Predictors of Hepatic Decompensation Post-Y90 Treatment in Hepatocellular Carcinoma: New Insights into Segmental TARE and Post-Treatment Dosimetry

Background Transarterial radioembolization (TARE) with yttrium-90 (Y-90) microspheres is an established treatment for unresectable hepatocellular carcinoma (HCC). Although segmental TARE offers a favorable safety profile, hepatic decompensation remains a clinically significant complication. This study aimed to identify clinical, laboratory, and post-treatment dosimetric predictors of hepatic decompensation following segmental Y-90 TARE. Methods In this retrospective cohort study, 102 patients with HCC who underwent segmental Y-90 TARE between 2015 and 2025 were analyzed. Baseline demographic, clinical, laboratory, and imaging data were collected. Hepatic decompensation was defined as new or worsening ascites, hepatic encephalopathy, or bilirubin elevation greater than three times the upper limit of normal within 3 ± 1 month after treatment. Post-treatment dosimetry was performed using SPECT/CT with voxel-based analysis. Univariate and multivariate logistic regression models were used to identify predictors of hepatic decompensation. Results Hepatic decompensation occurred in 14 patients (13.7%). On univariate analysis, decompensation was associated with baseline hypoalbuminemia (< 3.5 g/dL), higher MELD and ALBI scores, Child-Pugh class B/C, INR ≥ 1.2, lower white blood cell count, and higher alkaline phosphatase levels. Patients who developed decompensation received lower median absorbed radiation doses to the treated segment (133 Gy vs. 196 Gy, p = 0.01) and had smaller total liver volumes (1536 cm³ vs. 1699 cm³, p = 0.02). In multivariate analysis, baseline hypoalbuminemia (< 3.5 g/dL) was the only independent predictor of hepatic decompensation (OR = 7.98, 95% CI 1.16–80.39, p = 0.04). Conclusion Hepatic decompensation after segmental Y-90 TARE is primarily driven by impaired baseline hepatic reserve rather than post-treatment dosimetry. Baseline hypoalbuminemia is a strong independent predictor of early hepatic decompensation and should be carefully considered during patient selection for radioembolization.