Prognostic value of the C-reactive protein to albumin ratio in colorectal cancer: an updated systematic review and meta-analysis

Backgrounds

The inflammatory biomarker “C-reactive protein to albumin ratio (CAR)” has been reported to significantly correlate to a variety of human cancers. However, there are conflicting results regarding the prognostic value of CAR in colorectal cancer. Previous studies mainly assessed patients in Eastern countries, so their findings may not be applicable to the Western population. Therefore, this updated meta-analysis aimed to investigate the prognostic value of pre-treatment CAR and outcomes of patients with colorectal cancer.

Methods

We conducted a systematic search for eligible literature until October 31, 2020, using PubMed and Embase databases. Studies assessing pre-treatment CAR and outcomes of colorectal cancer were included. Outcome measures included overall survival, disease-free survival, progression-free survival, and clinicopathological features. The pooled hazard ratios (HR) with 95% confidence intervals (CI) were used as effective values.

Results

A total of 15 studies involving 6329 patients were included in this study. The pooled results indicated that a high pre-treatment CAR was associated with poor overall survival (HR 2.028, 95% CI 1.808−2.275, p < 0.001) and poor disease-free survival/progression-free survival (HR 1.768, 95% CI 1.321–2.365, p < 0.001). Subgroup analysis revealed a constant prognostic value of the pre-treatment CAR despite different study regions, sample size, cancer stage, treatment methods, or the cut-off value used. We also noted a correlation between high pre-treatment CAR and old age, male sex, colon cancer, advanced stage (III/IV), large tumor size, poor differentiation, elevated carcinoembryonic antigen levels, neutrophil-to-lymphocyte ratio, and the modified Glasgow prognostic score.

Conclusions

High pre-treatment CAR was associated with poor overall survival, disease-free survival, and progression-free survival in colorectal cancer. It can serve as a prognostic marker for colorectal cancer in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02253-y.

Can C-Reactive Protein to Albumin Ratio Predict In-Hospital Death Rate Due to COVID-19 in Patients With Hypertension?

Hypertension is one of the main morbidity and mortality risk factors in patients with coronavirus disease 2019 (COVID-19). We investigated the association between the C-reactive protein (CRP) to albumin ratio (CAR) and in-hospital mortality in patients with hypertensive COVID-19. A total of 176 patients with hypertension diagnosed with COVID-19 were included in this study. The CAR was compared between survivors and nonsurvivors. Logistic regression analysis was used to detect independent predictors of mortality due to COVID-19 in patients with hypertension. A cutoff value of CAR was obtained for predicting in-hospital death in patients with hypertensive COVID-19. Kaplan-Meier analysis was performed for survival analysis in the study population. The CAR values were significantly higher in nonsurvivors than in survivors with hypertension. Moreover, the CAR was an independent predictor of in-hospital death in patients with hypertensive COVID-19, as shown in multivariable logistic regression analysis. Receiver operating characteristic analysis yielded a cutoff value of 20.75 for the CAR for predicting in-hospital death in patients with hypertension. Kaplan-Meier curve analysis showed that patients with hypertensive COVID-19 with a CAR value of ≥20.75 had a higher incidence of in-hospital death. The CAR might be used as an independent predictor of in-hospital mortality in patients with hypertensive COVID-19.

Relationship Between C-Reactive Protein to Albumin Ratio and Coronary Collateral Circulation in Patients With Stable Coronary Artery Disease

We investigated the relationship between the C-reactive protein (CRP) to albumin ratio (CAR) and coronary collateral circulation (CCC) in stable coronary artery disease (CAD). Patients with stable CAD (n = 354) who underwent coronary angiography for suspected CAD and had a total occlusion ≥1 major coronary artery were included in the study. The participants were divided into 2 groups according to the Rentrop score as satisfactory CCC (Rentrop 2-3) and poor CCC (Rentrop 0-1). Patients who had poor CCC had a higher CRP, neutrophil/lymphocyte ratio (NLR), and CAR levels compared with those who had satisfactory CCC (P < .001, P = .046, P < .001, respectively). The CAR (odds ratio: 3.522, 95% CI: 2.515-4.932, P < .001), CRP, NLR, and diabetes mellitus were independent predictors of poor CCC. In receiver operator characteristic curve (ROC) analysis, the optimal cutoff value of CAR to predict poor CCC was 1.27 (area under ROC curve = 0.735 [95% CI: 0.667-0.803], P < .001). A raised CAR may be an independent predictor of poor CCC.

