Neutrophil-to-Lymphocyte Ratio Predicts Early Mortality in Patients with HBV-Related Decompensated Cirrhosis. Gastroenterol Res Pract. 2016;2016:4394650. [PMID: 26949385 PMCID: PMC4754485 DOI: 10.1155/2016/4394650]

Elevated neutrophil-to-hemoglobin ratio as an indicator of poor survival in hepatitis B virus-related decompensated cirrhosis

Aim: Our goal was to explore the prognostic value of the neutrophil-to-hemoglobin ratio (NHR) in HBV-related decompensated cirrhosis (HBV-DC) patients. Methods: 172 HBV-DC patients were enrolled. Multivariate analyses were used to identify risk factors influencing 30-day mortality. Results: The 30-day mortality was 12.8% (22/172). nonsurvivors exhibited a higher NHR than survivors. On multivariate analysis, NHR and model for end-stage liver disease (MELD) score were the only independent predictors of mortality. Notably, the predictive capabilities of NHR were found to be comparable to those of the MELD score. Conclusion: High NHR was associated with poor prognosis in HBV-DC patients, and NHR can serve as an effective and readily available indicator for the prediction of mortality in these patients.

The Value of Neutrophil-to-Lymphocyte Ratio to Identify Bacterial Infection and Predict Short-Term Mortality in Patients with Acutely Decompensated Cirrhosis

Liver cirrhosis patients are highly susceptible to infections, affecting survival, but current parameters for detecting infection are not reliable enough in this population. We investigated the ability of white blood cell (WBC), ∆WBC, neutrophil and ∆neutrophil counts, neutrophil-to-lymphocyte (NLR) and ∆NLR ratios and C-reactive protein (CRP) and procalcitonin (PCT) levels to identify infection and predict short-term mortality in liver cirrhosis patients. We recruited 233 patients with liver cirrhosis hospitalized with acute decompensation (AD) who had an outpatient visit within 1 month (baseline laboratory data) and followed them for 90 days. Difference between laboratory values at baseline and the AD episode was defined as delta (∆) values of the parameters. Delta values did not increase the diagnostic and predictive ability of investigated parameters. The CRP level was found to be the best diagnostic marker for infection in patients with cirrhosis. However, NLR seems to be superior for short-term mortality prediction, better than the WBC count. Distinguishing inflammations of different origin is a remaining clinical challenge in acutely decompensated cirrhosis. Based on our results, NLR might be more suitable for predicting short-term mortality in patients with AD than the WBC count currently included in the CLIF-C AD score.

Clinical Data based XGBoost Algorithm for infection risk prediction of patients with decompensated cirrhosis: a 10-year (2012-2021) Multicenter Retrospective Case-control study

OBJECTIVES

To appraise effective predictors for infection in patients with decompensated cirrhosis (DC) by using XGBoost algorithm in a retrospective case-control study.

METHODS

Clinical data were retrospectively collected from 6,648 patients with DC admitted to five tertiary hospitals. Indicators with significant differences were determined by univariate analysis and least absolute contraction and selection operator (LASSO) regression. Further multi-tree extreme gradient boosting (XGBoost) machine learning-based model was used to rank importance of features selected from LASSO and subsequently constructed infection risk prediction model with simple-tree XGBoost model. Finally, the simple-tree XGBoost model is compared with the traditional logical regression (LR) model. Performances of models were evaluated by area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity.

RESULTS

Six features, including total bilirubin, blood sodium, albumin, prothrombin activity, white blood cell count, and neutrophils to lymphocytes ratio were selected as predictors for infection in patients with DC. Simple-tree XGBoost model conducted by these features can predict infection risk accurately with an AUROC of 0.971, sensitivity of 0.915, and specificity of 0.900 in training set. The performance of simple-tree XGBoost model is better than that of traditional LR model in training set, internal verification set, and external feature set (P < 0.001).

CONCLUSIONS

The simple-tree XGBoost predictive model developed based on a minimal amount of clinical data available to DC patients with restricted medical resources could help primary healthcare practitioners promptly identify potential infection.

