Identifying a Cardio-Hepatic Phenotype by Integrating the Albumin-Bilirubin Score Into Risk Assessment in Pulmonary Arterial Hypertension

Hacer Ceren Tokgoz, Barkin Kultursay, Seda Tanyeri, Dicle Sırma, Cagdas Bulus, Tezel Kovanci, Mustafa Kara, Seyma Zeynep Atici, Seyma Nur Cicek, Caglar Emre Cagliyan …  

https://doi.org/10.1002/pul2.70412

Abstract

Risk stratification is essential in pulmonary arterial hypertension (PAH), yet the prognostic utility of the albumin-bilirubin (ALBI) score as a marker of hepatic dysfunction remains underexplored. In this single-center study, we evaluated the clinical, neurohumoral, echocardiographic and hemodynamic correlates and prognostic value of the ALBI score, and to assess whether this score offers an incremental benefit over the Registry to EValuate Early And Long-term pulmonary arterial hypertension disease management (REVEAL) 2.0 risk score in patients with PAH. This study evaluated the prognostic value of the ALBI score and its incremental benefit in a cohort of 380 PAH patients (mean age 47.6 ± 18.3 years, 74.3% female). Patients were stratified into low (<= −2.60) and high (> −2.60) ALBI groups. High ALBI scores were significantly associated with worse functional class, reduced exercise capacity, elevated Nt-proBNP, right ventricular systolic dysfunction, and vena cava plethora (all p < 0.001). Hemodynamically, elevated ALBI correlated with increased right atrial pressure (RAP) (p = 0.005), reduced cardiac index (p = 0.002), and a narrowed trans-systemic pressure gradient (p = 0.001). Multivariable Cox regression demonstrated that ALBI was an independent predictor of mortality [Adjusted HR: 1.80 (95% CI: 1.30–2.49), p < 0.001], outperforming MELD variants and the FIB-4 index. Integrating ALBI into REVEAL 2.0 yielded higher risk discrimination (C-index: 0.756) than adding direct echocardiographic indices of right ventricular function or coupling (C-indices: 0.748–0.749). In sensitivity analyses adjusting for TAPSE/PASP, invasive cardiac index, mean RAP, and background therapy, ALBI maintained its independent prognostic value [Adjusted HR: 1.44 (95% CI: 1.01–2.05), p = 0.044], with the full model achieving a C-index of 0.801. Within the REVEAL 2.0 intermediate-risk subgroup, a high ALBI score identified patients with a three-fold higher mortality risk [HR: 3.04 (95% CI: 1.25–7.38), p = 0.014], improving discriminative performance by 26.3%. The ALBI score independently predicts mortality beyond standard pulmonary hemodynamics and echocardiographic right ventricular parameters. Incorporating ALBI into REVEAL 2.0 enhances survival prediction and aids risk refinement in intermediate-risk PAH.

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