HALP Score in Predicting Post-Liver Transplant Outcomes in Patients with Hepatocellular Carcinoma

Background: Accurate prognostic stratification remains essential for optimizing outcomes in hepatocellular carcinoma (HCC) patients undergoing liver transplantation (LT). The hemoglobin-albumin-lymphocyte-platelet (HALP) score is a composite biomarker reflecting systemic inflammation, nutritional status, and immune competence, and has demonstrated prognostic value in several malignancies. This study aimed to evaluate the predictive utility of the HALP score for survivals and recurrence in HCC patients undergoing LT. Methods: A total of 476 consecutive patients who underwent LT for HCC between 2006 and 2024 were retrospectively analyzed. Pretransplant HALP scores were calculated for all patients. Receiver operating characteristic (ROC) analysis identified an optimal cut-off value of 29 for recurrence prediction. Patients were stratified into HALP ≥ 29 and HALP < 29 groups. DFS and recurrence rates were compared. Prognostic performance was assessed using the concordance index (C-index) and area under the ROC curve (AUC). Outcomes were further compared with the Milan and Expanded Malatya criteria. Results: Of the 476 patients, 335 (70.4%) had HALP ≥ 29 and 141 (29.6%) had HALP < 29. The HALP ≥ 29 group demonstrated significantly higher 5- and 10-year DFS rates compared with the HALP < 29 group (67.1% vs. 58.5% and 49.5% vs. 33.5%, respectively; p < 0.001). Recurrence rates were significantly lower in the HALP ≥ 29 group (14.0% vs. 31.9%; p < 0.001). However, patients within the Milan and Expanded Malatya criteria showed superior long-term DFS and lower recurrence rates in the HALP ≥ 29 compared to the HALP < 29 group (p ≤ 0.037). HALP ≥ 29 was associated with lower tumor burden parameters and improved hepatic functional reserve. Despite its significance, HALP demonstrated inferior discriminative performance (C-index: 0.565) compared with the Milan (0.621) and Expanded Malatya (0.648) criteria. Patients beyond the Milan criteria (n = 233) with HALP ≥ 29 achieved a 5-year overall survival of 54.2%, compared with 37.8% with HALP < 29. Conclusions: Low HALP score is associated with poor DFS and a high post-transplant recurrence rate. Although it represents a non-invasive and cost-effective biomarker, its prognostic accuracy remains inferior to established transplant selection criteria, limiting its use as a standalone selection tool. However, individuals beyond Milan with HALP ≥ 29 achieved survival outcomes exceeding internationally accepted post-transplant benchmarks. Incorporating HALP into pre-transplant evaluation may help identify a biologically favorable subgroup among patients traditionally considered high risk based solely on tumor burden.