Evaluation of five lymphocyte-based scores for prediction of mortality in hepatitis B virus-associated decompensated cirrhosis

Background

Lymphocytes are generally accepted to be a key component of the immune response, and an inadequate immune response is closely associated with disease severity and adverse outcomes in hepatitis B virus (HBV)-infected patients. The present study aimed to determine and compare the prognostic values of five lymphocyte-based scores (monocyte-to-lymphocyte ratio [MLR], mean platelet volume-to-lymphocyte ratio [MPVLR], neutrophil-to-lymphocyte ratio [NLR], red cell distribution width-to-lymphocyte ratio [RLR], and C-reactive protein-to-lymphocyte ratio [CLR]) for HBV-associated decompensated cirrhosis (HBV-DC).

Methods

Data were extracted from an institutional database. The outcome was 30-day mortality. Receiver operating characteristic curve analyses were conducted, and the resulting area under the curve (AUC) values were used to evaluate the predictive capabilities of the five lymphocyte-based scores for mortality in HBC-DC relative to Model for End-Stage Liver Disease (MELD) score.

Results

The study included 273 patients, and the 30-day mortality was 20.9%. Lymphocyte counts were slightly lower in non-survivors than in survivors. The prognostic values of CLR, NLR, MLR, MPVLR, and RLR for mortality in HBV-DC were different. The predictive powers of NLR and MLR were superior to those of the other three scores and similar to that of MELD score. Multivariate analyses identified NLR, MLR, and MELD score as independent prognostic predictors.

Conclusion

High NLR and MLR are easily accessible and reliable indicators for predicting 30-day mortality in HBV-DC and have superior prognostic ability compared with other lymphocyte-based scores.

Psychometric tests, critical flicker frequency, and inflammatory indicators in covert hepatic encephalopathy diagnosis

Background and Aim

Hepatic encephalopathy (HE) is a frequent complication of liver diseases. Systemic inflammation is key for HE pathogenesis. The main goal of the study was to investigate the role of psychometric tests, critical flicker frequency (CFF), and comparative evaluation of inflammatory indicators for the diagnosis of covert HE (CHE).

Materials and Methods

The study was a prospective, nonrandomized, case-control study with a total of 76 cirrhotic patients and 30 healthy volunteers. The West Haven criteria were used to determine the occurrence of CHE in cirrhotic patients. Psychometric tests were applied to healthy and cirrhotic groups. CFF, venous ammonia, serum endotoxin, IL-6, IL-18, tumor necrosis factor alpha (TNF-α) levels, and hemogram parameters were evaluated for cirrhotic patients.

Results

CFF values and psychometric tests were found to accurately discriminate CHE positives from CHE negatives (p<0.05). When the control group was excluded, the digit symbol test and the number connection A test failed, unlike CFF and other psychometric tests. Using CFF, a 45 Hz cutoff value had 74% specificity and 75% sensitivity. Basal albumin levels (p=0.063), lymphocyte-to-monocyte ratio (LMR) (p=0.086), and neutrophil-to-lymphocyte ratio (p 0.052) were significant, albeit slightly, among CHE groups. Basal albumin levels had 50% sensitivity and 71% specificity when 2.8 g/dL was used as a cutoff value to determine CHE.

Conclusion

Both psychometric tests and CFF can be useful in diagnosing CHE. Using cytokine and endotoxin levels seems to be inadequate to diagnose CHE. Using LMR and albumin levels instead of psychometric tests for diagnosing CHE can be promising.

A potential novel inflammation biomarker for predicting the prognosis of decompensated liver cirrhosis

OBJECTIVE

This study aimed to explore the prognostic value of the lymphocyte (LYM)-to-white blood cell (WBC) ratio (LWR) in patients with decompensated liver cirrhosis (DLC).

METHODS

This study was conducted by recruiting 214 patients with DLC with different aetiologies (development cohort). Receiver operating characteristic (ROC) curve analyses were used to assess the predictive accuracy of the LWR, and Youden's index was used to determine the optimal cut-off values of the LWR based on the ROC curve. Next, patients were divided into high- and low-LWR groups according to the cut-off values. Multivariate logistic analyses were performed to determine the independent predictors for the 1-, 3- and 6-month mortality. Restricted cubic spline (RCS) was used to determine and visualize the association between LWR and the risk of death. We verified the predictive ability of LWR in the validation cohort of 139 patients.

