Blood neutrophil-to-lymphocyte ratio independently predicts survival in patients with liver cirrhosis

Predictive value of neutrophil-to-lymphocyte ratio for long-term adverse outcomes in cirrhosis patients post-transjugular intrahepatic portosystemic shunt

The neutrophil-to-lymphocyte ratio (NLR) may predict outcomes in end-stage liver disease, but its value after transjugular intrahepatic portosystemic shunt (TIPS) is unclear. This study explored the link between NLR and long-term outcomes in decompensated cirrhosis patients post-TIPS. We retrospectively analyzed 184 patients treated between January 2016 and December 2021, noting demographic data, lab results, and follow-up outcomes, including liver transplantation or death. Cox regression, adjusted for various factors, showed that NLR is an independent predictor of post-TIPS progression (HR 1.665; 95% CI 1.149-2.414; P = 0.007). Patients were divided into tertiles based on NLR. The medium tertile had a 3.51-fold increased risk of progression compared to the lowest (HR 3.510; 95% CI 1.104-11.153, P = 0.033), and the highest tertile had a 5.112-fold increase (HR 5.112; 95% CI 1.653-15.806, P = 0.005). This suggests that NLR is a valuable prognostic marker for long-term progression in these patients, highlighting the role of systemic inflammation.

Role of C-Reactive Protein/Lymphocyte and Neutrophil/Lymphocyte Ratios in Predicting Mortality in Patients with Fournier's Gangrene

BACKGROUND AND OBJECTIVES

Fournier's gangrene (FG) is a polymicrobial-induced necrotizing fasciitis that affects the deep and superficial tissues of the perineal, perianal, scrotal, and genital regions. This study aimed to investigate the role of C-reactive protein (CRP)/lymphocyte and neutrophil/lymphocyte ratios, which are objective markers of inflammatory response, in predicting mortality in patients with FG.

PATIENTS AND METHODS

Seventy-one patients who underwent surgery for FG between 2019 and 2023 were evaluated retrospectively. Demographic and clinical characteristics, laboratory results, the FG severity index (FGSI) score, and the CRP/lymphocyte and neutrophil/lymphocyte ratios were analyzed for the patient groups with and without in-hospital mortality.

RESULTS

The characteristics of the patients with and without mortality were compared. A total of 71 patients, 51 (71.8%) males and 20 (28.2%) females, were evaluated. Eight patients died during treatment. The median age was 67 (56-86) years in the mortality group and 58 (27-82) years in the non-mortality group. Statistically significant differences were observed between the two groups in terms of age, lymphocyte count, CRP/lymphocyte, neutrophil/lymphocyte, potassium, blood urea nitrogen, and FSGI. In the receiver operating characteristic analysis of the CRP/lymphocyte and neutrophil/lymphocyte ratios, the cutoff values were calculated as 183.3 and 19.93, respectively. By comparing the data between the mortality and non-mortality groups, the sensitivity and specificity rates of these ratios were also determined.

CONCLUSION

The CRP/lymphocyte and neutrophil/lymphocyte ratios may be important parameters in predicting mortality in patients with FG.

Addition of neutrophil-to-lymphocyte ratio to Pre-DAA FIB-4 does not increase prediction value for de novo liver complications in hepatitis C

BACKGROUND AND AIMS

Direct-acting antiviral agents (DAAs) achieve high sustained virologic response (SVR) in chronic hepatitis C patients; yet a proportion of patients still experience de novo liver complications after SVR. Identification of risk factors is clinically important. FIB-4 index is a useful noninvasive tool to assess fibrosis, while neutrophil-to-lymphocyte ratio (NLR) is a biomarker for systemic inflammation. Our study aimed to investigate whether the addition of NLR can increase the prediction power of pre-DAA FIB-4 for de novo liver complications after SVR.

METHODS

We recruited patients via The Taiwan HCV Registry (TACR) and National Health Insurance Registry Database. The inclusion criteria were patients who achieved SVR12 after DAA and were followed for at least 24 months after SVR12. Liver complications included ascites, hepatic encephalopathy, variceal bleeding, and HCC.

RESULTS

Totally 7657 patients were recruited from 2013 to 2018. Among them, 3674 patients (48.0%) had a FIB-4 value > 3.25 and 491 patients (6.4%) had a NLR >4 before DAA. After two-year of follow-up after SVR 12, 214 patients (2.8%) developed de novo liver complications. Factors associated with liver complications included male gender, diabetes mellitus, hyperlipidemia, chronic kidney disease, and pre-DAA FIB-4 >3.25 in multivariate analyses. Addition of NLR slightly did not increase the power of predicting liver complications.

CONCLUSIONS

The overall incidence of de novo liver complications after SVR is low during short-term follow-up. Elevated pre-DAA FIB-4 is associated with de novo liver complications after SVR, whereas the addition of pre-DAA NLR does not increase the prediction power.

A propensity score matching analysis of neutrophil to lymphocyte ratio forecasts the survival of individuals undergoing the transjugular intrahepatic portosystemic shunt

The neutrophil-to-lymphocyte ratio (NLR) has been shown to predict patient outcomes in various disorders. This study was carried out to evaluate the value of NLR in predicting mortality in decompensated cirrhosis patients having transjugular intrahepatic portosystemic shunt (TIPS). The end-stage liver disease model (MELD) is a scoring system to evaluate the liver function reserve. Retrospective investigation was conducted on the clinical information of 244 decompensated cirrhosis individuals with a MELD score ≤15 who underwent TIPS production at two academic medical centres between January 2017 and August 2021. The main result was 12-month post-TIPS mortality. The area under the receiver operating characteristic curve (AUC) was used to investigate the predictive potential of prognostic markers correlated with 12-month mortality using a logistic regression approach. To minimize the effects of potential factors, a 1:2 propensity score matching (PSM) was carried out. The non-surviving group had 21 (8.6%) patients who passed away within 12mo, while the surviving group included 223 (91.4%) patients who survived for more than 12mo. According to the multivariate analyses, NLR>4.8 was an independent prognostic factor of 12-month mortality after PSM analysis (OR=3.4, 95%CI, 1.052-10.985, P =0.041). In comparison to the non-surviving group, the proportion of NLR-high (>4.8) cells in the surviving group were considerably greater (71.4%vs.38.1%, P =0.017). Whether Unmatched group or the Matched group, NLR exhibited the highest diagnostic performance (AUCs of 0.646 and 0.667, respectively, P <0.05). The NLR is a reasonable and effective indicator of 12-month mortality in decompensated cirrhosis patients with a MELD ≤15 receiving TIPS.

Association of systemic immune biomarkers with metabolic dysfunction-associated steatotic liver disease: a cross-sectional study of NHANES 2007-2018

Objective

Numerous studies emphasize the pivotal role of inflammation in metabolic dysfunction-associated steatotic liver disease (MASLD) development. Some link specific systemic immune biomarkers (e.g., systemic immuno-inflammatory index [SII], neutrophil-to-albumin ratio [NPAR] and neutrophil-to-lymphocyte ratio [NLR]) to hepatic steatosis risk. However, the relevance of other markers like systemic immune-inflammation index [SIRI], platelet-to-lymphocyte ratio [PLR] and lymphocyte/monocyte ratio [LMR] in MASLD remains unclear. Limited literature covers all six markers together. This study aims to investigate the association between SII, SIRI, LMR, NLR, PLR, and NPAR and MASLD, assessing their predictive value.

Methods

In this cross-sectional analysis of adults from NHANES (2007-2018), we investigated the relationship between six systemic immune biomarkers, stratified by quartiles: quartile1 (Q1), quartile2 (Q2), quartile3 (Q3) and quartile4 (Q4), and the outcome of MASLD assessed by Fatty Liver Index (FLI) and United States Fatty Liver Index (USFLI). Logistic regression and restricted cubic splines (RCS) were employed to assess the association between systemic immune biomarkers and MASLD risks. Propensity score matching controlled for potential confounders, and receiver operating characteristic (ROC) curve analysis evaluated the biomarkers' predictive performances for MASLD. Subgroup and interaction analysis were conducted to explore the effects of systemic immune biomarkers on MASLD risks. Multicollinearity was quantified using the variance inflation factor.

Results

In total, 14,413 participants were included and 6,518 had MASLD. Compared with non-MASLD, participants with MASLD had higher SII, SIRI, NLR, PLR, and NPAR (p < 0.001). SII, SIRI, NLR, and NPAR were further validated in the restricted cubic splines (RCS) regression model and identified as positive linear relationships (p for nonlinear >0.05). The prevalence of MASLD increased with the Q4 of SII [OR = 1.47, 95%CI (1.24, 1.74)], SIRI [OR = 1.30, 95%CI (1.09, 1.54)], NLR [OR = 1.25, 95%CI (1.04, 1.49)], PLR [OR = 1.29, 95%CI (1.09, 1.53)] and NPAR [OR = 1.29, 95%CI (1.09, 1.54)] compared to the Q1 after adjusting for the bias caused by potential confounders. However, the propensity score matching analysis only supported an association between the highest SII, SIRI, NLR NPAR and the risk of MASLD. The results of the subgroup analysis showed considerable robustness in the relationship.

Conclusion

Higher SII, SIRI, NLR and NPAR were positively associated with a heightened risk of MASLD. NPAR showed the superior predictive value, followed by SII, SIRI and NLR. This needs to be validated in additional longitudinal studies and clinical trials.

The Value of Neutrophil-to-Lymphocyte Ratio in Predicting Mortality After Transjugular Intrahepatic Portosystemic Shunt Placement

Background and Aims

The objective of this study was to investigate the effect of neutrophil-to-lymphocyte ratio (NLR) on the survival of cirrhotic patients with esophagogastric variceal bleeding (EGVB) treated with transjugular intrahepatic portosystemic shunt (TIPS).

Methods

A total of 293 patients treated with TIPS were included. The receiver operator characteristic curve (ROC) was used to calculate the optimal cut-off values of parameters such as NLR. The Kaplan-Meier curve and Cox proportional risk model were used to evaluate the effects of NLR and other variables on 2-year all-cause mortality.

Results

The area under the ROC for NLR was 0.634, with an optimal cutoff value of 4.9. Two-year mortality rates for patients with high (≥4.9) and low (<4.9) NLR were 22.1% and 9.3%, respectively (Log rank test: P = 0.002). After correcting for confounders, multivariate analysis demonstrated that NLR ≥ 4.9 (HR = 2.741, 95% CI 1.467-5.121, P = 0.002), age ≥ 63 (HR = 3.403, 95% CI 1.835-6.310, P < 0.001), and gender (male) (HR = 2.842, 95% CI 1.366-5.912, P = 0.001) were independent risk factors for the mortality outcome. Considering the stratification of early and selective TIPS treatment, high NLR still significantly increased the risk of mortality for patients (Log rank test: P = 0.007, HR = 2.317, 95% CI 1.232-4.356).

