Preoperative von Willebrand factor is an independent predictive biomarker for posthepatectomy liver failure - a multivariable model with APRI+ALBI.

Background: Portal hypertension is a key factor in posthepatectomy liver failure (PHLF). While preoperative liver function tests like APRI+ALBI assess liver function, they only partially reflect portal hypertension severity. Elevated von-Willebrand-factor-antigen (vWF-Ag) indicates endothelial dysregulation and correlates with portal hypertension. Combining vWF-Ag with APRI+ALBI may enhance PHLF prediction.

Methods: A total of 534 patients who underwent liver resection at Mayo Clinic Rochester (2020-2024) were analyzed for PHLF incidence, postoperative morbidity, and 90-day mortality. Predictive probability for PHLF was assessed using ROC analysis and validated in an external Austrian cohort of 283 patients (2008-2017). vWF-Ag was then integrated into the existing APRI+ALBI multivariable model.

Results: PHLF grade B/C was reported in 56 patients (10.5%). 90-day mortality rate was 0.9% (n=5). Using two cutoffs (182%, 240%), vWF-Ag was found to be an independent predictive factor for PHLF grade B/C that remained statistically significant upon multivariable analysis. The combination of preoperative APRI+ALBI and vWF-Ag increased the positive predictive value to 27.9% for PHLF grade B/C in the APRI+ALBI high and vWF-Ag high group. Incorporation of vWF-Ag into the established APRI+ALBI based multivariable model revealed a superior area under the curve (AUC) of 0.772 for PHLF risk stratification and was successfully validated in an independent cohort (AUC=0.834).

Conclusion: The combination of vWF-Ag with APRI+ALBI demonstrates a favorable predictive potential for PHLF risk assessment. We provide two pathways for clinical assessment: 1) a cut-off-based system and 2) a more complex multivariable model that can be calculated in a specifically designed smartphone application.