RESULTS

In the development cohort, there were 16 (7.5%), 22 (10.3%) and 30 patients (14.0%) who died at 1, 3 and 6 months, respectively. The LWR was significantly lower in non-survivors than in survivors and was an independent predictor of poor outcomes. The ROC analyses with the Delong test showed that the LWR had comparable predictive power with the Model for End-Stage Liver Disease (MELD) score, neutrophil-to-LYM ratio (NLR) and Chronic Liver Failure consortium score for acute decompensated (CLIF-C ADs). RCS showed a non-linear relationship between the LWR and the risk of death at 1 and 3 months, whereas a linear relationship was observed between the LWR and the risk of death at 6 months. We verified that the decreased LWR was an independent predictor of adverse outcomes at 3-, and 6-month follow-up endpoints in the validation cohort.

CONCLUSIONS

Our findings indicate that a lower LWR is an independent factor for unfavourable outcomes and may serve as a potential novel prognostic predictor in patients with DLC.KEY MESSAGESThis study is the first report on the prognostic value of the lymphocyte (LYM)-to-white blood cell (WBC) ratio (LWR) in patients with decompensated liver cirrhosis (DLC).Decreased LWR is an independent factor for adverse outcomes in patients with DLC.

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.

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.

Potential plasma biomarkers: miRNA-29c, miRNA-21, and miRNA-155 in clinical progression of Hepatocellular Carcinoma patients

This study evaluated differences in the clinical appearance of patients with hepatocellular carcinoma (HCC) based on plasma level and regulation of microRNAs (miRNA-29c, miRNA-21, and miRNA-155). The observational-analytical study with a cross-sectional design was conducted on 36 HCC patients and 36 healthy controls. The blood samples were collected from 2 Province Hospitals (Dr. Sardjito Hospital and Prof. Dr. Margono Soekarjo Hospital) for HCC and the Blood Bank Donor of the Indonesian Red Cross for 36 healthy controls. These blood samples were treated as follows: plasma isolation, RNA isolation, cDNA synthesis, quantification by qRT-PCR using a sequence-specific forward primer, and normalization of miRNA using housekeeping-stably miRNA-16. There were only 27 HCC patients with complete clinical variables (neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), platelet count, albumin, C-reactive protein (CRP), and cholinesterase (ChE)) that were able to analyses for regulation miRNAs based on its fold change expression miRNA target. All 27 HCC subjects were follow-up until 3-years of monitoring for their overall survival. The miRNA plasma expression was analyzed by Bio-Rad CFX 96 Manager software to determine the cycle of quantification, followed by the calculation of expression levels using Livak’s methods. Data were analyzed using STATA 11.0, with a significant value of p<0.05. The miRNAs expression of HCC subjects were lower than that healthy control subjects in miRNA-29c (down-regulation 1.83-fold), higher than that healthy control subjects in miRNA 21 and miRNA-155 (up-regulation, 1.74-fold; 1.55-fold) respectively. NLR, CRP, ChE, and platelet count showed a significant difference in miRNA-29c regulation, though neutrophil count showed a significant difference in miRNA-21 and miRNA-155 regulation (p<0.05). Conclusion: Plasma biomarkers: miRNA-21 and miRNA-155 might be potential biomarkers as onco-miR in HCC subjects, while miRNA-29c might act as a tumor suppressor. Significant evidence was identified with clinical progression based on the regulation of miRNAs, which was consistent with miRNA -29c.