Conclusion

NLR can help to predict survival in EGVB patients after TIPS, and the type of TIPS should also be considered in practical applications.

Meta-analysis of the Relationship Between Neutrophil to Lymphocyte Ratio and Nasal Polyps

Our study aimed to enhance understanding of nasal polyp pathophysiology by reviewing the data for variations of NLR values between patients with nasal polyp and healthy controls. We searched Web of Science, PubMed, ProQuest, and Scopus up to 2 April 2023. The search strategy was not limited to any specific language. Twelve studies were included in our study. Of them, ten studies, involving 898 nasal polyp patients and 590 control patients, were included in the meta-analysis. The NLR levels in nasal polyp patients were statistically greater than in the control group (SMD = 0.56; 95%CI 0.04-1.08, P = 0.036). Subgroup analysis based on study design yielded that patients with nasal polyp exhibited significantly higher NLR levels than healthy controls in retrospective studies (SMD = 0.83; 95%CI 0.30-1.35, P = 0.002) but not in prospective studies (SMD = 0.10; 95%CI = -1.03 to 1.23, P = 0.85). Also, we found that the NLR levels in nasal polyp patients were significantly higher than healthy controls in high-quality studies (SMD = 1.00; 95%CI 0.38-1.62, P = 0.002) but not in low-quality studies (SMD = 0.11; 95%CI = -0.69 to 0.91, P = 0.79). A total of 312 patients with recurrence and 550 patients without recurrence were included in the study. The combined results revealed that NLR levels in nasal polyp recurrence patients were significantly higher than those of the nasal polyp without recurrence group (SMD = 0.06, 95% CI 0.39-0.81, P = 0.000). These results showed the relationship between the NLR in nasal polyps and can help medical doctors to predict the recurrence of the disease in such patients.

Can quantitative surface antigen levels and systemic immune-inflammation index be predictive as a new indicator for the initiation of treatment in chronic hepatitis b?

OBJECTIVES

The natural history of chronic HBV infection (CHB) is generally divided into four phases: HBeAg-positive chronic HBV infection (EPCI) and -hepatitis (EPCH), HBeAg-negative chronic HBV infection (ENCI) and -hepatitis (ENCH). This study aimed to investigate changes in serum quantitative surface antigen (qHBsAg), systemic immune-inflammation index (SII) and systemic inflammatory response index (SIRI) in a large number of CHB patients.

METHOD

Three hundred seventy-two CHB patients who underwent liver biopsy between January 2015 and February 2020 were evaluated.

RESULTS

The SII-values were strongly significant between EPCI-EPCH ( P = 0.002), however, there was significant difference between ENCI-ENCH ( P = 0.025). Considering the SIRI results, there was a significant difference between both EPCI-EPCH ( P = 0.009) and ENCI-ENCH ( P = 0.118). In HBeAg-positive patients HBV-DNA, qHBsAg, and SII were found to be predictive ( P = 0.029, P = 0.039, P = 0.027, respectively) while in HBeAg-negative patients, age, AST, HBV-DNA, qHBsAg, SII, and SIRI were found to be predictive ( P = 0.047, P = 0.084, P = <0.001, P = 0.001, P = 0.012, P = 0.002, respectively). In EPCH phase, whereby accuracy rate results of HBV-DNA, qHBsAg, and SII were 75.3%, 73.4%, and 60.4%, respectively, while in the ENCH phase the accuracy rates of age, AST, HBV-DNA, qHBsAg, SII, and SIRI values were 57.8%, 65.6%, 68.3%, 63.8%, 57.3% and 53.2%, respectively.

CONCLUSION

HBV-DNA, qHBsAg, and SII are predictive in EPCH patients. Age, AST, HBV-DNA, qHBsAg, SII and SIRI are all predictive in ENCH patients. In patients with CHB, we recommend using SII to distinguish between EPCI-EPCH and ENCI-ENCH. Based on its sensitivity and features, we believe that qHBsAg and SII are suitable measuring instruments in discrimination both of EPCI-EPCH and ENCI-ENCH.

Mac-2-Binding Protein Glycosylation Isomer to Albumin Ratio Predicts Bacterial Infections in Cirrhotic Patients

INTRODUCTION

Mac-2-binding protein glycosylation isomer (M2BPGi) is a novel biomarker for liver fibrosis, but little is known about its role in cirrhosis-associated clinical outcomes. This study aimed to investigate the predictive role of M2BPGi in cirrhosis-associated complications.

METHODS

One hundred and forty-nine cirrhotic patients were retrospectively enrolled. Patients were followed up for 1 year, and cirrhosis-associated clinical events were recorded. Receiver operating characteristic curve (ROC) analysis was used to establish the values of the predictive models for cirrhotic outcomes, and Cox proportional hazards regression models were used to identify predictors of clinical outcomes.

RESULTS

Sixty (40.3%) patients experienced cirrhosis-associated clinical events and had higher M2BPGi levels compared to those without events (8.7 vs. 5.1 cutoff index, p < 0.001). The most common cirrhosis-associated complications were bacterial infections (24.2%). On ROC analysis, M2BPGi to albumin ratio (M2BPGi/albumin) had comparable discriminant abilities for all cirrhosis-associated events (area under the ROC curve [AUC] = 0.74) compared with M2BPGi, Child-Pugh, model for end-stage liver disease, albumin-bilirubin scores, and neutrophil-to-lymphocyte ratio and was superior to M2BPGi alone for all bacterial infectious events (AUC = 0.80). Cox regression analysis revealed that the M2BPGi/albumin, but not M2BPGi alone, independently predicted all cirrhosis-associated events (hazard ratio [HR] = 1.34, p = 0.038) and all bacterial infectious events (HR = 1.51, p = 0.011) within 1 year. However, M2BPGi/albumin did not predict other cirrhotic complications and transplant-free survival.

DISCUSSION/CONCLUSION

M2BPGi/albumin might serve as a potential prognostic indicator for patients with cirrhosis, particularly for predicting bacterial infections.

Neutrophils: tissue and circulating signatures of pediatric non-alcoholic fatty liver disease

The recent rise in non-alcoholic fatty liver disease (NAFLD) among children and adolescents led to a thorough investigation of the peculiarities of the cellular infiltrate which characterize the disease at young ages. This review aims to highlight the key involvement of neutrophils in the pathogenesis of pediatric NAFLD and the potential biomarker role of neutrophil-to-lymphocyte ratio (NLR) in the same pediatric disorder. Neutrophils, which are first responders to inflammation, constitute an abundant component of an infiltrate which is particularly disposed within the portal area of children with NAFLD. The involvement of neutrophils in triggering liver fibrosis has been related amongst others to reactive oxygen species (ROS) production, to the stimulation of hepatic stellate cells, and to their synthesis of neutrophil elastase. As immune imbalance characterizes NAFLD, potentially emerging non-invasive biomarkers such as NLR have been proposed for the detection and prognosis of NAFLD. In adults, several studies asserted the role of NLR in the prediction of advancing liver fibrosis and mortality in subjects with NAFLD. In children, data is scarce with contradicting findings, as some studies failed to identify significant shifting in NLR values in children with NAFLD when compared with obese controls without liver impairment. However, NLR seems to significantly increase in children with obesity and different degrees of NAFLD when compared to healthy counterparts and their changes seem to be reversible with weight loss. Still, paucity of pediatric studies calls for future research addressing the role of NLR in predicting NAFLD development and progression in children with obesity.

Identifying optimal candidates for autologous peripheral blood stem cell therapy in patients with decompensated liver cirrhosis: a prognostic scoring system

BACKGROUND

Stem cell transplantation shows great potential to improve the long-term survival of cirrhosis patients. However, therapeutic effects may not be homogeneous across the whole study population. This study constructed an easy-to-use nomogram to improve prognostic prediction and aid in treatment decision making for cirrhotic patients.

METHODS

From August 2005 to April 2019, 315 patients with decompensated cirrhosis receiving autologous peripheral blood stem cell (PBSC) transplantation were enrolled in this study. They were randomly classified into training (2/3) and validation (1/3) groups. A predictive model was developed using Cox proportional hazard models and subsequently validated. The predictive performance of the model was evaluated and also compared with other prognostic models.

RESULTS

Age, creatinine, neutrophil-to-lymphocyte ratio, and Child-Turcotte-Pugh class were included in the nomogram as prognostic variables. The nomogram showed high discrimination power concerning the area under receiver operating characteristic curves (3/5-year AUC: 0.742/0.698) and good consistency suggested by calibration plots. Patients could be accurately stratified into poor- and good-outcome groups regarding liver-transplantation free survival after receiving PBSC therapy (P < 0.001). Compared with poor-outcome group, the liver function of patients listed for liver transplantation in the good-outcome group was significantly improved (P < 0.001). Besides, our nomogram achieved a higher C-index (0.685, 95% CI 0.633-0.738) and better clinical utility compared with other conventional prognostic models.

CONCLUSIONS

The proposed nomogram facilitated an accurate prognostic prediction for patients with decompensated cirrhosis receiving PBSC transplantation. Moreover, it also held the promise to stratify patients in clinical trials or practice to implement optimal treatment regimens for individuals.

Circulating neutrophil anti-pathogen dysfunction in cirrhosis

Neutrophils are the largest population of leucocytes and are among the first cells of the innate immune system to fight against intruding pathogens. In patients with cirrhosis, neutrophils exhibit altered functionality, including changes in phagocytic ability, bacterial killing, chemotaxis, degranulation, reactive oxygen species production and NET (neutrophil extracellular trap) formation. This results in their inability to mount an adequate antibacterial response and protect the individual from infection. Prognosis and survival in patients with cirrhosis are greatly influenced by the development of infectious complications. Multidrug-resistant bacterial infections in patients with cirrhosis are currently a growing problem worldwide; therefore, alternative methods for the prevention and treatment of bacterial infections in cirrhosis are urgently needed. The prevention and treatment of neutrophil dysfunction could be a potential way to protect patients from bacterial infections. However, the reasons for changes in neutrophil function in cirrhosis are still not completely understood, which limits the development of efficient therapeutic strategies. Both cellular and serum factors have been proposed to contribute to the functional impairment of neutrophils. Herein, we review the current knowledge on features and proposed causes of neutrophil dysfunction in cirrhosis, with a focus on current knowledge gaps and limitations, as well as opportunities for future investigations in this field.

