Low preoperative serum creatinine levels are associated with poor prognosis in patients with hepatocellular carcinoma after liver resection: a multicenter study

Previous studies have typically focused on the effect of high preoperative serum creatinine (SCr) levels on the prognosis of hepatocellular carcinoma (HCC) patients but have often ignored the role of low SCr levels. This study aimed to assess the impact of low SCr levels on HCC patient prognosis. 3857 patients who underwent primary liver resection from seven centers were divided into low, normal and high SCr groups according to their baseline SCr levels. Factors independently associated with textbook outcome (TO) and overall survival (OS) were analyzed. Propensity score matching (PSM) was used to balance the baseline characteristics between the low- and normal-SCr groups, as well as between the high- and normal-SCr groups. TO was observed in 2403 (62.3%) patients. The TO rate in the normal SCr group was 63.4%, which was significantly higher than that in the low (48.5%, P < 0.001) and high (53.3%, P = 0.017) SCr groups in the whole cohort. Multivariate analysis confirmed that both low and high SCr levels independently contributed to non-TO achievement. The 5-year OS was 67.6% for the normal SCr group, which was significantly better than that of the low SCr group (51.1%, P < 0.001) but similar to that of the high SCr group (66.4%, P = 0.697) in the whole cohort. Similar results were observed after PSM. Multivariate analysis suggested that a low SCr level (HR = 1.328, 95% CI = 1.076–1.639, P = 0.008) was independently associated with OS, whereas a high SCr level (HR = 1.173, 95% CI = 0.870–1.583, P = 0.294) was not. Low SCr levels could affect both TO achievement and OS in HCC patients after liver resection. A low SCr level offers useful information for preoperative risk stratification, optimizes perioperative care and improves the prognosis of HCC patients. We should not ignore the effect of low preoperative SCr levels on HCC patient prognosis.