The Effect of TGF-β1 Reduced Functionality on the Expression of Selected Synaptic Proteins and Electrophysiological Parameters: Implications of Changes Observed in Acute Hepatic Encephalopathy

Decreased platelet count represents a feature of acute liver failure (ALF) pathogenesis. Platelets are the reservoir of transforming growth factor 1 (TGF-β1), a multipotent cytokine involved in the maintenance of, i.a., central nervous system homeostasis. Here, we analyzed the effect of a decrease in TGF-β1 active form on synaptic proteins levels, and brain electrophysiology, in mice after intraperitoneal (ip) administration of TGF-β1 antibody (anti-TGF-β1; 1 mg/mL). Next, we correlated it with a thrombocytopenia-induced TGF-β1 decrease, documented in an azoxymethane-induced (AOM; 100 mM ip) model of ALF, and clarified the impact of TGF-β1 decrease on blood–brain barrier functionality. The increase of both synaptophysin and synaptotagmin in the cytosolic fraction, and its reduction in a membrane fraction, were confirmed in the AOM mice brains. Both proteins’ decrease in analyzed fractions occurred in anti-TGF-β1 mice. In turn, an increase in postsynaptic (NR1 subunit of N-methyl-D-aspartate receptor, postsynaptic density protein 95, gephyrin) proteins in the AOM brain cortex, but a selective compensatory increase of NR1 subunit in anti-TGF-β mice, was observed. The alterations of synaptic proteins levels were not translated on electrophysiological parameters in the anti-TGF-β1 model. The results suggest the impairment of synaptic vesicles docking to the postsynaptic membrane in the AOM model. Nevertheless, changes in synaptic protein level in the anti-TGF-β1 mice do not affect neurotransmission and may not contribute to neurologic deficits in AOM mice.

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.

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.

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.

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.

Identification of exacerbation risk in patients with liver dysfunction using machine learning algorithms

The prediction of the liver failure (LF) and its proper diagnosis would lead to a reduction in the complications of the disease and prevents the progress of the disease. To improve the treatment of LF patients and reduce the cost of treatment, we build a machine learning model to forecast whether a patient would deteriorate after admission to the hospital. First, a total of 348 LF patients were included from May 2011 to March 2018 retrospectively in this study. Then, 15 key clinical indicators are selected as the input of the machine learning algorithm. Finally, machine learning and the Model for End-Stage Liver Disease (MELD) are used to forecast the LF deterioration. The area under the receiver operating characteristic (AUC) of MELD, GLMs, CART, SVM and NNET with 10 fold-cross validation was 0.670, 0.554, 0.794, 0.853 and 0.912 respectively. Additionally, the accuracy of MELD, GLMs, CART, SVM and NNET was 0.669, 0.456, 0.794, 0.853 and 0.912. The predictive performance of the developed machine model execept the GLMs exceeds the classic MELD model. The machine learning method could support the physicians to trigger the initiation of timely treatment for the LD patients.

Platelet-to-white blood cell ratio: A novel and promising prognostic marker for HBV-associated decompensated cirrhosis

Aim

The present study aimed to investigate associations of the platelet‐to‐white blood cell ratio (PWR)—a novel hematological indicator of inflammatory responses—with 30‐day outcomes in patients with HBV‐associated decompensated cirrhosis (HBV‐DeCi).

Methods

We recruited 131 patients with HBV‐DeCi for this retrospective study and extracted baseline clinical data and laboratory characteristics from medical records. Univariate and multivariate analyses were performed to determine major factors influencing 30‐day mortality. Area under the receiver operating characteristic curve analyses was performed to compare the predictive values of prognostic markers.

Results

During the 30‐day follow‐up period, 15 patients died. The PWR was significantly different between nonsurvivors and survivors. Lower PWR was found to be associated with an increased risk of mortality, and PWR was found to be an independent predictor of mortality in patients with HBV‐DeCi.

Conclusions

Our results demonstrate that low PWR may be a predictor of poor prognosis in patients with HBV‐DeCi, and this factor may be a useful supplement to standard approaches to enable effective management of these patients.

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.