Predictors of Short-term Mortality in Patients of Cirrhosis of Liver Presenting as Acute Kidney Injury: An In-hospital Prospective Observational Study

Background

Acute kidney injury (AKI) is known to be associated with increased short-term mortality among cirrhotic patients. On this background, we designed this study to evaluate various causes of AKI among admitted patients with cirrhosis of liver and predictors of 90-day mortality.

Methods

One hundred and two consecutive adult patients with cirrhosis of liver with AKI hospitalized between November 2016 and March 2018 were enrolled in this prospective study. Their detailed clinical profile, including biochemical parameters, the etiology of AKI, and their clinical outcome of survival or mortality at 90-days, were recorded.

Results

The most common causes of AKI were infections, followed by hypovolemia, seen in 55.88% and 31.37% of the patients, respectively. Hepatorenal syndrome (HRS) was seen in 10.78%, while parenchymal renal disease was the least common (1.9%). The in-hospital mortality rate was 28.4%, while 90-day mortality was 39.21%. The HRS group had a high 90-day mortality rate of 54.54%. ROC analysis of various biochemical parameters revealed that serum creatinine (sCr), Model for End-Stage Liver Disease (MELD), International Normalized Ratio (INR), and Neutrophil-Lymphocyte ratio (NLR), followed by Child Turcotte Pugh (CTP), had high area under the curves of 0.785, 0.773, 0.747, 0.740, and 0.718, respectively, for the prediction of 90-day mortality.

Conclusion

Infection is the commonest cause of AKI in cirrhosis; however, mortality in patients with HRS-AKI is higher than that in those with infection-related AKI. Serum creatinine at admission, INR, NLR, and CTP scores predict short-term mortality among patients with AKI in cirrhosis. Further, large prospective studies are needed to confirm these findings.

Association between neutrophil lymphocyte ratio and status of symptom control in children and adolescents with bronchial asthma

Neutrophil lymphocyte ratio (NLR), an easy and readily available biomarker of systemic inflammation, has been less studied so far as a putative marker of asthma control. Our study aimed to assess its feasibility. A total of 90 asthmatic children, aged 5-18 years, diagnosed according to Global Initiative for Asthma (GINA) guidelines, were. Control status of asthma was assessed using the asthma control test (ACT) or childhood ACT and categorized as controlled group-1 (ACT > 19) and uncontrolled group-2 (ACT ≤ 19). The difference between mean values in both groups was analysed, finding a significant difference between children with and without a family history (p = 0.004) and those with and without a need for admission (p = 0.045). Also, a significant association was established between NLR and the type of severity of asthma (p = 0.049), but none between NLR and age, gender, BMI, coexisting allergic rhinitis, or asthma exacerbation. Thus we found no significant association between NLR and symptom control status. However, NLR has the potential to be a putative marker of inflammation, although its relative status to CRP needs further studies.

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.

The Association Between Peripheral Blood Neutrophil-to-Lymphocyte Ratio and Cirrhosis Complications in Adults with Compensated Liver Cirrhosis in Ahvaz, Iran

Background: The neutrophil-to-lymphocyte ratio (NLR) is an inflammation biomarker in patients with liver cirrhosis. While increased NLR is linked to poor clinical outcomes and mortality in diseases like cancers, its association with cirrhosis complications has been sparsely examined. Objectives: This study aimed to evaluate the association between NLR and cirrhosis complications in patients with compensated liver cirrhosis. Methods: This retrospective cohort study was conducted on 256 patients with compensated liver cirrhosis visiting the Gastroenterology Clinic of Imam Khomeini Hospital, Ahvaz, Iran, in 2020. The peripheral blood lymphocyte and neutrophil counts were evaluated, and the NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. Cirrhosis complications were assessed based on clinical and laboratory evaluation during 1 year of follow-up. Results: During the retrospective follow-up period, 59 patients (23.05%) experienced cirrhosis complications such as spontaneous bacterial peritonitis (n = 23), gastrointestinal bleeding (n = 22), and hepatic encephalopathy (n = 14). The baseline NLR, Model for End-Stage Liver Disease (MELD) score and Child-Pugh score were significantly higher in patients who later developed complications than in those who did not (P < 0.0001). The NLR with an optimal cut-off of > 1.95 had a sensitivity of 84.75% and specificity of 93.91% in predicting complications during the 1-year follow-up (AUC = 0.905, P < 0.0001). Conclusions: Our results indicated that the NLR is a simple, non-invasive, and cost-effective marker for predicting short-term complications in patients with compensated liver cirrhosis.

Hematological Indices Are Useful in Predicting Complications of Liver Cirrhosis

BACKGROUND

Liver cirrhosis is the final stage of chronic liver disease. We aimed to evaluate non-invasive scores as predictors of complications and outcome in cirrhotic patients.

METHODS

A total of 150 cirrhotic patients were included. Models for end-stage liver disease (MELD), albumin-bilirubin (ALBI) score, neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MoLR), and neutrophil-lymphocyte-albumin ratio (NLA) scores were tested in relation to the development of complications and mortality using receiver operating characteristic (ROC) curves.

RESULTS

The ROC curve analysis showed (area under the curve) AUC values of NLR, NLA, ALBI, and MELD of 0.711, 0.730, 0.627, and 0.684, respectively, for short-term mortality. MELD, ALBI, and NLA scores showed a statistically significant correlation with hepatic encephalopathy (p = 0.000 vs. 0.014 vs. 0.040, respectively), and the MELD cut-off value of 16 had a sensitivity of 70% and a specificity of 52% (AUC: 0.671, 95% CI (0.577-0.765)). For the assessment of the presence of ascites, the AUC values for NLA and MoLR were 0.583 and 0.658, respectively, with cut-offs of 11.38 and 0.44.

CONCLUSIONS

MELD, ALBI, and NLA are reliable predictors of hepatic encephalopathy. NLA and MoLR showed a significant correlation with the presence of ascites, and MELD, ALBI, NLR, and NLA have prognostic value to predict 30-day mortality in cirrhotic patients.

Neutrophil-to-lymphocyte ratio predicts 30-, 90-, and 180-day readmissions of patients with hepatic encephalopathy

Introduction

Hepatic encephalopathy (HE) is a significant complication of cirrhosis, known to be associated with hospital readmission. However, few new serological indicators associated with readmission in HE patients have been identified and reported. The objective of our study was to identify simple and effective predictors reated to readmission in HE patients.

Materials and methods

We conducted a retrospective study at a single center on adult patients admitted with HE from January 2018 to December 2022. The primary endpoint was the first liver-related readmission within 30, 90, and 180 days, and we collected electronic medical records from our hospital for sociodemographic, clinical, and hospitalization characteristics. We utilized logistic regression analysis and multiple linear regression analysis to determine the predictors that were associated with the readmission rate and the length of the first hospitalization.

Results

A total of 424 patients were included in the study, among whom 24 (5.7%), 63 (14.8%), and 92 (21.7%) were readmitted within 30, 90, and 180 days, respectively. Logistic regression analysis showed that insurance status, alcoholic liver disease (ALD), ascites, the model for end-stage liver disease (MELD) score, and neutrophil-to-lymphocyte ratio (NLR) were significantly associated with 30-, 90-, and 180-day readmissions. Age and hepatocellular carcinoma (HCC) were predictors of 90- and 180-day readmissions. ALD was identified as a unique predictor of readmission in men, while hypertension was a predictor of 180-day readmission in women. Variceal bleeding, chronic kidney disease, and MELD score were associated with the length of the first hospitalization.

Conclusions

NLR at discharge was identified as a significant predictor of 30-, 90- and 180-day readmissions in patients with HE. Our findings suggest that incorporating NLR into routine clinical assessments could improve the evaluation of the prognosis of liver cirrhosis.

The value of NLR versus MLR in the short-term prognostic assessment of HBV-related acute-on-chronic liver failure

BACKGROUND

Systemic inflammation is associated with the development and progression of hepatitis B-associated acute-on-chronic liver failure (HBV-ACLF). The neutrophil-to-lymphocyte ratio (NLR) has been reported to be a prognostic biomarker in patients with HBV-ACLF. However, the role of the monocyte-to-lymphocyte ratio (MLR) as a prognostic inflammatory biomarker in multiple diseases is rarely mentioned in HBV-ACLF.

METHODS

We included a total of 347 patients with HBV-ACLF who met the definition of the Chinese Guidelines for the Diagnosis and Treatment of Liver Failure (2018 edition). Among them, 275 cases were included retrospectively, and 72 cases were collected prospectively. Clinical characteristics and laboratory examination data were collected from medical records within 24 h after diagnosis to calculate MLR and NLR levels, and lymphocyte subpopulation counts were collected in prospectively included patients.

RESULTS

Of the 347 patients with HBV-ACLF, 128 patients in the non-surviving group had a mean age of 48.87 ± 12.89 years; 219 patients in the survival group had a mean age of 44.80 ± 11.80 years and a combined 90-day mortality rate of 36.9%. The median MLR was higher in the non-survivors than in the survivors (0.690 vs 0.497, P < 0.001). MLR values were significantly associated with 90-day mortality in HBV-ACLF (OR 6.738; 95% CI 3.188-14.240, P < 0.001). The AUC for the predictive power of the combined MLR and NLR analysis for HBV-ACLF was 0.694, and the calculated MLR threshold was 4.495. In addition, in the analysis of peripheral blood lymphocyte subsets in HBV-ACLF, a significant decrease in the number of circulating lymphocytes was found in HBV-ACLF patients in the non-surviving group (P < 0.001), with a predominant decrease in the number of CD8 + T cells and no significant difference in the number of CD4 + T cells, B cells or NK cells.

CONCLUSION

Increased MLR values are associated with 90-day mortality in patients with HBV-ACLF, and the MLR may serve as a potential prognostic indicator for patients with HBV-ACLF. Decreased CD8 + T-cell counts may be associated with poor survival in patients with HBV-ACLF.

Prognostic and predictive significance of circulating biomarkers in patients with advanced upper gastrointestinal cancer undergoing systemic chemotherapy

Objective

The prognosis of patients with advanced cancers of the upper gastrointestinal (UGI) tract is poor. Systemic chemotherapy forms the basis for their treatment, with limited efficacy. Biomarkers have been introduced into clinical practice for cancer management. This study aimed to investigate the predictive and prognostic values of circulating biomarkers in patients with advanced esophageal and gastric cancers receiving chemotherapy.

Design

Overall, 92 patients with advanced esophageal squamous cell carcinoma (ESCC; n = 38) and gastric adenocarcinoma (GAC; n = 54) were enrolled. We analyzed the association of circulating lymphocyte subsets, inflammatory markers, and blood cell counts with treatment efficacy and patient survival.

