Neutrophil-lymphocyte, platelet-lymphocyte and lymphocyte-monocyte ratios may not be useful markers to assess disease activity in rheumatoid arthritis: A STROBE-compliant article

Diagnostic accuracy of the neutrophil-to-lymphocyte ratio and the platelet-to-lymphocyte ratio in rheumatoid arthritis: a systematic review and meta-analysis

Existing challenges with the early diagnosis of rheumatoid arthritis (RA) and active disease, mainly by non-rheumatologists, have prompted the search for novel biomarkers. Elevations in indices derived from blood cell counts, e.g., the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR), have been reported in RA patients. However, their diagnostic accuracy has not been comprehensively assessed. Therefore, we conducted a systematic review and meta-analysis of studies reporting the sensitivity and specificity of the NLR and PLR, obtained by receiver operating characteristic (ROC) curve analysis, for the presence of RA and active disease. We searched electronic databases from inception to 15 March 2024 and assessed the risk of bias using the JBI Critical Appraisal Checklist (PROSPERO registration number: CRD42024533546). In 15 studies, the NLR exhibited acceptable accuracy for the presence of RA (area under the curve, AUC = 0.76, 95% CI 0.72 to 0.80) and active disease (AUC = 0.70, 95% CI 0.66 to 0.74). The PLR exhibited good accuracy for the presence of RA (AUC = 0.80, 95% CI 0.76 to 0.83). There were insufficient studies to assess the accuracy of the PLR for the presence of active disease. Our systematic review and meta-analysis suggests that the NLR and the PLR are promising biomarkers of RA (NLR and PLR) and active disease (NLR). Further research is required to investigate whether the NLR and PLR can significantly enhance the capacity to diagnose RA and active disease in clinical practice.

Correlation of Hematological Indices and Acute-Phase Reactants in Rheumatoid Arthritis Patients on Disease-Modifying Antirheumatic Drugs: A Retrospective Cohort Analysis

Acute-phase markers are often used to evaluate the disease activity of rheumatoid arthritis (RA). Occasionally, the serum levels of acute-phase reactants remain normal in patients with obvious inflamed joints. Hematological indices derived from complete blood counts have been shown to correlate with disease activity. This provides a potential practical implementation in daily practice. Only a few studies have evaluated the relation between hematological indices and novel RA treatment (i.e., biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs); no research has examined the changes in hematological indices in RA treatments longitudinally. We conducted a retrospective study involving 273 RA patients with b/tsDMARD treatment and followed them for at least a year. Baseline, 3-month, and 6-month lab data were collected. The results indicated a reduction in the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-lymphocyte ratio (MLR), and systemic immune-inflammation index (SII) post-treatment. Higher baseline PLRs and SIIs were associated with a more significant reduction in ESR at three months (η2 = 0.03/0.13, p = 0.21/0.023). NLR and SII correlated with CRP moderately at three months (r = 0.373/0.394, p < 0.001/< 0.001). A correlation comparison showed that the correlation of NLR and PLR with CRP differs during different periods (p = 0.037/0.004). Subgroup analysis revealed that the time effect on correlation is related to treatment with Janus kinase inhibitor and anti-interleukin-6 but not antitumor necrosis factors.

Relationship of Complete Blood Count Derived Biomarkers With Methotrexate Resistance