Predictive value of C-reactive protein to albumin ratio as a biomarker for initial and repeated intravenous immunoglobulin resistance in a large cohort of Kawasaki disease patients: a prospective cohort study

BACKGROUND

Intravenous immunoglobulin (IVIG) resistance prediction is one pivotal topic of interests in Kawasaki disease (KD). This study aimed to prospectively investigated the value of C-reactive protein-to-albumin (CAR) in predicting both initial and repeated IVIG resistance in patients with KD, and to test the hypothesis that CAR was more valuable or accurate than either C-reactive protein (CRP) or albumin (ALB) alone in IVIG resistance prediction.

METHOD

A prospective cohort study involving 550 patients with KD was conducted. The clinical and laboratory data were compared between IVIG-response group and IVIG-resistance group. Multivariate logistic regression analysis was performed to identify the independent risk factors of initial/repeated IVIG resistance. Receiver operating characteristic (ROC) curves analysis was applied to assess the validity of CAR, CRP and ALB in predicting both initial and repeated IVIG resistance.

RESULTS

CAR was significantly higher in IVIG non-responders and was identified as independent risk factor for both initial and repeated IVIG resistance in KD. The best cut-off value of CAR for initial and repeated IVIG resistance prediction was 2.07 and 3.34, with a corresponding sensitivity of 0.610 and 0.548, a specificity of 0.552 and 0.813, respectively. The value of CAR was not better than either CRP or ALB alone for both initial and repeated IVIG resistance prediction.

CONCLUSION

A higher CAR was an independent risk factor for both initial and repeated IVIG resistance. However, similar with that of CRP or ALB, the predictive value of CAR was not good enough for both initial and repeated IVIG resistance prediction in KD.

C-Reactive Protein to Albumin Ratio in Patients With Saphenous Vein Graft Disease

Atherosclerosis plays an important role in saphenous vein graft disease (SVGD). Previous studies showed that inflammatory blood cells play an active role in this process. C-reactive protein to albumin ratio (CAR) is considered as a novel predictor for cardiovascular risk and an indicator of inflammation. We aimed to assess the relationship between SVGD and CAR. A total of 711 participants with saphenous vein graft (SVG) were included; 348 patients had SVGD and 363 patients had patent (no stenosis) SVG. C-reactive protein to albumin ratio was higher in patients with SVGD (P < .001). There was a significant positive correlation between CAR and the age of SVG (r = 0.123; P = .001) and SYNTAX score (r = 0.568; P < .001). Multivariate logistic regression analyses showed that lymphocyte count, CAR, and SYNTAX score were independent predictors of SVGD (P < .05). C-reactive protein to albumin ratio may be a useful marker after bypass surgery to predict SVGD.

The C-reactive protein to albumin ratio is an excellent prognostic predictor for gallbladder cancer

A number of inflammation indicators based on C-reactive protein (CRP) and albumin have been widely used to predict the prognosis in several types of tumors, but their functions in gallbladder cancer (GBC) have rarely been explored. The aim of our study is to evaluate and compare the prognostic values of the C-reactive protein to albumin ratio (CAR), Glasgow prognostic score (GPS), modified Glasgow prognostic score (mGPS) and high-sensitivity modified Glasgow prognostic score (HS-mGPS) in patients with GBC. 144 GBC patients who received curative surgery in our hospital from January 2010 to May 2017 were enrolled in this research. The Kaplan-Meier analysis showed that the median OS of the patients in the high CAR group was significantly shorter than the patients in the low group (p < 0.001), and higher scores of GPS, mGPS and HS-mGPS were also associated with decreased OS, respectively. However, according to the Receiver Operating Characteristic (ROC) curve, the CAR was superior to the other prognostic scores in determining the prognosis for the GBC patients. In the multivariate analysis, CAR was verified as an independent risk factor for poor prognosis, together with tumor differentiation, T stage and postoperative complications. All in all, compared to the other three CRP-albumin-related prognostic predictors, CRA is a better indicator in predicting poor long-term outcomes in GBC patients after radical surgery.

Dynamic prediction for clinically relevant pancreatic fistula: a novel prediction model for laparoscopic pancreaticoduodenectomy

Background

With the recent emerge of dynamic prediction model on the use of diabetes, cardiovascular diseases and renal failure, and its advantage of providing timely predicted results according to the fluctuation of the condition of the patients, we aim to develop a dynamic prediction model with its corresponding risk assessment chart for clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy by combining baseline factors and postoperative time-relevant drainage fluid amylase level and C-reactive protein-to-albumin ratio.