CIN or not: An approach to the evaluation and management of chronic idiopathic neutrophilia

Neutrophilia refers to an increase in the number of circulating neutrophils in the peripheral blood. Some common etiologies include infection, inflammatory conditions, myeloproliferative disorders, malignancies, endocrinopathies, drugs, and anemia. Rare disorders such as leukocyte adhesion deficiency can also cause neutrophilia. In many cases, there is an elevation of neutrophil count that persists for months or even years with no clear underlying cause in an otherwise asymptomatic patient. This is referred to as chronic idiopathic neutrophilia (CIN). Despite being a condition encountered by many physicians, there is a paucity of literature addressing CIN. Certain conditions such as stress, exercise, smoking, obesity, and obstructive sleep apnea have been associated with CIN and may provide explanations for neutrophilia previously thought to be idiopathic. Herein, we present a review of the literature on CIN and propose a systematic approach to this commonly encountered clinical condition.

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.

Hepatitis Flares Are Associated With Better Outcomes Than No Flare in Patients With Decompensated Cirrhosis and Chronic Hepatitis B Virus Infection

BACKGROUND & AIMS

Little is known about the effects of baseline hepatitis flares (level of alanine aminotransferase ≥5-fold above the upper limit of normal) on the outcomes of patients with chronic hepatitis B virus (HBV) infection with decompensated cirrhosis treated with nucleos(t)ide analogues. We aimed to investigate these effects.

METHODS

We performed a cohort study of 511 consecutive patients (78.1% men; 58.7% with flares at baseline) with chronic HBV infection and decompensated cirrhosis who were treated with nucleos(t)ide analogues as soon as decompensation was noted. Patients were enrolled from January 2002 to March 2018 at a tertiary care center in Taiwan and followed up for 16 years.

RESULTS

Patients with hepatitis flares had higher mean baseline levels of HBV DNA (6.44 ± 1.52 vs 6.08 ± 1.46 log₁₀ IU/mL; P = .003), hepatitis B surface antigen, and total bilirubin; prolonged prothrombin time; higher platelet counts (108.0 ± 42.9 vs 83.6 ± 44.7 103/μL; P < .001); and a higher proportion were infected with HBV genotype B, compared with patients without flares. Patients with flares had lower ratios of neutrophils to lymphocytes than patients with flares (6.14 ± 9.18 vs 9.12 ± 1.36; P = .019); were less likely than patients without flares to be positive for hepatitis B e antigen, ascites, esophageal varices, or splenomegaly; and a lower proportion died or underwent liver transplantation (46.5% vs 73.2% of patients without flares; P < .001), even though the patients without flares had similar short-term (<3 mo) outcomes. Factors associated independently with baseline flares were esophageal varices (odds ratio [OR], 0.165; 95% CI, 0.067-0.406), ascites (OR, 0.415; 95% CI, 0.178-0.969), levels of total bilirubin (OR, 1.158; 95% CI, 1.041-1.269), prolonged prothrombin time (OR, 1.095; 95% CI, 1.033-1.168), and higher platelet counts (OR, 1.009; 95% CI, 1.00-1.018). After we used propensity score matching to match patients with and without baseline flares, factors associated with the cumulative incidence of death or liver transplantation were flares (hazard ratio [HR], 0.491; 95% CI, 0.317-0.76), ratio of neutrophils to lymphocytes (HR, 1.278; 95% CI, 1.027-1.591), and prolonged prothrombin time (HR, 1.223; 95% CI, 1.052-1.423).

CONCLUSIONS

In a 16-year study of patients with chronic HBV infection and decompensated cirrhosis treated with nucleos(t)ide analogues, a baseline flare of hepatitis was associated independently with better long-term (≥3 mo) outcomes than no flare.

Evaluation of the neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, and red cell distribution width for the prediction of prognosis of patients with hepatitis B virus-related decompensated cirrhosis

Background

The development and progression of hepatitis B virus‐related decompensated cirrhosis (DeCi) is associated with inflammatory responses. The monocyte‐to‐lymphocyte ratio (MLR), neutrophil‐to‐lymphocyte ratio (NLR), and red cell distribution width (RDW) are well‐known inflammation markers. We aimed to assess the utility of these parameters for predicating the prognosis of patients with HBV‐DeCi.