Background Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic inflammation and joint damage. Among the therapeutic agents, methotrexate remains a cornerstone of initial treatment. Complete blood count (CBC)-derived biomarkers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), and systemic immune response index (SIRI) have been extensively studied in various diseases. Still, their specific role in RA patients undergoing methotrexate treatment has not been investigated. Objective This study aimed to investigate the relationship of CBC-derived biomarkers with methotrexate resistance in newly diagnosed rheumatoid arthritis patients. Methods We performed a comprehensive analysis of 54 RA patients, divided into methotrexate-resistant (MTXR) and methotrexate-sensitive (MTXS) groups. Analysis of variance (ANOVA) was used to assess differences in hematological biomarkers between groups. Standard t-tests were used to compare specific biomarkers between the MTXR and MTXS groups. The chi-squared test was used to compare categorical variables between groups. Pearson's correlation test was also used to examine correlations between these biomarkers and Disease Activity Score 28 (DAS28) in both groups. Receiver operating characteristic (ROC) curve analysis was performed for each biomarker to determine predictive ability. Results A statistically increased PLR ratio was observed in the MTXR group compared to the MTXS group. Significant correlations between DAS28 and NLR, PLR, SII, and SIRI were observed in the MTXR group. In contrast, these correlations were absent in the MTXS group. In addition to PLR, DAS28 and ESR were significantly higher in the MTXR group than in the MTXS group. None of these biomarkers showed prognostic value for methotrexate treatment outcomes. Conclusion PLR could be used as a biomarker for resistance to methotrexate treatment in a specific RA patient population. Increased PLR and ESR, together with higher DAS28, might be associated with a more pronounced inflammatory state in MTXR patients.

The association between neutrophil-to-lymphocyte ratio and disease activity in rheumatoid arthritis

The inflammatory response is responsible for the promotion of pannus development over the joint, which is the primary factor in joint injury in rheumatoid arthritis (RA). More in-depth investigations have been conducted in recent years leading to a greater understanding of RA. Yet, it's difficult to gauge inflammation levels in RA patients. Some people who have RA do not exhibit normal symptoms, which makes it more challenging to make a diagnosis. Typical RA evaluations are subject to a few restrictions. Earlier research demonstrated that some patients continued to experience the progression of bone and joint degeneration even while in clinical remission. This progression was attributed to ongoing synovial inflammation. As a result, performing a precise evaluation of the level of inflammation is of the utmost importance. The neutrophil-to-lymphocyte ratio (NLR) has consistently been one of the most interesting novel non-specific inflammatory indicators. It is a reflection of the equilibrium between lymphocytes and neutrophils, which are inflammatory regulators and inflammatory activators, respectively. A higher NLR is linked to more severe levels of imbalance and inflammation. The aim of this study was to depict the role of NLR in RA progression and to show if NLR could predict the response to disease-modifying antirheumatic drugs (DMARDs) therapy in RA.

Neutrophil-to-monocyte ratio is the better new inflammatory marker associated with rheumatoid arthritis activity

Background

Rheumatoid arthritis (RA) is a systemic autoimmune disease that chronically affects patients with episodes of inflammation. New inflammatory hematological markers were investigated for follow-up, such as the neutrophil-monocyte ratio (NMR), lymphocyte monocyte ratio (LMR), and neutrophil-lymphocyte ratio (NLR). This study was conducted to determine the most useful marker based on studies of association with RA disease activity and correlation with the classical markers C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and rheumatoid factor (RF).

Methods

This case-control study included 62 chronic RA patients who had previously been diagnosed and experienced episodes of symptoms while attending a variety of public and private rheumatology clinics in Ibb City, Republic of Yemen, for the period of September 1 to November 30, 2021. Twenty healthy volunteers were included in this study. Complete blood count, CRP, ESR, and RF levels were measured in all participants.

Results

The total leukocyte count, neutrophil count, platelet count, NMR, LMR, and NLR were positively correlated with CRP and ESR, but the monocyte count was reversed. The area under the curve (AUC = 0.861, 95% confidence interval [CI] = 0.769-0.948) for the NMR cutoff value of 4.7 was equal to that of CRP and close to that of ESR. This NMR cutoff value had 87% sensitivity and 80% specificity. LMR and NLR cutoff values of 4.35 and 1.35, respectively, resulted in AUCs of (AUC = 0.807, 95% CI, 0.708-0.905) and (AUC = 0.699, 95% CI, 0.571-0.819); their sensitivity and specificity were 62.3%, 90%, 57.4%, and 80%, respectively.