Results

Significant differences were identified in peripheral blood parameters between the groups with different clinicopathological features. Hemoglobin (Hb, p = 0.014), eosinophil counts (p = 0.028), CD4⁺CD28⁺T/CD4⁺T percentage (p = 0.049), CD8⁺CD38⁺T/CD8⁺T percentage (p = 0.044), memory CD4⁺T (p = 0.007), and CD4⁺CD28⁺T (p = 0.007) were determined as predictors for achieving non-PD (progression disease) in the ESCC cohort. High levels of eosinophils (p = 0.030) and memory CD4⁺T cells (p = 0.026) and high eosinophil-to-lymphocyte ratio (ELR, p = 0.013) were predictors of non-PD in patients with GAC. The combined detection models exhibited good ability to distinguish between partial response (PR)/non-PR and PD/non-PD in patients with ESCC and GAC, respectively. Using the multivariate Cox model, the Eastern Cooperative Oncology Group (ECOG) score status (hazard ratio [HR]: 4.818, 95% confidence intervals [CI]: 2.076-11.184, p < 0.001) and eosinophil count (HR: 0.276, 95% CI: 0.120-0.636, p = 0.003) were independent prognostic factors of progression-free survival (PFS) in patients with ESCC. Metastatic sites (HR: 2.092, 95% CI: 1.307-3.351, p = 0.002) and eosinophil-to-lymphocyte ratio (ELR; HR: 0.379, 95% CI: 0.161-0.893, p = 0.027) were independent prognostic factors for overall survival (OS) in patients with ESCC. Differentiation (HR: 0.041, 95% CI: 0.200-0.803, p = 0.010), memory CD4⁺T (HR: 0.304, 95% CI: 0.137-0.675, p = 0.003), NK cells (HR: 2.302, 95% CI: 1.044-3.953, p = 0.037), and C-reactive protein-to-lymphocyte ratio (CLR; HR: 2.070, 95% CI: 1.024-4.186, p = 0.043) were independent prognostic factors for PFS in patients with GAC. Total lymphocyte counts (HR: 0.260, 95% CI: 0.086-0.783, p = 0.017), CD8⁺T (HR: 0.405, 95% CI: 0.165-0.997, p = 0.049), NK cells (HR: 3.395, 95% CI: 1.592-7.238, p = 0.002), and monocyte-to-lymphocyte ratio (MLR; HR: 3.076, 95% CI: 1.488-6.360, p = 0.002) were identified as independent prognostic factors associated with OS of GAC.

Conclusion

Lymphocyte subsets, blood cell counts, and inflammatory parameters may predict the chemotherapeutic response and prognosis in ESCC and GAC. A combination of these markers can be used to stratify patients into risk groups, which could improve treatment strategies.

Predictive Role of Neutrophil-Percentage-to-Albumin Ratio (NPAR) in Nonalcoholic Fatty Liver Disease and Advanced Liver Fibrosis in Nondiabetic US Adults: Evidence from NHANES 2017-2018

Nonalcoholic fatty liver disease (NAFLD) is highly prevalent globally and includes chronic liver diseases ranging from simple steatosis to nonalcoholic steatohepatitis (NASH). The neutrophil-to-albumin ratio (NPAR) is a cost-effective, readily available biomarker of inflammation used to assess cancer and cardiovascular disease prognosis, and it may be of predictive value in NAFLD. This study was to evaluate the associations between the NPAR, the neutrophil-to-lymphocyte ratio (NLR), and the presence of NAFLD or advanced liver fibrosis, and to assess the predictive value of the NPAR in NAFLD in a nationally representative database. This population-based, cross-sectional, retrospective study analyzed the secondary data of adults with NAFLD or advanced liver fibrosis extracted from the National Health and Nutrition Examination Survey (NHANES) database 2017-2018. NHANES participants with complete information of vibration-controlled transient elastography (VCTE) and controlled attenuation parameter (CAP) were enrolled. A logistic regression analysis was used to determine the associations between the variables in the participants with and without NAFLD or advanced liver fibrosis. The mean values of the lymphocyte counts, neutrophil counts, NPAR, aspartate aminotransaminase (AST), alanine aminotransaminase (ALT), total cholesterol, triglycerides, and HbA1c were significantly higher in the participants with NAFLD than in those without NAFLD or advanced liver fibrosis. The mean blood albumin levels of the subjects without NAFLD or advancing fibrosis were considerably greater than those of the individuals with these conditions. The mean values of the NLR, NPAR, AST, ALT, triglycerides, lymphocyte count, neutrophil count, and HbA1c were significantly higher in patients with advanced fibrosis than in those without advanced fibrosis. A multivariate analysis showed that per unit increases in both the NLR and NPAR were significantly associated with an increased risk of developing NAFLD, while neither the NLR nor NPAR was significantly associated with higher odds of advanced fibrosis. In conclusion, the novel biomarker NPAR demonstrates a good association with NAFLD, along with participants' clinical characteristics, in a nationwide population. The NPAR may serve as a biomarker for NAFLD and help clinicians refine the diagnosis and treatment of chronic liver disease.

Rifaximin Improves Liver Functional Reserve by Regulating Systemic Inflammation

Rifaximin, a non-absorbable antibiotic, has been demonstrated to be effective against hepatic encephalopathy (HE); however, its efficacy on liver functional reserve remains unknown. Here, we evaluated the efficacy of rifaximin on the liver functional reserve and serological inflammation-based markers in patients with cirrhosis. A retrospective study was conducted on patients who received rifaximin for more than three months at our hospital between November 2016 and October 2021. The recurrence and grade of HE, serological ammonia levels, Child–Pugh score (CPS), and serological inflammation-based markers such as the neutrophil–lymphocyte ratio (NLR), lymphocyte–monocyte ratio (LMR), platelet–lymphocyte ratio (PLR), C-reactive protein (CRP), and CRP to albumin ratio (CAR) were evaluated. The correlations between serological inflammation-based markers and liver functional reserve were evaluated. HE grades, serum ammonia levels, and inflammation-based markers significantly improved at three months compared with those at baseline. Patients with improved albumin levels showed significantly higher CRP improvement rates at both 3 and 12 months. Patients with an improvement in CAR at 3 months demonstrated a significant improvement in CPS at 12 months. Rifaximin improved the liver functional reserve in patients with cirrhosis. Improvements in inflammation-based markers, particularly CRP and albumin, may be involved in this process.

Blood concentrations of mediators released from activated neutrophils are related to the severity of alcohol-induced liver damage

BACKGROUND

Immune dysregulation and neutrophil infiltration are hallmarks of alcohol-related liver disease (ALD). Our objective was to evaluate the blood profile of neutrophil-derived mediators [neutrophil elastase (NE), myeloperoxidase (MPO), alpha1-antitrypsin (A1AT)], and their potential relevance in ALD.

METHODS

62 patients with ALD /47 males, and 15 females, aged 49,2 ± 9,9/ were prospectively recruited and distributed according to their 1/ gender, 2/ severity of liver dysfunction (by Child-Turcotte-Pugh, MELD scores, and mDF) 3/ presence of complications of ALD complications, and followed for 90 days. 24 age- and sex-matched healthy volunteers served as the control group. Neutrophil-derived biomarkers were quantified using enzyme-linked immunosorbent assays (ELISAs).

RESULTS

Blood concentrations of MPO and NE were significantly higher in ALD patients in comparison with controls. A1AT levels were not different. There were no gender-related differences in the studied biomarker levels. Both NE and MPO correlated with routine markers of inflammation, while NE with MELD and mDF scores. Patients with a severe ALD course i.e. MELD>20 or mDF>32, presented with significantly higher NE blood concentrations.

CONCLUSIONS

Our results point out the critical role of neutrophils in the pathogenesis of ALD. NE and MPO correlated with the intensity of inflammation, and NE was related to the severity of liver dysfunction.

High Neutrophil-Lymphocyte Ratio and Delta Neutrophil-Lymphocyte Ratio Are Associated with Increased Mortality in Patients with Hepatocellular Cancer

BACKGROUND

The neutrophil-lymphocyte ratio (NLR) has been proposed as a prognostic biomarker for cirrhosis and non-liver malignancies. We aimed to evaluate the prognostic value of NLR in a diverse cohort of patients with hepatocellular carcinoma (HCC).

METHODS

We performed a retrospective study of patients diagnosed with HCC between 2008 and 2017 at two large US health systems. We used Cox proportional hazard and multivariable ordinal logistic regression models to identify factors associated with overall survival and response to first HCC treatment, respectively. Primary variables of interest were baseline NLR and delta NLR, defined as the difference between pre- and post-treatment NLR.

RESULTS

Among 1019 HCC patients, baseline NLR was < 5 in 815 (80.0%) and ≥ 5 in 204 (20.0%). Patients with NLR ≥ 5 had a higher proportion of infiltrative tumors (36.2% vs 22.3%), macrovascular invasion (39.6% vs 25.5%), metastatic disease (20.6% vs 11.4%), and AFP > 200 ng/mL (45.6% vs 33.8%). Baseline NLR ≥ 5 was independently associated with higher mortality (median survival 4.3 vs 15.1 months; adjusted HR 1.70, 95%CI 1.41-2.06), with differences in survival consistent across BCLC stages. After adjusting for baseline covariates including NLR, delta NLR > 0.26 was also independently associated with increased mortality (HR 1.42, 95%CI 1.14-1.78). In a secondary analysis, high NLR was associated with lower odds of response to HCC treatment (20.2% vs 31.6%; adjusted OR 0.55, 95%CI 0.32-0.95).

CONCLUSIONS

In a large Western cohort of patients with HCC, high baseline NLR and delta NLR were independent predictors of mortality.

IMPACT

NLR is an inexpensive test that may be a useful component of future HCC prognostic models.

ABO blood group does not influence Child-Pugh A cirrhosis outcome: An observational study from CIRRAL and ANRS CO12 CIRVIR cohorts

BACKGROUND AND AIMS

Non-O blood group promotes deep vein thrombosis and liver fibrosis in both general population and hepatitis C. We aimed to evaluate the influence of Non-O group on the outcome of Child-Pugh A cirrhotic patients.

METHODS

We used two prospective cohorts of Child-Pugh A cirrhosis due to either alcohol or viral hepatitis. Primary end point was the cumulated incidence of 'Decompensation' at 3 years, defined as the occurrence of ascites , hydrothorax, encephalopathy, gastrointestinal bleeding related to portal hypertension, or bilirubin >45 μmol/L. Secondary end points were the cumulated incidences of (1) 'Disease Progression' including a « decompensation» or « the occurrence of one or more parameters » among: prothrombin time (PT) <45%, albumin <28 g/L, Child-Pugh worsening (B or C vs A or B, C vs B), hepatorenal syndrome, and hepato-pulmonary syndrome, (2) other events such as non-malignant portal vein thrombosis (nmPVT), and (3) overall survival.