Methods

We collected data of 251 patients undergoing LPD at West China Hospital of Sichuan University from January 2016 to April 2019. We extracted preoperative and intraoperative baseline factors and time-window of postoperative drainage fluid amylase and C-reactive protein-to-albumin ratio relevant to clinically relevant pancreatic fistula by performing univariate and multivariate analyses, developing a time-relevant logistic model with the evaluation of its discrimination ability. We also established a risk assessment chart in each time-point.

Results

The proportion of the patients who developed clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy was 7.6% (19/251); preoperative albumin and creatine levels, as well as drainage fluid amylase and C-reactive protein-to-albumin ratio on postoperative days 2, 3, and 5, were the independent risk factors for clinically relevant postoperative pancreatic fistula. The cut-off points of the prediction value of each time-relevant logistic model were 14.0% (sensitivity: 81.9%, specificity: 86.5%), 8.3% (sensitivity: 85.7%, specificity: 79.1%), and 7.4% (sensitivity: 76.9%, specificity: 85.9%) on postoperative days 2, 3, and 5, respectively, the area under the receiver operating characteristic curve was 0.866 (95% CI 0.737–0.996), 0.896 (95% CI 0.814–0.978), and 0.888 (95% CI 0.806–0.971), respectively.

Conclusions

The dynamic prediction model for clinically relevant postoperative pancreatic fistula has a good to very good discriminative ability and predictive accuracy. Patients whose predictive values were above 14.0%, 8.3%, and 7.5% on postoperative days 2, 3, and 5 would be very likely to develop clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy.

Effects of Zinc supplementation on serum copper to Zinc and CRP to albumin ratios in hemodialysis patients

Background

Zinc (Zn) deficiency is a common condition and could contribute to poor outcomes in hemodialysis (HD) patients. The aim of this study was to evaluate the effects of Zn supplementation on serum copper (Cu) to Zn and C-reactive protein (CRP) to albumin ratios (CAR) in HD patients.

Methods

Seventy-seven HD patients were enrolled in a multicentre simple-blind randomized clinical trial. Only 37 HD patients completed the study; they were randomly divided into two groups and supplemented with zinc sulphate (n=17) or placebo (n=20) for two months. Serum Zn and Cu were measured by atomic absorption spectrophotometry. Serum albumin and hypersensitive-CRP were assessed by colorimetric and immunoturbidimetric method, respectively. Determinations were performed before and after supplementation.

Results

After two months of supplementation, serum Zn significantly increased, and Cu to Zn ratio decreased in Zn supplemented group, but remained unchanged in the placebo group. In parallel, serum albumin concentrations significantly increased, and CAR decreased in Zn supplemented group only.

Conclusions

Zn supplementation reduces Cu to Zn and CRP to albumin ratios in HD patients. These changes point towards an improvement in nutritional, oxidative and inflammatory status. The study findings suggest that correcting Zn deficiency reduces poor outcomes in HD patients.

Predictive Value of C-Reactive Protein to Albumin Ratio in ST-Segment Elevation Myocardial Infarction Patients Treated With Primary Percutaneous Coronary Intervention

The present study aimed to examine the association of C-reactive protein to albumin ratio (CAR) with short-term major adverse cardiac events (MACEs) in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). We included 539 STEMI patient treated with pPCI in this study. Patients were divided into 2 groups according to MACE development. Patients with MACE had higher CAR than those without (1.18 [0.29-1.99] vs 0.21 [0.09-0.49], P < .001). Multivariate analysis showed that The Global Record for Acute Coronary Events score, Percutaneous Coronary Intervention with TAXus and cardiac surgery (SYNTAX) score, glucose and CAR (odds ratio:1.326, 95% CI: 1.212-1452, P < .001) were independent predictors of MACE. The CAR may be proven useful for risk stratification in STEMI patients undergoing pPCI.

