### A Development of New Assessment Tool for Hepatic Function: ALBI Grade  
As noted above, the need for an objective and more detailed assessment tool, especially for patients with good hepatic function, has become an urgent issue. Recently, a simple and objective method for the evaluation of hepatic reserve function using only albumin and total-bilirubin measurements, termed albumin-bilirubin (ALBI) grade based on a formula (log\({}_{10}\) bilirubin (\(\mu\)mol/L) \(\times\) 0.66) + (albumin (g/L) \(\times\) -0.085), has been proposed, with the values \(\leq\)-2.60, \(>\)-2.60 to \(\leq\)-1.39, and \(>\)-1.39 used to denote grades 1, 2, and 3, respectively [14]. Calculating only with two objective factors (bilirubin and albumin) is one of advantages because they are very common serum data and the frequency of a lack of data is low, especially in retrospective analyses. Following its development, it has been confirmed that ALBI grade can be used as an alternative  
\begin{table}
\begin{tabular}{l l l} \hline \hline  & **Child-Pugh Classification** & **ALBI/mALBI Grades** \\ \hline \multirow{3}{*}{Total Bilirubin} & score 1: \textless{}2.0 mg/dL, & \\  & score 2: 2.0–3.0 mg/dL, & \\  & score 3: \textgreater{}3.0 mg/dL & \\ \hline \multirow{3}{*}{Albumin} & score 1: \textgreater{}3.5 g/dL, & \\  & score 2: 2.8–3.5 g/dL, & \\  & score 3: \textless{}2.8 g/dL & \\ \hline \multirow{3}{*}{Prothrombin time} & score 1: \textgreater{}70\%, & \\  & score 2: 40–70\%, & No use \\  & score 3: \textless{}40\% & \\ \hline \multirow{3}{*}{Ascites} & score 1: none, & \\  & score 2: mild/controlled, & No use \\  & score 3: moderate/refractory & \\ \hline \multirow{3}{*}{Encephalopathy} & score 1: none, & \\  & score 2: minimal, & No use \\  & score 3: advanced & \\ \hline \multirow{3}{*}{Calculation for score} & Sum up all scores and baseline & log\({}_{10}\) bilirubin (\(\mu\)mol/L) \(\times\) 0.66) + (albumin \\  & score 5 & (g/L) \(\times\) -0.085 \\ \hline \multirow{3}{*}{Classification} & A 5–6 score, & ALBI grade 1: \(\leq\)–2.60, \\  & B 7–9 score, & grade 2: \(>\)–2.60 to \(\leq\)–1.39, grade 3 \(>\)–1.39. \\ \cline{1-1}  & C 10–15 score & mLBI grade 2a: \(>\)–2.60 to \(\leq\)–2.27. \\ \cline{1-1}  & grade 2b: \(>\)–2.27 to \(\leq\)–1.39. \\ \hline \hline \end{tabular}
\end{table}
Table 1: Comparisons of the Child–Pugh classification with ALBI and mALBI grades.  
assessment to the Child-Pugh classification, both in the evidence based clinical practice guideline for HCC of JSH (\(n=3495\)) [15] and in the BCLC staging, with a weighted kappa value (which is a statistic for measuring the interevaluator reliability of qualitative items) of 0.917 noted with a multicenter cohort (\(n=3696\)) [16]. As a result, ALBI grade has become recognized as a useful assessment tool for hepatic reserve function worldwide. However, a weak point of this grading system that has been pointed out is that grade 2 covers a wide range, similar to class B in the Child-Pugh classification. On the other hand, as opposed to the Child-Pugh score, which is a nominal variable, ALBI scoring has a great advantage as a continuous variable. To provide a more detailed assessment of hepatic reserve function, a modified ALBI (mALBI) grade has been proposed, with four grades including subgrades 2a and 2b, divided by the use of an ALBI score of \(-2.27\) as the cutoff value for an indocyanine green retention rate at 15 min (ICG-R15) at 30% [17], because the ALBI score has been shown to have a correlation with ICG-R15 (r = 0.616, \(p<0.001\)) [18]. The distribution of mALBI grades in comparison with Child-Pugh scores is shown in Figure 1 (1850 naive HCC patients treated at Ehime Prefectural Central Hospital from 2000 to 2019). We consider that both ALBI and mALBI grades should be used for the assessment of hepatic function in patients, not only with early stage but also with intermediate and advanced stage HCC BCLC-B and -C, as they provide an opportunity to assess changes of hepatic function in detail during a clinical course (Figure 1).