RESULTS

Patients (n = 1789; 59.9% Non-O group; 40.1% group O) were followed during a median of 65.4 months. At 3 years cumulated incidence of Decompensation was 8.3% in Non-O group and 7.2% in group O (P = .27). Cumulated incidence of Disease Progression was 20.7% in Non-O group and 18.9% in group O (P = .26). Cumulated incidence of nmPVT was 2.7% in Non-O group and 2.8% in group O (P = .05). At 3 years overall survival was 92.4% in Non-O group and 93.4% in group O (P = 1).

CONCLUSION

Non-O group does not influence disease outcome in Child-Pugh A cirrhotic patients. Clinicals trial number NCT03342170.

Correlation between the Lymphocyte-To-Monocyte Ratio (LMR) and Child–Pugh and MELD/MELDNa Scores in Vietnamese Patients with Liver Cirrhosis

Objectives: This study aims to determine cirrhotic patients’ clinical and laboratory characteristics, thereby examining the correlation between lymphocyte-to-monocyte ratio and Child–Pugh and MELD/MELDNa scores. Methods: A cross-sectional study with an analysis of 153 patients admitted to the Department of Gastroenterology–Clinical Hematology at Can Tho Central General Hospital. Data were collected via patient interviews and medical records. Results: The included patients were more likely to be male (66.7%) and were ≥60 years old (51.6%). Excessive alcohol consumption and hepatitis B were the dominant causes of cirrhosis (35.3% and 34.0%). The clinical and laboratory characteristics were similar to previous studies in cirrhotic patients. The mean Child score was 9.3 ± 2.1, including 9.8% of patients with Child A, 44.4% for Child B, and 45.8% for Child C. The mean MELD and MELDNa scores were 16.9 ± 7.1 and 19.4 ± 8.1, respectively. The mean lymphocyte-to-monocyte ratio (LMR) is 2.0 ± 2.2 (from 0.09 to 25.3), being negatively correlated with the other scores (Pearson correlation coefficients were −0.238; −0.211 and −0.245, respectively, all p-values < 0.01). Patients with LMR below 3.31 were more likely to be classified as Child–Pugh B and C. Conclusion: The correlation between LMR with Child–Pugh, MELD, and MELDNa scores was weak and negative.

Platelet-to-White Blood Cell Ratio Is Associated with Adverse Outcomes in Cirrhotic Patients with Acute Deterioration

Background: The platelet-to-white blood cell ratio (PWR) is a hematologic marker of the systemic inflammatory response. Recently, the PWR was revealed to have a role as an independent prognostic factor for mortality in patients with hepatitis B virus (HBV)-related acute-on-chronic failure (ACLF) and HBV-related liver cirrhosis (LC) with acute decompensation (AD). However, the prognostic role of the PWR still needs to be investigated in LC patients with AD. In this study, we analyzed whether the PWR could stratify the risk of adverse outcomes (death or liver transplantation (LT)) in these patients. Methods: A prospective cohort of 1670 patients with AD of liver cirrhosis ((age: 55.2 ± 7.8, male = 1226 (73.4%)) was enrolled and evaluated for 28-day and overall adverse outcomes. Results: During a median follow-up of 8.0 months (range, 1.9−15.5 months), 424 (25.4%) patients had adverse outcomes (death = 377, LT = 47). The most common etiology of LC was alcohol use (69.7%). The adverse outcome rate was higher for patients with a PWR ≤ 12.1 than for those with a PWR > 12.1. A lower PWR level was a prognostic factor for 28-day adverse outcomes (PWR: hazard ratio 1.707, p = 0.034) when adjusted for the etiology of cirrhosis, infection, ACLF, and the MELD score. In the subgroup analysis, the PWR level stratified the risk of 28-day adverse outcomes regardless of the presence of ACLF or the main form of AD but not for those with bacterial infection. Conclusions: A lower PWR level was associated with 28-day adverse outcomes, indicating that the PWR level can be a useful and simple tool for stratifying the risk of 28-day adverse outcomes in LC patients with AD.

ALDH2 Polymorphism rs671 *1/*2 Genotype is a Risk Factor for the Development of Alcoholic Liver Cirrhosis in Hakka Alcoholics

Background

Alcoholics are prone to alcoholic cirrhosis (ALC). Aldehyde dehydrogenase 2 (ALDH2) is involved in alcohol metabolism. Herein, the relationship between ALDH2 genotypes and ALC was analyzed among Hakka alcoholics in southern China.

Methods

A total of 213 alcoholics and 214 non-alcoholics were included in the study. The ALDH2 gene rs671 polymorphism was analyzed, life history, disease history, and auxiliary examination results of these participants were collected.

Results

The alcoholics had higher level of total serum protein, and serum globulin, lower level of serum albumin, serum albumin/globulin ratio, serum prealbumin, neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) than non-alcoholics. In the 213 alcoholics, 180 developed ALC. There were 206 non-ALC persons in the 214 non-alcoholics. The proportion of the ALDH2 rs671 G/G homozygous (*1/*1) was significantly lower in ALC patients (83.3%) than that of other groups (100.0% in non-ALC in alcoholics, 95.6% in non-ALC in non-alcoholics), while the proportion of the G/A heterozygous (*1/*2) was significantly higher in ALC patients (16.7%) than that of other groups (0% in non-ALC in alcoholics, 4.4% in non-ALC in non-alcoholics). Logistic regression analysis indicated that participants with low level of NLR (adjusted OR 5.543, 95% CI 2.964–10.368, P<0.001), LMR (adjusted OR 9.256, 95% CI 4.740–18.076, P<0.001), and PLR (adjusted OR 6.047, 95% CI 3.372–10.845, P<0.001), and ALDH2 G/A genotype (adjusted OR 6.323, 95% CI 2.477–16.140, P<0.001) had a significantly higher risk of ALC.

Conclusion

ALDH2 polymorphism rs671 *1/*2 genotype is a potential risk factor for the development of ALC among Hakka alcoholics.

Prognostic value of neutrophil-to-lymphocyte ratio in cirrhosis patients undergoing transjugular intrahepatic portosystemic shunt

BACKGROUND AND AIMS

The neutrophil-to-lymphocyte-ratio (NLR) is used as an inflammatory index and has proven to be an accurate prognostic indicator for decompensated cirrhotics; however, its role in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) has not been evaluated. We examined whether NLR is associated with mortality in decompensated cirrhosis patients undergoing TIPS.

METHODS

We performed a retrospective review of 268 decompensated cirrhotics who underwent TIPS from January 2011 to December 2015 at an academic medical center. NLR, patient demographics, manifestations of cirrhosis, TIPS indications and mortality were recorded. Univariate and multivariate Cox regression analyses for prognostic factors associated with 30-day and 90-day post TIPS mortality were performed.

RESULTS

A total of 129 (48%) patients received TIPS for refractory ascites with 79 (29%) for variceal bleeding, 14 (5%) for hepatic hydrothorax, and 46 (17%) for other indications. Cirrhosis etiology included hepatitis C (36%), alcohol (28%), nonalcoholic steatohepatitis (20%), or other (15%). Median NLR was 4.42 (IQR 2.75-7.19). Univariate and multivariate analysis showed NLR as an independent predictive factor of 30-day and 90-day mortality. Furthermore, in patients with a Model of End-Stage Liver Disease (MELD) ≤ 15, NLR is superior to MELD/MELD-Na score in predicting 30-day and 90-day mortality. In patients with MELD > 15, MELD/MELD-Na score is superior to NLR.

CONCLUSION

Our data indicate that elevated NLR independently predicts 30-day and 90-day mortality. In patients with a MELD ≤ 15, NLR is a better prognostic factor than MELD or MELD-Na in predicting short-term mortality.

Neutrophils as potential therapeutic targets in hepatocellular carcinoma

The success of atezolizumab plus bevacizumab treatment contributed to a shift in systemic therapies for hepatocellular carcinoma (HCC) towards combinations that include cancer immunotherapeutic agents. Thus far, the principal focus of cancer immunotherapy has been on interrupting immune checkpoints that suppress antitumour lymphocytes. As well as lymphocytes, the HCC environment includes numerous other immune cell types, among which neutrophils are emerging as an important contributor to the pathogenesis of HCC. A growing body of evidence supports neutrophils as key mediators of the immunosuppressive environment in which some cancers develop, as well as drivers of tumour progression. If neutrophils have a similar role in HCC, approaches that target or manipulate neutrophils might have therapeutic benefits, potentially including sensitization of tumours to conventional immunotherapy. Several neutrophil-directed therapies for patients with HCC (and other cancers) are now entering clinical trials. This Review outlines the evidence in support of neutrophils as drivers of HCC and details their mechanistic roles in development, progression and metastasis, highlighting the reasons that neutrophils are well worth investigating despite the challenges associated with studying them. Neutrophil-modulating anticancer therapies entering clinical trials are also summarized.

Lipid Profiles as Markers for the Severity of Liver Diseases in Cirrhotic Patients

Background

Liver cirrhosis is a diffuse process in which the anatomical structure and function of the liver are disturbed. Lipid metabolism occurs mainly in the hepatocytes. In liver cirrhosis, it is expected to detect abnormal lipid profile and abnormal neutrophil to lymphocyte ratio due to necro-inflammation and hepatocyte dysfunction. This study aimed to estimate the lipid profile in patients with liver cirrhosis and to assess its relation to the severity of the liver disease based on Child-Pugh Turcotte score and Neutrophil to Lymphocyte Ratio (NLR).

Methods:

This study included 500 cirrhotic patients. All patients are subjected to history taking, clinical examination, liver and renal function tests, lipid profile, and also abdomino-pelvic ultrasound. Child -Pugh score, fibrosis-4 score (FIB4), and neutrophil and platelet lymphocyte ratio were calculated.

Results:

A total of 500 patients were enrolled in this study; 12 patients were excluded (two patients were on the immunosuppressive drug, three patients had body mass index (BMI) >30, and seven patients took lipid-lowering drugs). Cholesterol level was significantly higher in patients with Child- Score A than B and C. Cholesterol, Low-Density Lipoprotein (LDL), and very-low-density lipoprotein (VLDL) cholesterol were significantly higher in Child B than C. A significant negative correlation was found between cholesterol level and each of FIB4 and NLR ratios.

Conclusion:

There was a significant negative correlation between the severity of liver cirrhosis and lipid profiles (except triglyceride), FIB4 and NLR ratio.