Diagnostic utility of C-reactive protein to albumin ratio as an early warning sign in hospitalized severe COVID-19 patients

C-reactive protein-to-albumin ratio (CAR) has been used as an indicator of prognosis in various diseases. Here, we intended to assess the CAR’s diagnostic power in early differentiation of hospitalized severe COVID-19 cases. In this retrospectively designed study, we evaluated 197 patients in total. They were divided into two groups based on their severity of COVID-19 as non-severe (n = 113) and severe (n = 84). The comparison of groups’ demographic data, comorbidities, clinical symptoms, and laboratory test results were done. Laboratory data of the patients within the first 24 h after admission to the hospital were evaluated. The calculation of receiver operating characteristic (ROC) curve was used to determine the diagnostic power of CAR in differentiating severity of COVID-19. Independent risk factors predictive of COVID-19 severity were determined by using logistic regression analysis. Although lymphocyte count levels were lower, severe COVID-19 patients had higher mean age, higher levels of neutrophil count, CRP, aspartate aminotransferase (AST), ferritin, and prothrombin time (P < 0.05). Compared with non-severe patients (median, 0.23 [IQR = 0.07–1.56]), patients with severe COVID-19 had higher CAR levels (median, 1.66 [IQR = 0.50–3.35]; P < 0.001). Age (OR = 1.046, P = 0.003), CAR (OR = 1.264, P = 0.037), and AST (OR = 1.029, P = 0.037) were independent risk factors for severe COVID-19 based on the multivariate logistic regression analysis. ROC curve analysis assigned 0.9 as the cut-off value for CAR for differentiation of severe COVID-19 (area under the curve = 0.718, 69.1% sensitivity, 70.8% specificity, P < 0.001). CAR is a useful marker in early differentiation of severity in patients hospitalized due to COVID-19 that have longer hospital stay and higher mortality.

Preoperative C-Reactive Protein/Albumin Ratio as a Predictive Factor for Gallbladder Carcinoma

BACKGROUND/AIM

The C-reactive protein (CRP) to albumin ratio (CAR) is associated with outcomes in patients with sepsis. We aimed to evaluate the significance of preoperative CAR in therapeutic outcomes after gallbladder carcinoma (GBC) resection.

PATIENTS AND METHODS

Fifty-three patients who underwent surgical resection for GBC between January 2008 and September 2019 were enrolled. We retrospectively investigated the relation between preoperative CAR and overall and disease-free survival.

RESULTS

The optimal cut-off CAR was 0.07. Multivariate analysis showed that i) R1 or R2 resection (p=0.033), ii) advanced tumor stage (p=0.047), iii) CAR≥0.07 (p=0.011), and iv) postoperative complications (p=0.028) were significant independent predictors of overall survival; moreover, higher carbohydrate antigen levels (p=0.036) and R1 or R2 resection (p<0.001) were significant independent predictors of disease-free survival.

CONCLUSION

Preoperative CAR may be a significant independent predictor of long-term outcomes after GBC resection.

Association Between C-Reactive Protein to Albumin Ratio and Left Ventricular Thrombus Formation Following Acute Anterior Myocardial Infarction

Left ventricular thrombus (LVT) is associated with inflammatory response in survivors with anterior ST-elevation myocardial infarction (STEMI). The C-reactive protein to albumin ratio (CAR) has been proposed as a marker of inflammation. However, there is a lack of data with respect to the role of CAR in LVT development. We investigated the relationship between CAR and LVT development in patients with anterior STEMI treated percutaneously; 955 consecutive patients were enrolled and LVT was observed in 126 (13.2%) patients. Clinical, demographic, and laboratory parameters were recorded. The CAR was significantly higher in patients with LVT (12.6 [8.6-16.1] vs 18.1 [11.5-23], P < .001). Other independent predictors for LVT development were lower ejection fraction, the presence of left ventricular apical aneurysm, proximal left anterior descending lesion location, glycoprotein IIb/IIIa inhibitors treatment, >1 diseased arteries, higher total protein level, neutrophil count, and peak creatine kinase myocardial band activity. In conclusion, the CAR may be useful as a simple tool for predicting LVT development among survivors of anterior STEMI.

The C-reactive protein to albumin ratio predicts postoperative complication in patients who undergo gastrectomy for gastric cancer

The aim of this study was to evaluate the preoperative C-reactive protein (CRP) to albumin ratio (CAR) of patients with gastric cancer and to investigate the factors correlated with perioperative complications. From March 2016 to December 2019, 128 patients who underwent curative gastrectomy for gastric cancer were enrolled in a retrospective study. The preoperative cutoff value of the CAR for predicting postoperative complications was 0.265 on receiver operating characteristic (ROC) curve analysis. Clinical characteristics were compared between patients with complications (Clavien-Dindo grade ≥2, n = 20) and without complications (Clavien-Dindo grade <2, n = 108). On univariate and multivariate analyses, estimated blood loss (EBL) during the operation (HR 1.003, p = 0.039) and CAR (HR 2.832, p = 0.045) were independent predictors of postoperative complications. In conclusion, preoperative CAR appears to be a predictor of postoperative complications in the patients undergoing surgical treatment of gastric cancer.

