Dynamic Changes in Bilirubin Predict 90-Day Mortality in Patients With Hepatocellular Carcinoma and Acute Decompensations of Cirrhosis: The HCC-AD Score.

Objective: To develop a score to predict 90-day mortality in patients with hepatocellular carcinoma (HCC) admitted with an acute decompensation (AD) event of chronic liver disease. Patients and Methods: This retrospective cohort study was conducted at Blacktown and Westmead Hospitals in Australia, including patients with decompensated cirrhosis and concomitant HCC between January 1, 2012, and May 31, 2023. Participants were separated into derivation (n=233) and validation (n=132) cohorts. Demographic and clinical data were collected at admission and day 7. Independent predictors for 90-day transplant-free survival were entered into classification and regression tree analysis to develop the HCC-AD score. Discrimination was assessed in the validation cohort using Harrell C statistic. Subgroup analysis was conducted for each Barcelona Clinic Liver Cancer (BCLC) class with comparisons made to current scores. Results: A cohort of 355 patients was considered. Admission bilirubin (P=.009) and 7-day change in bilirubin (P=.018) remained significant for 90-day mortality in multivariable analysis. The HCC-acute decompensation (AD) score stratified patients into 3 risk groups with predicted mortality of 26%, 49%, and 89%, respectively. The HCC-AD score showed good discrimination (Harrell C=0.731). Cox regression analysis determined the HCC-AD score remained predictive in BCLC B (P<.001), C (P<.001), and D (P=.010) scored HCC. The model for end-stage liver disease 3.0 (P=.058) and Child-Pugh (P=.11) scores were not predictive in BCLC D HCC. Conclusion: A simple score that stratifies patients with HCC into 3 risk categories based on changes in bilirubin predicts 90-day mortality following an acute decompensatory event. It is superior to other scores in advanced HCC.