The Red Cell Distribution Width to Albumin Ratio: A Novel Prognostic Indicator in Hepatitis B Virus-Related Hepatocellular Carcinoma

<b>Background:</b> The prognostic significance of the red blood cell distribution width to albumin ratio (RAR) spans various diseases, yet its utility as a biomarker for hepatitis B virus-related hepatocellular carcinoma (HBV-HCC) remains unclear. <b>Methods:</b> We retrospectively studied 1,413 patients with HBV-HCC. Receiver operating characteristic curves identified optimal RAR cut-offs, stratifying patients into H-RAR and L-RAR groups. Propensity score matching helped balance baseline characteristics. We further evaluated the incremental predictive value of RAR by incorporating it into established conventional models. <b>Results:</b> Overall, 906 patients with HBV-HCC were enrolled (H-RAR group, 600 (66.2%); L-RAR group, 306 (33.8%)). After propensity score matching, 209 patients were included in each group with balanced baseline characteristics (all <i>p</i> > 0.05). RAR demonstrated superior prognostic discrimination compared to red blood cell distribution width, albumin, total bilirubin, and Child-Pugh scores alone, with an area under the curve (AUC) of 0.751. The risk of all-cause mortality increased progressively within a specific RAR range. High RAR was identified as an independent risk factor for long-term overall survival in patients with HBV-HCC (hazard ratio = 1.707, 95% confidence interval [CI]: 1.338-2.176). Stratification by tumour stage revealed substantially lower overall survival for H-RAR than for L-RAR across Tumour, Node, Metastasis I-IV stages. Incorporating RAR into traditional HCC staging systems substantially improved the ability to predict overall mortality risk. <b>Conclusion:</b> RAR is a novel and valuable prognostic indicator for patients with HBV-HCC.