Clinical significance of prognostic inflammation-based and/or nutritional markers in patients with stage III gastric cancer

BACKGROUND

Although many studies have identified several inflammation-based and/or nutritional markers with prognostic value for patients with various types of cancer, the optimal markers and cut-off values for these markers remain obscure. Therefore, this retrospective study aimed to identify optimal markers and their cutoffs.

METHODS

We compared prognostic values among established preoperative inflammation-based and/or nutritional markers in 225 patients who underwent R0 resection for stage III gastric cancer. Inflammation-based and/or nutritional markers comprised C-reactive protein to albumin ratio (CAR), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), prognostic nutritional index (PNI), Glasgow prognostic score (GPS), and prognostic index (PI). Time-dependent receiver operating characteristic curves were analyzed to assess predictive ability and to determine the optimal cut-off values. Prognostic factors predicting overall survival (OS) and cancer specific survival (CSS) were analyzed using Cox proportional hazards models.

RESULTS

Multivariate analyses revealed that CAR and PLR cut-off values of 0.47 and 172, respectively, were independent prognostic factors for overall survival (OS) (HR, 2.257; 95% CI, 1.180-4.319; p = 0.014 and HR, 1.478; 95% CI, 1.025-2.133; p = 0.037, respectively) and cancer-specific survival (CSS) (HR, 2.771; 95% CI, 1.398-5.493; p = 0.004 and HR, 1.552; 95% CI, 1.029-2.341; p = 0.036, respectively). These results were different from those we previously reported in patients with stage II.

CONCLUSIONS

Among inflammation-based and/or nutritional markers, CAR and PLR were independent prognostic factors of OS and CSS in patients with stage III gastric cancer. The optimal markers and their cut-off values should be determined in specific populations.

Influence of the Preoperative C-Reactive Protein-to-Albumin Ratio on Survival and Recurrence in Patients With Esophageal Cancer

BACKGROUND

Several immune-inflammatory markers are associated with cancer progression. The purpose of the present study was to clarify the influence of the preoperative C-reactive protein-to-albumin ratio (CRP/ALB ratio) on survival of patients with esophageal cancer and recurrence after curative resection.

PATIENTS AND METHODS

The preoperative CRP/ALB ratio was evaluated in 122 patients who underwent radical resection for esophageal cancer from 2005 to 2018. The correlations between the CRP/ALB ratio and cancer-specific overall (OS), recurrence-free (RFS) survival and the clinicopathological status were analyzed.

RESULTS

The optimal cut-off value of the CRP/ALB ratio determined using receiver operating characteristic curve analysis was 0.04. Patients were divided into two groups based on this cut-off value: the low CRP/ALB group (n=59) and the high CRP/ALB group (n=50). The OS rate at 5 years after surgery was significantly lower in the group with high CRP/ALB at 40.5% whilst it was 63.5% in the low CRP/ALB group (p=0.005). The corresponding RFS rates at 5 years after surgery were 32.5% and 48.3%, respectively, which was a statistically significant difference (p=0.007). A multivariate analysis showed that a high CRP/ALB ratio was a significant independent risk factor for poorer cancer-specific OS and RFS.

CONCLUSION

The preoperative CRP/ALB ratio was a strong prognostic marker for patients with esophageal cancer. The surgical strategy, including procedure and perioperative care should be carefully planned for patients with a high CRP/ALB ratio.

Prognostic and Clinicopathological Significance of C-Reactive Protein to Albumin Ratio in Patients With Pancreatic Cancer: A Meta-Analysis

BACKGROUND

This meta-analysis explored the correlation between the C-reactive protein to albumin ratio (CAR) and survival outcomes and clinicopathological characteristics in patients with pancreatic cancer.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library databases were comprehensively searched through October 17, 2019. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were used to evaluate the association between CAR and overall survival (OS), progression-free survival (PFS), and disease-free survival (DFS) in pancreatic cancer.

RESULTS

The meta-analysis included 11 studies comprising 2271 patients. The pooled results showed that a high CAR was predictive of worse OS (HR = 1.84, 95% CI = 1.65-2.06, P < .001), PFS (HR = 1.53, 95% CI = 1.27-1.85, P < .001), and DFS (HR = 1.77, 95% CI = 1.30-2.41, P < .001). An elevated CAR was also associated with male sex (OR = 1.38, 95% CI = 1.10-1.74, P = .006).

CONCLUSION

Elevated pretreatment CAR effectively predicts inferior survival outcomes in patients with pancreatic cancer and may be a powerful prognostic indicator for these patients.

The C-reactive protein to albumin ratio predicts postoperative complications in oldest-old patients with colorectal cancer

PURPOSE

The C-reactive protein to albumin ratio (CAR) is a simple and useful score for predicting the outcomes of patients with various cancers. The aim of this study was to evaluate the CAR and short-term outcomes in oldest-old patients with colorectal cancer.

METHODS

A total of 126 patients aged 85 years and older with colorectal cancer who underwent resection for primary colon cancer from April 2015 to December 2018 were included. The preoperative cutoff value of the CAR for predicting postoperative complications was 0.19 on receiver operating characteristic curve analysis. Clinical characteristics and inflammation-based scores were compared between patients with a high CAR (CAR ≥ 0.19, n = 44) and a low CAR (CAR < 0.19, n = 82).

RESULTS

A high preoperative CAR level (≥ 0.19) was significantly associated with stoma construction (p = 0.004), blood loss (p = 0.003), postoperative complications (p = 0.016), and systemic inflammation marker levels, including a low neutrophil to lymphocyte ratio (p = 0.006), a low platelet to lymphocyte ratio (p = 0.005), a low prognostic nutritional index (p < 0.001), and a high modified Glasgow prognostic score (p < 0.001). On univariate and multivariate analyses, only the CAR was an independent predictor of postoperative complications (HR 2.864, p = 0.029).

CONCLUSIONS

A high CAR was significantly associated with postoperative complications for oldest-old patients with colorectal cancer.

Comparing the Diagnostic Value of the C-Reactive Protein to Albumin Ratio With Other Inflammatory Markers in Patients With Stable Angina Pectoris

Several laboratory parameters have been used to assess inflammatory process and determine cardiovascular risk. The C-reactive protein to albumin ratio (CAR) is a novel marker of inflammation and its clinical importance has not been clearly elucidated in coronary artery disease (CAD). We compared the diagnostic value of CAR with other inflammatory parameters in detecting significant CAD. Patients (n = 421) with stable angina pectoris who underwent coronary angiography for the suspected CAD were included. Neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), platelet to lymphocyte ratio, uric acid, monocyte to high-density cholesterol (HDL-C) ratio, mean platelet volume to lymphocyte ratio (MPVLR), and platelet to mean corpuscular volume (MCV) ratio were measured. Patients with significant CAD had a significantly higher NLR (P = .043), MLR (P = .004), uric acid (P < .001), monocyte to HDL-C ratio (P = .004), and CAR (P < .001) compared to patients without significant CAD. However, MPVLR and platelet to MCV ratio weren't different between 2 groups. The area under the curve (AUC) of CAR was the highest AUC among all inflammatory parameters for predicting significant CAD. Multivariate analysis showed that age (odds ratio [OR]: 1.046, 95% confidence interval [CI], 1.020-1.072, P < .001) and CAR (OR: 1.175, 95% CI, 1.126-1.226, P < .001) were the only independent predictors of significant CAD. In conclusion, CAR had the strongest diagnostic value in detecting significant CAD among the inflammatory parameters evaluated in this study.

Correlation between albumin to fibrinogen ratio, C-reactive protein to albumin ratio and Th17 cells in patients with rheumatoid arthritis

BACKGROUND

The albumin to fibrinogen ratio (AFR) and the C-reactive protein to albumin ratio (CAR) have been served as inflammatory markers. However, their roles in RA remain unclear. We investigated the association of AFR/CAR with the concentration of autoantibodies and Th17 cells in RA.

METHODS

A total of 196 RA patients, 200 patients with systemic lupus erythematosus (SLE), and 200 healthy donors (HD) who were admitted to the First Affiliated Hospital of Fujian Medical University were enrolled. The results of FIB, ALB, CRP, anti-cyclic citrullinated peptide antibodies (anti-CCP), rheumatoid factor (RF) and erythrocyte sedimentation rate (ESR) from RA patients and SLE patients were retrospectively analyzed. The percentage of Th17 cells in peripheral blood of RA patients was detected by flow cytometry, and the relative expression of TNF-α, IL-6 and IL-17A was detected by RT-qPCR. Correlation analysis of AFR/CAR and Th17 cells, CRP, ESR, TNF-α, IL-6 and IL-17A in RA was conducted.