Methods

We retrospectively recruited 174 patients diagnosed with HBV‐DeCi. Univariate and multivariate regression models were used to determine risk factors for mortality. Areas under the receiver operating characteristic curves were calculated to estimate and compare the predictive values of the three parameters. Hepatic function was evaluated using the Model for End‐Stage Liver Disease (MELD) score.

Results

The NLR, RDW, and MLR were found to be significantly higher in patients who did not survive compared with surviving patients. Moreover, these variables were all able to predict early poor outcomes in patients with HBV‐DeCi, with NLR exhibiting the highest accuracy. Furthermore, a combination of the NLR and MELD score was a more accurate prognostic marker for predicting mortality than either marker alone in such patients.

Conclusions

Hematological parameters can provide prognostic information for patients with HBV‐DeCi. Routine assessment of these parameters at admission may provide valuable data to complement other conventional measures for assessing disease condition in patients with HBV‐DeCi.

Haematologic indices in hepatitis B virus-related liver disease

Several markers and prognostic scores have been identified for predicting the development and progression of liver disease; among them, haematological parameters (the neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), platelet to lymphocyte ratio (PLR), red cell distribution width (RDW), RDW to platelet ratio (RPR), mean platelet volume (MPV), and mean corpuscular volume (MCV)) have recently gained significant interest. Compared with traditional prognostic factors, haematological indices are easy to obtain and relatively inexpensive. There is growing evidence that these haematological indices play a key role in HBV-related liver diseases and has been proposed as a predictive marker of adverse outcomes in these patients. This article focuses on discussing the diagnostic and prognostic value of the haematological indices in patients with HBV-related liver diseases.

RDW, NLR and RLR in predicting liver failure and prognosis in patients with hepatitis E virus infection

BACKGROUND & AIMS

Hepatitis E virus (HEV) infection contributes to substantial proportion of acute liver injury. This study aims to evaluate the ability of red cell distribution width (RDW), neutrophil to lymphocyte ratio (NLR) and RDW to lymphocyte ratio (RLR) in predicating the development of liver failure following HEV infection and the prognosis.

METHODS

93 healthy controls, 152 current/recent HEV infected patients without liver failure (HEV-non-LF) and 62 HEV patients who developed liver failure (HEV-LF) were enrolled in the study. The clinical and laboratory characteristics on admission, including RDW, neutrophil, lymphocyte, were recorded. Additional 24 HEV-LF patients and 24 HEV-non-LF patients were enrolled to validate the diagnostic efficacy of the three parameters.

RESULTS

RDW, NLR and RLR were higher in HEV patients developing liver failure, compared with HEV-non-LF patients. Positive associations of increased RDW, RLR, NLR and incidence of liver failure were found. The AUC of RLR for predicting HEV-related liver failure was 0.74, superior to NLR and RDW. The sensitivity and specificity of RLR for predicting HEV-related liver failure were 0.74 and 0.65 respectively, superior to NLR (0.66, 0.70) and RDW (0.58, 0.67). However, no correlation between any of the three parameters and prognosis of HEV-LF was found. In addition, the three parameters were correlated with ALB, TBIL and Child-Pugh score in HEV-non-LF subjects, other than in HEV-LF patients.

CONCLUSION

RDW, NLR and RLR are capable to predicate the development of liver failure in HEV patients, among which RLR showed the best sensitivity and specificity. These routinely available parameters shall be considered as new preliminarily diagnostic markers for fulminant hepatic damage in HEV patients.

Hematological Indices in Portal Hypertension: Cirrhosis versus Noncirrhotic Portal Hypertension

Portal hypertension (PHT) leads to several alterations on hematological indices (HI). The aim of the study is to investigate the differences in HI between cirrhotic subjects and subjects who have noncirrhotic PHT (NCPHT). This retrospective study included 328 patients with PHT (239 cirrhosis and 89 NCPHT). Demographic and clinical features, endoscopic and radiological findings, and HI including neutrophil to lymphocyte ratio (NLR) at the time of PHT diagnosis were recorded. Severity of cirrhosis was assessed according to the Child–Turcotte–Pugh (CTP) classification and Model for End-Stage Liver Disease (MELD) scores. