Background and aim: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide. Most patients are diagnosed at an advanced stage, limiting their treatment options. The traditional assessment of liver function using the Child–Pugh score has limitations due to its subjectivity. The albumin-bilirubin (ALBI) grade delivers a more precise evaluation of liver function. This study examines overall survival (OS) in advanced HCC patients treated with first-line systemic therapy and the impact of ALBI grading on these outcomes. Materials and methods: A total of 104 patients with advanced HCC treated between January 2017 and December 2023 with one of the three first-line therapy options: Sorafenib, lenvatinib or atezolizumab/bevacizumab were retrospectively analyzed. The Kaplan–Meier method was utilized to examine the survival results, and the log-rank test was employed to evaluate the variations in survival among ALBI grades and therapy types. Cox proportional hazards regression examined the impact of ALBI grading and other covariates on OS, with a significance threshold of p < 0.05 for the multivariable model. Results: The median age of HCC patients was 58.5 years, with 70% males, and a primary etiology of hepatitis C (43%). The median OS and time to progression (TTP) in this cohort were 9 months and 3.25 months. In ALBI grade I patients, the OS was 21 months, while in grade II or III patients, it was just 5 months. Treatment-related side effects necessitated dose reductions in over 84% of patients. Albumin-bilirubin grade, Child–Pugh class, and treatment modifications due to adverse effects were significant predictors of survival. Conclusion: Lenvatinib appears to have better survival outcomes compared to other options. The albumin-bilirubin grading is a useful method for evaluating liver function and forecasting survival rates for individuals with HCC. Clinical significance: Our findings support the use of ALBI grading in clinical decision-making for advanced HCC.