RESULTS

Compared with SLE patients and healthy donors (HD), AFR concentration was significantly lower (P < 0.01) in RA patients, while CAR concentration was significantly increased (P < 0.01) in RA patients. AFR showed negative correlation with CRP (r = -0.7103), ESR (r = -0.6542), RF (-0.2219), Th17 cells (r = -0.5952) and IL-17A (r = -0.4681). CAR was positively correlated with CRP (r = 0.9899), ESR (r = 0.605), RF (0.1867), Th17 cells (r = 0.6818), TNF-α (r = 0.3388), and IL-17A (r = 0.2046).

CONCLUSIONS

The concentration of AFR in RA patients was reduced, while CAR concentration was increased. AFR and CAR are associated with CRP, ESR, RF, and Th17 cell ratios in RA patients, which can be used as potential indicators for determining RA inflammation.

Preoperative C-reactive protein to albumin ratio is a predictor of survival after pancreatic resection for pancreatic ductal adenocarcinoma

AIM

Systemic inflammation and nutritional status are associated with clinical outcomes of cancer patients. We investigated the prognostic value of preoperative C-reactive protein to albumin ratio (CAR) in patients with pancreatic ductal adenocarcinoma (PDA) after pancreatic resection.

METHODS

One-hundred and thirty-six PDA patients who underwent pancreatic resection between January 2005 and June 2017 were retrospectively enrolled. Preoperative inflammation-based scores including CAR, modified Glasgow prognostic score (mGPS), neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, lymphocyte to monocyte ratio (LMR) and prognostic nutritional index (PNI) were evaluated as potential predictor of overall survival (OS) using Cox regression models. An optimal cutoff value for the continuous variable was estimated by receiver-operating characteristic (ROC) analysis.

RESULTS

Patients were categorized by CAR using a cutoff value of 0.09. High CAR was associated with advanced stage, increased mGPS and decreased LMR and PNI, but not with other factors such as tumor location, preoperative biliary drainage or preoperative chemotherapy. In univariate analysis, patients with high CAR had poor OS compared with those with low CAR (P = 0.01). Multivariate analysis indicated that high CAR was an independent predictor of poor OS (P = 0.03) in addition to advanced stage and residual tumors. The predictive ability of CAR evaluated by area under the ROC curve was consistently higher than that of other inflammation-based factors.

CONCLUSION

Preoperative CAR was an independent and superior predictor of survival after pancreatic resection in patients with PDA. [Correction added on 17 January 2019, after first online publication: In Conclusion, "in" has been corrected to "independent" for clarity.].

C-Reactive Protein to Albumin Ratio in Colorectal Cancer: A Meta-Analysis of Prognostic Value

BACKGROUND

The relationship between pretreatment C-reactive protein to albumin ratio (CAR) and colorectal cancer (CRC) prognosis has been extensively studied in various tumors. However, little is known on CAR and its association with prognosis in CRC. This study aims to investigate the prognostic value of pretreatment CAR in CRC.

METHODS

We conducted a systematic search of MEDLINE, EMBASE, and Cochrane Library databases for eligible studies evaluating the associations of CAR with survival and/or clinicopathology of CRC. Overall survival (OS), disease-free survival (DFS), relapse-free survival (RFS), and clinicopathological features were synthesized and compared.

RESULTS

Nine studies including 3431 patients were analyzed in this meta-analysis. Pooled results showed that elevated pretreatment CAR was associated with poor OS (pooled hazards ratio [HR]: 2.18, 95% confidence interval [CI]: 1.70-2.78, P < .001) and DFS/RFS (pooled HR: 2.36, 95% CI: 1.40-3.98, P < .001). Moreover, elevated pretreatment CARs were correlated with male patients, large tumor diameter, late III-IV tumor node metastasis stage tumors, high serum carcinoembryonic antigen and carbohydrate antigen 19-9, and presence of lymphatic invasion and venous invasion.

CONCLUSION

Elevated pretreatment CAR could be an adverse prognostic indicator in patients with CRC.

