The hippurate ratio as an indicator of functional hepatic reserve for resection of hepatocellular carcinoma in cirrhotic patients

Predicting the ability of the cirrhotic liver to withstand resection remain s a challenge for the surgeon. This study evaluates the use of the hippurat e ratio, a novel assessment of glycine conjugation of paraaminobenzoic acid by the liver, as a preoperative indicator of functional hepatic reserve. B etween 1998 and 2000, sixty-one cirrhotic patients were prospectively asses sed for hepatic resection using the hippurate ratio, indocyanine green rete ntion at 15 minutes (ICG R-15), and other standard measures of liver functi on. Twenty-six patients were excluded as candidates for resection on the ba sis of inadequate functional hepatic reserve. Patients excluded from resect ion had significantly higher ICG R-15 values (29% +/- 9% vs. 16% +/- 12%, P = 0.001), higher Child-Pugh scores (5.9 +/- 0.9 vs. 5.3 +/- 0.4, P = 0.01) , and lower hippurate ratios (30% +/- 14% vs. 45% +/- 15%, P = 0.005). Ther e was a significant correlation between the hippurate ratio and ICG R-15. O ther indicators of liver function such as factor V, factor VII, albumin, bi lirubin, prothrombin time, and transaminases were no different between pati ents who did and those who did not undergo resection. Of the 35 patients re sected, there were seven (20%) who developed varying degrees of liver failu re with three perioperative deaths (8.5%). Patients who had some degree of liver failure had significantly lower hippurate ratios than patients who ha d no liver failure (29% +/- 10% vs. 48% +/- 14%, P = 0.002). There was no d ifference in ICG R-lj values between patients who had liver failure and tho se who did not. The hippurate ratio offers information on hepatocellular re serve that is not provided by other measures of liver function and may allo w better selection of cirrhotic patients for liver resection.