Conclusions

As a convenient and low-cost inflammatory marker of RA activity, NMR outperformed LMR and NLR.

Relationship of Blood Inflammatory Composite Markers with Cardiovascular Risk Factors and Subclinical Atherosclerosis in Patients with Rheumatoid Arthritis

The neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammatory index (SIRI, neutrophils × monocytes/lymphocytes) have been described as potential blood-derived inflammatory biomarkers in several diseases. Rheumatoid arthritis is an inflammatory disease that has been related to an increased risk of cardiovascular (CV) disease. In the present work, we analyze how these hematological composite scores of inflammation are related to classic CV risk factors and subclinical atherosclerosis in patients with RA. In this cross-sectional study that included 430 patients with RA, the NLR, MLR, PLR, and SIRI scores were calculated. Multivariable analysis was performed to examine the relationships of these composite blood scores with subclinical carotid atherosclerosis and with traditional cardiovascular factors, producing a complete profile of lipid molecules and insulin resistance or indices of beta-cell function, and a Systematic Coronary Risk Assessment (SCORE2) calculation. C-reactive protein and disease activity were significantly and positively associated with the four blood composite scores. SCORE2 was significantly associated with higher values of SIRI, NLR, and MLR, but not PLR. These relationships were maintained when SCORE 2 was considered categorical; patients in the very high CV risk category had higher values in all hematological composite scores, except PLR. In the multivariable analysis, SIRI and NLR were independently associated with higher levels of beta cell dysfunction. In conclusion, SCORE2 and the values of the hematological composite scores were positively correlated in patients with RA. In addition, there were some relationships of these scores with traditional CV risk factors, with their association with beta cell dysfunction being the most consistent.

Neutrophil-to-lymphocyte and platelet-to-lymphocyte ratio and disease activity in rheumatoid arthritis: A systematic review and meta-analysis

BACKGROUND

Inflammatory indexes derived from routine haematological parameters, particularly the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR), have been shown to discriminate between patients with and without rheumatoid arthritis (RA). However, their capacity to discriminate between RA patients with and without active disease has not been systematically appraised.

METHODS

We searched PubMed, Web of Science, Scopus and Google Scholar, from inception to June 2022, for studies comparing NLR and/or PLR values between RA patients with and without active disease. Risk of bias and certainty of evidence were assessed using the Joanna Briggs Institute Critical Appraisal Checklist and GRADE, respectively.

RESULTS

In 18 studies (2122 RA patients with active disease, mean age 50 years, 20% males; 1071 RA patients with nonactive disease, mean age 50 years, 25% males), active disease was associated with significantly higher NLR (standard mean difference, SMD = 0.37, 95% CI 0.19 to 0.55, p < .001; low certainty of evidence) and PLR values (SMD = 0.48, 95% CI 0.32 to 0.64, p < .001; low certainty of evidence). In sensitivity analysis, the SMD values were not substantially influenced by sequentially removing individual studies. There was no publication bias. In meta-regression, the effect size was not associated with other study and patient characteristics, including sex, Disease Activity Score-28, C-reactive protein and erythrocyte sedimentation rate.

CONCLUSIONS

NLR and PLR can significantly discriminate between RA patients with and without active disease. Further studies are required to determine their diagnostic performance, singly or in combination with other parameters, in routine practice.

Preoperative monocyte-to-lymphocyte ratio as a potential predictor of bladder cancer

OBJECTIVES

The aim of this study was to investigate the role of preoperative Monocyte-to-Lymphocyte ratio (MLR) as a potential predictor of bladder cancer (BC).

METHODS

Clinical data of patients who underwent TURBT at our institution between 2017 and 2021 were collected and retrospectively analysed. MLR was obtained from preoperative blood analyses performed within 1 month from hospital admission. The association of MLR with different clinic-pathological features obtained from histological reports was further analysed. Statistical analysis was performed using the Kruskal Wallis test for non-parametric variables, assuming p<0.05 as statistically significant.