Prognostic value of the C-reactive protein to albumin ratio in esophageal cancer: A systematic review and meta-analysis

In recent years, some studies suggested that the pretreatment C-reactive protein to albumin ratio (CAR) may be predictive for prognosis of esophageal cancer (EC), but their results were inconsistent. Therefore, the current meta-analysis was preformed to better determine the prognostic value of pretreatment CAR in EC. The PubMed, EMBASE, Web of Science, Cochrane Library, and PubMed Central databases were searched up to January 10, 2019 to identify studies evaluating the correlation between CAR and prognosis of EC. The primary outcome was the overall survival (OS) and secondary outcomes were disease-free survival (DFS) and cancer-specific survival (CSS). Pooled hazard ratios (HRs) and corresponding 95% confidence intervals (95% CIs) were used to estimate the predictive role of CAR for prognosis in EC. Based on the results of this research, a total of 11 studies with 2930 patients diagnosed as EC were included. Pooled results suggested that elevated pretreatment CAR was significantly associated with poor OS (HR = 1.80, 95% CI: 1.31-2.47, P < .001) with high heterogeneity (I² = 86.5%, P < .001) and poor CSS (HR = 1.72, 95% CI: 1.33-2.22, P < .001) without heterogeneity (I² = 0.0%, P < .323); however, no significant association was observed between pretreatment CAR and DFS (HR = 1.41, 95% CI: 0.60-3.34, P = .429) with high heterogeneity (I² = 76.7%, P < .038). Subgroup analyses further manifested that EC patients with higher CAR had worse OS. An elevated pretreatment CAR may indicate poor survival in patients with EC. Thus, pretreatment CAR may serve as a promising biomarker in EC and could be used to predict prognosis and help decision-making in clinical work.

Assessment of relationship between C-reactive protein to albumin ratio and 90-day mortality in patients with acute ischaemic stroke

AIM AND CLINICAL RATIONALE FOR THE STUDY

It is now known that inflammation is involved in the pathophysiology of acute ischaemic stroke (AIS). It has been proven that CRP and albumin alone are useful in predicting a prognosis for stroke patients. A combination of these two parameters, namely the ratio of CRP to albumin (CAR), is believed to be a more accurate indicator of inflammatory status than CRP or albumin alone, and may be more valuable than either of them separately in predicting the prognosis of ıschaemic stroke patients. However, the role of CAR as a predictor of mortality in patients with AIS remains unclear.

MATERIALS AND METHODS

We retrospectively enrolled 260 patients who were referred to our clinic within the first 24 hours of symptom presentation and who were diagnosed with AIS between January 2015 and December 2018. The patient group was classified into two groups according to 90-day mortality. These groups were compared in terms of C-reactive protein, albumin, and CAR.

RESULTS

The C-reactive protein and CAR values were higher, and the albumin level was lower, in non-surviving patients. The CAR value was also found to be a significant independent variable of 90-day mortality in patients with AIS (p < 0.001). The optimum cut-off value of CAR in predicting the 90-day mortality for patients with AIS was 0.50, with 64.1% sensitivity and 56.2% specificity.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Our study demonstrated that a high CAR value is an independent predictor of 90-day mortality in patients with AIS.

Predicting marker for early progression in unresectable melanoma treated with nivolumab

BACKGROUND

The objective of this study was to identify predictive markers, including inflammatory and nutritional status measures, of early progressive disease (EPD) in unresectable melanoma patients treated with nivolumab.

METHODS

A retrospective review was performed on 39 consecutive patients with unresectable melanoma treated with nivolumab. EPD was defined as progressive disease within 60 days after starting nivolumab according to Response Evaluation Criteria in Solid Tumors version 1.1. The predictive index model [melanoma inflammation index (MII)] was determined by the number of predictive factors.

RESULTS

Seventeen patients had cutaneous melanoma and 22 patients had mucosal melanoma. The overall response rate was 18.4%, and the response rates for cutaneous and mucosal melanoma were 29.4% and 9.5%, respectively. EPD was observed in 13 patients (34.2%). By multivariate analysis, body mass index (BMI) and C-reactive protein to albumin ratio (CAR) were independently and significantly associated with EPD, disease control rate, progression-free survival, and overall survival. Low BMI (cutoff 20) and high CAR (cutoff 0.0055) were predictive factors of EPD and were determined to be prognostic factors. MII, from 0 to 2, was determined by the number of these factors. The incidence of EPD was 0% in the low-risk group (MII = 0), 50% in the intermediate-risk group (MII = 1), and 83% in the high-risk group (MII = 2).

CONCLUSIONS

An MII status of low BMI and high CAR may be used to predict EPD in unresectable melanoma patients treated with nivolumab.