Association between preoperative neutrophil-lymphocyte ratio and mortality after plastic and reconstructive surgery

Predictive factors associated with postoperative mortality have not been extensively studied in plastic and reconstructive surgery. Neutrophil-lymphocyte ratio (NLR), a systemic inflammation index, has been shown to have a predictive value in surgery. We aimed to evaluate association between preoperative NLR and postoperative outcomes in patients undergoing plastic and reconstructive surgery. From January 2011 to July 2019, we identified 7089 consecutive adult patients undergoing plastic and reconstructive surgery. The patients were divided according to median value of preoperative NLR of 1.84. The low NLR group was composed of 3535 patients (49.9%), and 3554 patients (50.1%) were in the high NLR group. The primary outcome was mortality during the first year, and overall mortality and acute kidney injury were also compared. In further analysis, outcomes were compared according to quartile of NLR, and a receiver operating characteristic curve was constructed to estimate the threshold associated with 1-year mortality. This observational study showed that mortality during the first year after plastic and reconstructive surgery was significantly increased in the high NLR group (0.7% vs. 3.5%; hazard ratio, 4.23; 95% confidence interval, 2.69-6.63; p < 0.001), and a graded association was observed between preoperative NLR and 1-year mortality. The estimated threshold of preoperative NLR was 2.5, with an area under curve of 0.788. Preoperative NLR may be associated with 1-year mortality after plastic and reconstructive surgery. Further studies are needed to confirm our findings.

Neutrophil/lymphocyte, platelet/lymphocyte and monocyte/lymphocyte ratios in mood disorders

Major depressive disorder (MDD) and bipolar disorders (BDs), the most severe types of mood disorders (MDs), are considered as among the most disabling illnesses worldwide. Several studies suggested that inflammatory neuroinflammation might be involved in the pathophysiology of MDs, while reporting increasing data on the relationships between these processes and classical neurotransmitters, hypothalamus-pituitary-adrenal axis (HPA), and neurotrophic factors. The assessment of neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR) and monocyte/lymphocyte ratio (MLR) in peripheral blood represents a simple method to evaluate the inflammatory status. The aim of the present paper was to review the literature on the possible relationships between NLR, PLR and MLR in MDs, and to comment on their possible wider use in clinical research. Thirty-five studies were included in the present review. The majority of them higher values of these parameters, particularly NLR values, in patients with MDs, when compared to healthy subjects. The increase would appear more robust in patients with BD during a manic episode, thus indicating that it could be considered as both state and trait markers. In addition, increased NLR and PLR levels seem to represent prognostic elements for the early discovery of post-stroke depression. The findings of the present review would indicate the need to carry our further studies in this field. In particular, NLR, PLR and MLR seem to be promising tools to detect economically and easily the activation of the inflammatory system, and to perhaps evaluate the etiology and course of MDs. Again, they could suggest some information to better understand the relationship between inflammatory and cardiovascular disease and MDs, and thus, to provide clinical implications in terms of management and treatment.

Baseline Neutrophil-to-Lymphocyte Ratio Is Independently Associated With 90-Day Transplant-Free Mortality in Patients With Cirrhosis

Background: Patients with cirrhosis have an increased risk of short-term mortality, however, few studies quantify the association between neutrophil-to-lymphocyte ratio (NLR) and 90-day transplant-free mortality in cirrhotic patients.

Methods: We prospectively analyzed 3,970 patients with chronic liver diseases from two multicenter cohorts in China (January 2015 to December 2016 and July 2018 to January 2019). Restricted cubic splines (RCS) were used to analyze the relation of NLR and all-causes 90-day transplant-free mortality in cirrhosis.

Results: A total of 2,583 cirrhotic patients were enrolled in our study. Restricted cubic splines showed that the odds ratio (OR) of all causes 90-day transplant-free mortality started to increase rapidly until around NLR 6.5, and then was relatively flat (p for non-linearity <0.001). The risk of 90-day transplant-free mortality in cirrhotic patients with NLR < 6.5 increased with an increment of 23% for every unit increase in NLR (p < 0.001). The patients with NLR < 4.5 had the highest risk (OR: 2.34, 95% CI 1.66–3.28). In multivariable-adjusted stratified analyses, the increase in the incidence of 90-day transplant-free mortality with NLR increasing was consistent (OR >1.0) across all major prespecified subgroups, including infection group (OR: 1.04, 95% CI 1.00–1.09) and non-infection (OR: 1.06, 95% CI 1.02–1.11) group. The trends for NLR and numbers of patients with organ failure varied synchronously and were significantly increased with time from day 7 to day 28.

Conclusions: We found a non-linear association between baseline NLR and the adjusted probability of 90-day transplant-free mortality. A certain range of NLR is closely associated with poor short-term prognosis in patients with cirrhosis.

NEUTROPHIL-LYMPHOCYTE RATIO PREDICTS SHORT-TERM MORTALITY IN PATIENTS HOSPITALIZED FOR ACUTE DECOMPENSATION OF CIRRHOSIS

BACKGROUND

Individuals with cirrhosis have a chronic systemic inflammation associated with an immune dysfunction, affecting the progression of the liver disease. The neutrophil-lymphocyte ratio (NLR) was proposed as a marker of systemic inflammatory response and survival in patients with cirrhosis.

OBJECTIVE

Evaluate the prognostic role of NLR in cirrhotic patients and its relation with inflammatory cytokines(IL-6, IL-10 and IL-17).

METHODS

In this prospective study two groups were evaluated: 1) Stable cirrhotic in outpatient follow-up (n=193); 2) Hospitalized cirrhotic for acute decompensation for at least 48 hours (n=334) with admission and 48 hours tests evaluation. Circulating inflammatory cytokines were available for 130 hospitalized patients.

RESULTS

In outpatients with stable cirrhosis, NLR correlated with MELD score and other variables associated with severity of disease. However, after a median of 32 months of follow up NLR was not associated with mortality (HR 1.058, 95%CI 0.900-1.243; P=0.495). In hospitalized patients, NLR at 48-hour after admission was independently associated with 90-day survival (HR 1.061, 95%CI 1.020-1.103; P=0.003) in multivariate Cox-regression analysis. The 90-day Kaplan-Meier survival probability was 87% for patients with a 48-hour NLR <3.6 and 62% for NLR ≥3.6 (P<0.001). Elevation of NLR in the first 48 hours was also independently associated with mortality (HR 2.038, 95%CI 1295-3207; P=0.002). The 90-day Kaplan-Meier survival probability was 83% when NLR did not increase and 62% when NLR increased (P<0.001). IL-6, IL-10 and IL-17 at admission were positively correlated with both admission and 48-hour NLR. Lower levels of baseline IL-10 were associated with NLR increase during first 48-hour.

CONCLUSION

NLR evaluated at 48 hours of hospitalization and its early increase after admission were independently associated with short-term mortality in patients hospitalized for acute decompensation of cirrhosis.

Neutrophil-to-Lymphocyte Ratio and Treatment Failure in Peritoneal Dialysis-Associated Peritonitis

Objective: We sought to explore if there is an association between neutrophil-to-lymphocyte ratio (NLR) and treatment failure in patients with peritoneal dialysis-associated peritonitis (PDAP).

Methods: Our cohort involved 337 episodes of PDAP experienced by 202 patients who were undergoing continuous ambulatory peritoneal dialysis at a single center from 1 July 2013 to 30 June 2018. The exposures were log-transformed NLR and a categorical variable grouped by the tertiles of NLR levels (T1, <3.75; T2, 3.75–6.53; and T3, >6.53) at baseline. Generalized estimating equation (GEE) and restricted cubic spline (RCS) analyses were done to determine the association between NLR and treatment failure, defined as catheter removal or all-cause mortality during therapy.

Results: After adjusting for other potential predictors, the log-transformed NLR exhibited an incremental relationship with the risk of treatment failure (odds ratio, 1.82; 95% confidence interval, 1.05–3.15). RCS analyses showed that the relationship was positively and linearly correlated (P for nonlinearity = 0.104). As a three-level categorical variable, in reference to T1, the T3 of NLR showed a 3.41-fold increased venture of treatment failure in fully adjusted model. Subgroup analyses suggested that the prognostic relevance of NLR in PDAP was particularly significant in gram-negative peritonitis.

Conclusions: A greater level of NLR at baseline was remarkably associated with a higher incidence of treatment failure among PDAP episodes regardless of other potential risk factors.

Two Faces of Neutrophils in Liver Disease Development and Progression

Neutrophils, the most abundant type of leukocyte in human blood, play a major role in host defense against invading pathogens and in sterile injury. Neutrophil infiltration is characteristic of inflammation because of its antimicrobial and cytotoxic activities. Neutrophils also actively participate in the resolution of inflammation and subsequent tissue repair by acting as a critical mediator between the inflammation and resolution phases of tissue damage. However, neutrophils that are consistently exposed to inflammatory conditions lose their self-resolving capabilities and maintain an inflammatory phenotype, further exacerbating tissue damage. The current review describes how neutrophils interact with tissue microenvironments and acquire disease-specific phenotypes under chronic inflammatory conditions. Here, we aim to provide a better understanding of neutrophil-mediated pathogenesis of various liver diseases.

Recompensation factors for patients with decompensated cirrhosis: a multicentre retrospective case-control study

OBJECTIVES

We aimed to evaluate recompensation factors among patients with decompensated cirrhosis.

DESIGN

A multicentre retrospective case-control study was conducted. Data were collected from and compared between groups of patients with recompensated and acute decompensated cirrhosis. Univariable and multivariable logistic regressions were used to select indicators associated with recompensation among patients with decompensated cirrhosis with different complications. A decision tree with 10-fold cross-validation was used to develop the model to identify patients with recompensation. We followed the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guideline for development and reporting of the new model.

SETTING

The study was conducted in six tertiary public hospitals in Chongqing, China.

PARTICIPANTS

This study included 3953 patients with decompensated cirrhosis.

RESULTS

In the total sample of included patients, there were 553 patients with recompensation and 3400 patients with acute decompensation, including 1158 patients with gastrointestinal bleeding, 1715 patients with a bacterial infection, 104 patients with hepatic encephalopathy and 423 patients with ascites. The most relevant indicator of recompensation selected by the decision tree model was albumin, with a threshold of 40 g/L. Total protein, haemoglobin, basophil percentage, alanine aminotransferase, neutrophil-to-lymphocyte ratio and diabetes were also selected to subsequently distinguish patients. The terminal nodes with a probability of recompensation was 0.89. The overall accuracy rate of the model was 0.92 (0.91-0.93), and it exhibited high specificity (86.9%) and sensitivity (92.6%).