RESULTS

510 patients were included in the study (81% males, 19% females), with a mean age of 71.66 ± 11.64 years. Mean MLR was higher in patients with any-type bladder cancer, reporting an MLR of 0.41 ± 0.11 compared to 0.38 ± 0.43 in patients without bladder cancer (p=0.043). In the subsequent comparison among low-grade and high-grade bladder cancer, MLR did not report statistically significant differences, with 0.29 ± 0.12 for low-grade BC and 0.51 ± 0.81 for high-grade BC (p=0.085).

CONCLUSIONS

Our findings reported elevated preoperative MLR should be considered a potential biomarker predicting malignancy for bladder tumours. Furthermore, research are necessary to assess its role in discerning low-grade from high-grade patients.

Diagnostic Value of Neutrophil-to-Lymphocyte, Platelet-to-Lymphocyte, and Monocyte-to-Lymphocyte Ratios for the Assessment of Rheumatoid Arthritis in Patients with Undifferentiated Inflammatory Arthritis

Background: To investigate the diagnostic performance of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) in the diagnosis of rheumatoid arthritis (RA) in subjects with undifferentiated inflammatory arthritis (UIA). Methods: This retrospective cohort study investigated 201 female patients with UIA (≥1 swollen joint) and 280 age-matched, healthy female controls. “Clinical RA” was defined based on the clinical judgment of a rheumatologist and “disease-modifying anti-rheumatic drugs (DMARDs) RA” was defined as a case of initiating DMARDs treatment within 6 months after the first visit. “Classified RA” was defined as fulfilling the 2010 classification criteria for RA. Receiver operating characteristics were used to determine the optimal cut-off value. Results: UIA patients had a significantly higher NLR, PLR, and MLR than the controls. Among the 201 UIA patients, 65 (32.3%), 63 (31.3%), and 61 (30.3%) subjects were classified as clinical RA, DMARDs RA, and classified RA, respectively. At a cut-off of 0.24, MLR showed moderate accuracy for the diagnosis of DMARDs RA (sensitivity, 65.1%; specificity, 62.3%; area under the curve [AUC], 0.701; p < 0.001). However, the diagnostic accuracies of NLR and PLR were low. Conclusions: MLR may be used as a complementary diagnostic indicator for RA diagnosis in patients with UIA.

Is there a correlation between preoperative neutrophil-to-lymphocyte, platelet-to-lymphocyte, and lymphocyte-to-monocyte ratios and postoperative pain in video-assisted thoracoscopic surgery?

Many thoracic surgery procedures are now performed with video-assisted thoracoscopic surgery (VATS). Postoperative pain is a common condition in patients undergoing VATS. In this study, we aimed to investigate whether neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) are effective in evaluating postoperative pain in patients undergoing VATS.This prospective observational study was performed between March 2021 and September 2021 at a tertiary thoracic surgery center. The study included patients who had undergone elective VATS. Preoperative and postoperative NLR, PLR, LMR, hemogram values and postoperative visual analog scale (VAS) were recorded.A total of 105 patients were analyzed. A positive correlation was observed between postoperative monocyte, neutrophils and VAS resting and VAS cough levels in the early postoperative period. No significant correlation was found between preoperative and postoperative NLR, PLR, and LMR values and VAS rest and VAS cough values. When compared to the preoperative period, a negative correlation was found between the change in the postoperative LMR value and the VAS rest and VAS cough values in the early postoperative period.When compared to the preoperative period, the change in postoperative neutrophil, postoperative monocytes, and postoperative LMR values in patients undergoing VATS in thoracic surgery can be used as a guide in the objective evaluation of postoperative acute pain. It is the belief of the researchers that comprehensive new studies on this subject will contribute significantly to the determination of objective criteria in postoperative pain evaluation.