivariate analyses strengthen the authors' conclusion that ALBI serves as an objective and clinically relevant prognostic indicator in this population. The prognostic relevance of baseline ALBI grade in TACE-treated HCC has been consistently supported by evidence from large cohorts. A meta-analysis including over 6500 patients confirmed that higher pretreatment ALBI grades are significantly associated with reduced overall survival, reinforcing its value as a standardized marker of hepatic functional reserve 2. In contrast to the Child–Pugh classification, ALBI is based exclusively on serum albumin and bilirubin, thereby minimizing interobserver variability. Although baseline ALBI allows effective pretreatment risk stratification, liver function is dynamic and may change substantially following TACE. Increasing evidence suggests that the deterioration of ALBI grade after the initial TACE session is associated with earlier recurrence and reduced recurrence-free survival, reflecting treatment-related hepatic injury and declining liver reserve 3. Furthermore, the progressive worsening of ALBI grade with repeated TACE procedures has been linked to reduced survival outcomes, underscoring the limitations of relying exclusively on single baseline measurements 4. These findings demonstrate that serial assessment of ALBI may offer additional prognostic value beyond pretreatment evaluation alone. Integration of ALBI with established clinical staging systems may further improve risk stratification. Treatment decision-making in HCC frequently integrates liver function assessment alongside the Barcelona Clinic Liver Cancer (BCLC) staging system. Several studies have demonstrated that prognostic models combining ALBI with tumor burden and performance status outperform either parameter alone in predicting outcomes following TACE 5. Additionally, the recently proposed simplified ALBI score (EZ-ALBI) has shown effective prognostic discrimination in intermediate-stage HCC, with performance comparable to or exceeding that of conventional scoring indices 6. Prospective validation of ALBI-integrated staging models may enhance individualized treatment selection and inform optimal timing of therapeutic transitions. Methodological limitations should be acknowledged. Most studies assessing ALBI, including the analysis by Ko et al. 1, are retrospective and therefore subject to selection bias, heterogeneity in TACE techniques, and variability in post-treatment management. Prospective, multicenter studies are needed to validate optimal ALBI thresholds, standardize definitions of dynamic ALBI change, and confirm applicability across diverse clinical settings. Beyond its prognostic role, an important unresolved issue is whether ALBI can be used to actively guide treatment sequencing. Early identification of patients exhibiting post-TACE deterioration in ALBI grade may allow a timely transition to systemic therapies, potentially preserving hepatic function and improving outcomes. Prospective interventional trials evaluating ALBI-guided therapeutic strategies are therefore necessary to clarify its role in clinical decision-making and guideline development. In conclusion, although the baseline ALBI grade is a robust and objective prognostic marker for patients with HCC undergoing TACE, the integration of dynamic ALBI changes, incorporation with established staging systems, and validation of these approaches prospectively may further enhance its clinical utility and support more personalized management strategies. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. No new data were generated for this research.
Khan et al. (Sun,) studied this question.