CONCLUSIONS

The occurrence of recompensated cirrhosis could be identified by albumin, total protein, haemoglobin, basophil percentage, alanine aminotransferase, neutrophil-to-lymphocyte ratio and diabetes. These simple variables may help clinicians develop a treatment plan to encourage patients with decompensated cirrhosis to recompensate.

Serum C-reactive protein and neutrophil-to-lymphocyte ratio as predictors of survival in cirrhotic patients with systemic inflammatory response syndrome and bacterial infection

BACKGROUND

Cirrhotic patients are prone to infections due to underlying immune dysfunction in them. We aimed to study the role of inflammatory markers, serum C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR), in predicting infection, blood culture positivity, and short-term (1 month) mortality in hospitalized cirrhotic patients.

METHODS

This prospective study was done over a period of 14 months (October 2017 to November 2018). Patient data included age, gender, etiology of cirrhosis, reason for admission, and comorbidity. Laboratory tests included blood chemistry and blood cell counts, and blood and urine culture. The specific tests included were CRP and NLR. Survival of patients in the following 1 month was noted. Area under receiver operating characteristic curve (AUROC), sensitivity, specificity, predictive values, diagnostic accuracy were calculated and logistic regression analysis performed. A p-value < 0.05 was considered significant.

RESULTS

Two hundred and eight patients formed the study cohort. The median age was 51.5 years and male predominance was noted. Alcohol-related liver disease (49%) was the commonest etiology. The infection rate was 62%, culture positivity was 58.5%, and mortality was 30.8%. NLR and CRP were significantly higher in those with documented infection (culture positive or negative) and among nonsurvivors. Optimal cutoffs for NLR and CRP to predict infection were 5.86 and 33.7, respectively. The risk of having an infection was 7.5 times and about 15 times if NLR and CRP were above the cutoffs. The risk of 1-month mortality was 2-3 times higher if patients had NLR and CRP above the cutoffs. The combination of NLR and CRP (≥ 5.86 and ≥ 33.7, respectively) increased specificity and diagnostic accuracy for infection.

CONCLUSION

NLR and CRP were independently good predictors of infection and 1-month survival among the patients with cirrhosis of liver included in this study.

Higher Frequency of Fish Intake May Be Associated with a Lower Neutrophil/Lymphocyte Ratio: Anti-Atherosclerotic Effects of Fish Consumption

BACKGROUND

Higher fish consumption has been reported to be associated with a lower incidence of coronary artery disease (CAD). An elevated neutrophil/lymphocyte ratio (NLR), a marker of systemic inflammation, is reportedly associated with the development of adverse CAD events. We hypothesized that a higher fish intake was associated with a lower NLR.

METHODS AND RESULTS

This cross-sectional study was conducted in a cohort of 8,237 Japanese subjects who had no history of atherosclerotic cardiovascular disease registered at the Health Planning Center of Nihon University Hospital between April 2018 and March 2019. The average weekly frequency of fish intake was 2.32 ± 1.31 days. The NLR decreased significantly as the weekly frequency of fish intake (0 day, 1-2 days, 3-4 days, or 5-7 days) increased (p = 0.001). A multiple stepwise regression analysis identified the weekly frequency of fish intake (β = -0.045, p < 0.0001) and habitual alcohol intake (β = -0.051, p < 0.0001) as significant but weak, negative, and independent determinants of the NLR. Conversely, the presence of metabolic syndrome (β = 0.046, p < 0.0001), the presence of treatment for diabetes mellitus (β = 0.054, p < 0.0001), and the presence of treatment for hypertension (β = 0.043, p < 0.0001) were significant positive and independent determinants of the NLR.

CONCLUSIONS

The present results suggest that a higher frequency of fish intake appears to be associated with a lower NLR, suggesting an anti-systemic inflammation effect. This association may partially explain the preventive effects of a higher fish intake on CAD events.

Mean Platelet Ratio, Neutrophil to Lymphocyte Ratio, and the Risk of Febrile Seizures in Children Aged 6–59 Months

BACKGROUND: The occurrence of febrile seizure is affected by numerous factors, but some studies indicated that inflammatory cytokines might contribute to the development of febrile seizure. In resource limited settings, complete blood count (CBC) might serve as potential indices for inflammatory response. AIM: The aim of the present study was to determine the role of mean platelet ratio and neutrophil to lymphocyte ratio (NLR) on the risk of febrile seizures in children aged 6–24 months and 25–59 months at S.K. Lerik Regional Public Hospital in Kupang City, East Nusa Tenggara, Indonesia. METHODS: A case-control study was carried out in 104 patients (52 in the case group and 52 in the control group) aged 6–59 months. The CBC tests were taken on the first visit in the emergency room at S.K. Lerik Regional Public Hospital. RESULTS: Our study found that the odds for experiencing febrile seizure in younger children aged 6–24 months were 3.281 (95% confidence interval 1.470, 7.324) times as large as the odds for older children aged 25–59 months. There was a significant but weak correlation between the types of febrile seizure or fever and age of children (r = 0.279; p = 0.012). CONCLUSIONS: Children aged 6–24 months had higher risk of developing febrile seizure, compared to children aged 25–59 months. Further, for each unit decrease in NLR, we expected a 0.883 decrease in the odds for febrile seizures in the case group, compared to control group.

Association between neutrophil-lymphocyte ratio change during living donor liver transplantation and graft survival

Preoperative neutrophil-lymphocyte ratio (NLR), has shown a predictive value in living donor liver transplantation (LDLT). However, the change in the NLR during LDLT has not been fully investigated. We aimed to compare graft survival between the NLR increase and decrease during LDLT. From June 1997 to April 2019, we identified 1292 adult LDLT recipients with intraoperative NLR change. The recipients were divided according to NLR change: 103 (8.0%) in the decrease group and 1189 (92.0%) in the increase group. The primary outcome was graft failure in the first year. In addition, variables associated with NLR change during LDLT were evaluated. During 1-year follow-up, graft failure was significantly higher in the decrease group (22.3% vs. 9.1%; hazard ratio 1.87; 95% confidence interval 1.10-3.18; p = 0.02), but postoperative complications did not differ between two groups. This finding was consistent for the overall follow-up. Variables associated with NLR decrease included preoperative NLR > 4, model for end-stage liver disease score, intraoperative inotropic infusion and red blood cell transfusion, and operative duration. The least absolute shrinkage and selection operator model yielded similar results. NLR decrease during LDLT appeared to be independently associated with graft survival. Further studies are needed to confirm our findings.

Neutrophil-to-Lymphocyte Ratio and Albumin: New Serum Biomarkers to Predict the Prognosis of Male Alcoholic Cirrhosis Patients

Background and Aims

Alcohol-associated liver disease is exhibiting an increasing disease burden. In terms of pathogenesis, inflammation is closely related to alcohol-induced liver injury. The neutrophil-to-lymphocyte ratio (NLR) is a novel inflammatory biomarker. Here, we aim to evaluate the role of the NLR and other biomarkers in predicting short-term mortality in alcoholic cirrhotic patients.

Methods

This was a retrospective study that included 459 male alcoholic cirrhosis patients. Among them, 345 patients completed follow-up. Based on their 30-day mortality information, patients were separated into surviving and nonsurviving groups. Demographic, clinical, and biochemical features were collected for further analysis. Logistic regression was used to identify factors associated with short-term mortality, and receiver operating characteristic (ROC) curve analysis was used to establish the predictive value of these factors.

Results

The prognostic scores were significantly higher in the nonsurviving group than in the surviving group: NLR: 5.5 vs. 3.2 (P < 0.001), model for end-stage liver disease (MELD): 15.4 vs. 7.9 (P < 0.001), Maddrey's discriminant function (MDF): 39.8 vs. 12.7 (P < 0.001), and the integrated MELD (i-MELD): 37.9 vs. 28.4 (P < 0.001). Logistic regression demonstrated that albumin (ALB), NLR, and i-MELD values were significantly correlated with patient death in 30 days. On ROC analysis, the diagnostic accuracy for 30-day mortality of the NLR (area under the ROC curve (AUROC) of 0.72, P < 0.001) was similar to that of the MELD or i-MELD (AUROCs of 0.71 and 0.74, respectively, P < 0.001). The new biomarker, NLA, calculated as 100 × NLR/ALB, had the best prognostic value. The cutoff values of the NLR and NLA for predicting 30-day mortality were 4.2 and 19.6, respectively.

Conclusions

The NLR and its related biomarker NLA are simple and robust predictors of 30-day mortality in alcoholic cirrhosis patients.

Lymphocyte-to-monocyte ratio predicts mortality in cirrhotic patients with septic shock

INTRODUCTION

Patients with liver cirrhosis and septic shock have a significantly higher risk of mortality and morbidity compared with non-cirrhotic patients. The peripheral blood lymphocyte-to-monocyte ratio (LMR) can determine the prognosis of cirrhotic patients. Our study aimed to investigate the usefulness of LMR as a predictive marker of mortality risk in cirrhotic patients with septic shock.

METHODS

This single-center, retrospective case-control study included adult patients who visited the emergency department between January 1, 2018 and June 30, 2020 and diagnosed with liver cirrhosis and septic shock. They were divided into survivor and non-survivor groups according to their survival status at the 60-day follow-up. We used a Cox proportional hazards regression model to identify independent factors associated with mortality risk and tested the mortality discriminative ability of those factors using the area under a receiver operating characteristic curve.

RESULTS

A total of 93 patients were eligible for this study. Compared with the patients in the survivor group, those in the non-survivor group had significantly higher Child-Pugh (11 ± 2 vs. 9 ± 2, p < 0.001) and MELD scores (29 ± 6 vs. 22 ± 8, p < 0.001), higher serum international normalized ratio (1.7 vs.1.4, p = 0.03), bilirubin (6.0 vs. 3.3 mg/dL, p = 0.02), lactate (5.4 vs. 2.7 mmol/L, p < 0.01), creatinine (2.2 vs. 1.6 mg/dL, p = 0.04), higher neutrophil-to-lymphocyte ratio (13.0 vs. 10.3, p = 0.02), and lower LMR (1.1 vs. 2.3, p < 0.01). The LMR (adjusted hazard ratio [aHR] = 1.54, p = 0.01) and lactate (aHR = 1.03, p < 0.01) were identified as independent predictive factors for mortality in the multivariate regression model. Furthermore, LMR (area under curve [AUC]: 0.87) revealed a superior discrimination ability in mortality prediction compared with the Child-Pugh (AUC: 0.72) and MELD (AUC: 0.76) scores.

CONCLUSIONS

The LMR can be used to predict mortality risk in cirrhotic patients with septic shock.

Towards an evaluation of alcoholic liver cirrhosis and nonalcoholic fatty liver disease patients with hematological scales

BACKGROUND

Seeking potentially novel blood markers of liver fibrosis and steatosis is constantly of crucial importance. Despite a growing number of studies in this field of hepatology, a certain role of hematological indices in the course of liver disorders has not been fully elucidated, yet.

AIM

To evaluate a diagnostic accuracy of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and mean platelet volume-to-platelet-ratio (MPR) in the course of alcoholic liver cirrhosis (ALC) and nonalcoholic fatty liver disease (NAFLD).

METHODS

One hundred forty-two patients with ALC, 92 with NAFLD and 68 persons in control group were enrolled in the study. Hematological indices (NLR, PLR and MPR), indirect and direct markers of liver fibrosis (aspartate transaminase to alkaline transaminase ratio, aspartate transaminase to platelet ratio index, fibrosis-4, gamma-glutamyl transpeptidase to platelet ratio, procollagen I carboxyterminal propeptide, procollagen III aminoterminal propeptide, transforming growth factor-α, platelet-derived growth factor AB, laminin) were measured in each person. Model for end-stage liver disease (MELD) score in ALC group and NAFLD fibrosis score together with BARD score were calculated in NAFLD patients. Receiver operating characteristic (ROC) curves and area under the curve (AUC) values were applied to assess the sensitivity and specificity of examined markers and to evaluate proposed cut-offs of measured indices in the course of ALC and NAFLD.

RESULTS

MPR and NLR values in ALC patients were significantly higher in comparison to control group; PLR level was significantly lower. MPR and PLR correlated with assessed indirect and direct markers of liver fibrosis. MPR, NLR and PLR correlated with MELD score. NLR level in NAFLD patients was significantly higher in comparison to controls. MPR correlated with indirect markers of liver fibrosis and NAFLD fibrosis score. AUC values and proposed cut-offs for NLR, PLR and MPR in ALC patients were: 0.821 (> 2.227), 0.675 (< 70.445) and 0.929 (> 0.048), respectively. AUC values and proposed cut-offs for NLR, PLR and MPR in NAFLD group were: 0.725 (> 2.034), 0.528 (> 97.101) and 0.547 (> 0.038), respectively.

CONCLUSION

Hematological markers are inseparably connected with serological indices of liver fibrosis in ALC and NAFLD patients. MPR and NLR turned out to be the most powerful parameters in ALC patients.

Role of systemic immune-inflammation index in asthma and NSAID-exacerbated respiratory disease

OBJECTIVE

Asthma is a heterogeneous disease characterized by chronic progressive airway inflammation. Although the disease has numerous phenotypes, there are no practical biomarkers for distinguishing the phenotypes from one another. To address this challenge, we aimed to reveal whether the systemic immune-inflammation index (SII), an important indicator of systemic inflammation and prognosis in various malignancies and vasculitis, can be used for distinguishing between asthma and NSAID-exacerbated respiratory disease (NERD).

METHODS

The study enrolled 105 patients (asthma: n = 69; NERD: n = 36). SII was calculated using the formula of neutrophil X platelet/lymphocyte number. Major risk factors, namely ACT score, eosinophil level, total IgE level, N-L ratio (NLR), P-L ratio (PLR), and SII, were evaluated by logistic regression analysis.

RESULTS

No significant differences were found between the clinical features of the two study groups. Patients with an SII value ≥895.6 had a probability of having NERD with a sensitivity of 30.56%, whereas those with a lower SII had a probability of having asthma with a sensitivity of 92.65%. In the logistic regression analysis, no risk factor was determined for identifying asthma or NERD. The N-L ratio was found to be the risk factor affecting categorized SII (OR = 264.2, 95% CI 9.9-7046.5, P = 0.001).

CONCLUSION

This is the first study to evaluate SII as a tool for differentiating asthma phenotypes. The presence of SII below the cutoff value can help exclude the diagnosis of NERD. There is a need for large-scale prospective studies to compare different phenotypes and determine the optimal cutoff value.

Prognostic value of neutrophil-to-lymphocyte ratio in cirrhotic patients with acute-on-chronic liver failure

BACKGROUND/AIMS

Patients with cirrhosis hospitalized in the intensive care unit (ICU) have a high risk for acute-on-chronic liver failure (ACLF) and short-term mortality. A major factor in the pathogenesis of ACLF is systemic inflammation, the assessment of which includes the use of surrogate markers, such as neutrophil-to-lymphocyte ratio (NLR). This study aimed to assess the accuracy of NLR in predicting the outcome of patients with cirrhosis and ACLF hospitalized in the ICU.

MATERIALS AND METHODS

This was a retrospective observational study on patients with cirrhosis with acute decompensation hospitalized in the ICU of a Romanian tertiary care center. ACLF was defined according to the CANONIC criteria, and NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count.

RESULTS

A total of 70 patients were included, of whom 70% were men with a mean age of 62±6.2 years. ACLF was diagnosed in 58 (82.9%) patients who presented with higher in-hospital mortality rates than patients without ACLF (84.5% vs. 33.3%, p=0.001). The mean NLR value was 11.7±9.5, higher in non-survivors than in survivors (12.6±9.8 vs. 8.6±7.8, p=0.170). NLR had a poor accuracy in predicting the outcome in patients without ACLF (area under the curve [AUC]=0.611) but a better accuracy in patients with ACLF (AUC=0.776). Patients with cirrhosis and a high NLR had higher levels of bilirubin; higher Child-Turcotte-Pugh score; and higher incidence of ascites, coagulation, and circulatory failure, presenting a poor outcome. Receiver operating characteristic analysis showed a good accuracy for predicting mortality for the Child-Turcotte-Pugh score (AUC= 0.864) and NLR (AUC=0.732).

CONCLUSION

NLR is a promising and cost-effective method for the prediction of a poor outcome in critically ill patients with cirrhosis hospitalized in the ICU and shows greater accuracy in those with ACLF.

Leucocyte ratios are biomarkers of mortality in patients with acute decompensation of cirrhosis and acute-on-chronic liver failure

BACKGROUND

In patients with cirrhosis, progression to acute decompensation (AD) and acute-on-chronic liver failure (ACLF) has been associated with poor prognosis. Differential leucocyte ratios might predict mortality in systemic inflammatory conditions.

AIM

To evaluate differential leucocyte ratios as prognostic biomarkers in patients with cirrhosis.

METHODS

Patients with AD and ACLF were recruited from four centres in three countries. Peripheral blood differential leucocytes were measured (three centres using flow cytometry) on hospital admission and at 48 hours. Ratios were correlated to model for end-stage liver disease (MELD), chronic liver failure-sequential organ failure (CLIF-SOFA), suspected/culture-positive bacterial infection and survival.

RESULTS

Nine hundred twenty-six patients (562 (61%) male, median age 55 (25-94) years) were studied. Overall, 350 (37%) did not survive to hospital discharge. Neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR) were elevated in patients with AD and ACLF who died during their hospital stay. On multivariate analysis NLR retained statistical significance independently of CLIF-SOFA or MELD. NLR >30 was associated with an 80% 90-day mortality in patients with ACLF but not AD. On sensitivity analysis for subgroups (alcohol-related liver disease and suspected sepsis), NLR and MLR retained statistically robust accuracy for the prediction of mortality. Significant predictive accuracy was only observed in centres using flow cytometry.

CONCLUSION

Leucocyte ratios are simple and robust biomarkers of outcome in ACLF, which are comparable to CLIF-SOFA score but dependent on leucocyte quantification method. NLR and MLR may be used as screening tools for mortality prediction in patients with acutely deteriorating cirrhosis.

Living Donor Liver Transplantation in Children: Perioperative Risk Factors and a Nomogram for Prediction of Survival

BACKGROUND

Living donor liver transplantation (LDLT) in children has achieved promising outcomes during the past few decades. However, it still poses various challenges. This study aimed to analyze perioperative risk factors for postoperative death in pediatric LDLT.

METHODS

We retrospectively analyzed medical records of pediatric patients who underwent LDLT surgery from January 1, 2014, to December 31, 2016, in our hospital. Predictors of mortality following LDLT were analyzed in 430 children. Cox regression and Kaplan-Meier curve analysis were used for covariates selection. A nomogram was developed to estimate overall survival probability. The performance of the nomogram was assessed using calibration curve, decision curve analysis, and time-dependent receiver operating characteristic curve.

RESULTS

Among the 430 patients in this cohort (median [interquartile range] age, 7 [6.10] mo; 189 [43.9%] female; 391 [90.9%] biliary atresia), the overall survival was 91.4% (95% confidence interval, 89.2-94.4), and most of the death events (36/37) happened within 6 months after the surgery. Multivariate analysis indicated that the Pediatric End-stage Liver Disease score, neutrophil lymphocyte ratio, graft-to-recipient weight ratio, and intraoperative norepinephrine infusion were independent prognostic factors. A novel nomogram was developed based on these prognostic factors. The C index for the final model was 0.764 (95% confidence interval, 0.701-0.819). Decision curve analysis and time-dependent receiver operating characteristic curve suggested that this novel nomogram performed well at predicting mortality of pediatric LDLT.

CONCLUSIONS

We identified several perioperative risk factors for mortality of pediatric LDLT. And the newly developed nomogram can be a convenient individualized tool in estimating the prognosis of pediatric LDLT.

Can Hematological Inflammatory Parameters Predict Mortality in Hepatocellular Carcinoma?

PURPOSE

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors. Inflammatory and hematological parameters such as neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) provided useful information especially in the diagnosis, treatment, and follow-up of malignancies. In this study, we planned to demonstrate the efficacy of NLR and PLR levels in the evaluation of the prognosis of patients with HCC in our clinic.

MATERIAL AND METHODS

This study was planned as a prospective observational cohort study. The study included 105 patients with HCC on the base of cirrhosis. Our study group was classified according to Barcelona Clinic Liver Cancer (BCLC), Okuda staging system, and Milan criteria at the time of admission.

RESULTS

The mean age of all cases was 60.6 ± 12.4 years, and 77 (73.3%) of the patients were male. The mean life expectancy of all patients was 7.7 ± 4.3 months. During 1-year follow-up, 61 (58.1%) HCC patients died. The mean survival of the patients who died was 4.6 ± 3.0 months. In our study, patients with NLR > 2.7, patients with PLR > 100.29, BCLC advanced stage, and Okuda advanced stage, and patients who did not meet the Milan criteria had shorter survival duration. NLR > 2.7, BCLC advanced stage, and Child C were determined as independent risk factors affecting mortality.

CONCLUSION

There was a strong correlation between NLR-PLR levels and mortality. PLR and NLR levels can be used in conjunction with other staging systems to regulate, monitor, and predict the survival of HCC patients.