Immediate prediction and early intervention for post-hepatectomy liver failure: external validation of the modified Rem-ALPlat index.

BACKGROUND: Posthepatectomy liver failure (PHLF) is a leading cause of mortality. We established a modified Rem-ALPlat index integrating preoperative (albumin, platelet count, future liver remnant) and intraoperative variables (blood loss and Pringle maneuver) for immediate postoperative prediction. This study aimed to externally validate the model and assess its utility for early interventions. METHODS: We retrospectively analyzed 198 patients who underwent anatomical hepatectomy without vascular or biliary reconstruction between 2015 and 2024. This external validation cohort was derived from an independent institution, separate from the original model development cohort. PHLF was defined according to the International Study Group of Liver Surgery grades. Predictive performance was assessed using receiver operating characteristic (ROC) analysis. RESULTS: PHLF grades were as follows: none (n = 144), grade A (n = 24), B (n = 26), and C (n = 4). ALPlat index had the highest AUC among the preoperative models (the area under the curve [AUC] 0.684 for grades B/C). The modified Rem-ALPlat index achieved an AUC of 0.847 for grades B/C. Model-derived probability cutoffs stratified patients into low (0-0.047), intermediate (0.047-0.066), high (0.066-0.109), and very high (≥ 0.109). Risk stratification was significantly associated with PHLF grade distribution (No-PHLF/A/B/C; low 98/6/3/0, intermediate 13/8/3/0, high 17/8/8/0, very high 16/2/12/4, P < 0.001). Exploratory analysis of early intervention (n = 18) among 67 high/very high-risk patients showed favorable postoperative trends, although statistical significance was not reached (no/A/B/C; 12/1/5/0 vs. 21/9/15/4, P = 0.118). CONCLUSION: The modified Rem-ALPlat index enables accurate PHLF prediction and may facilitate risk-adapted postoperative management. The clinical benefit of early intervention requires prospective validation.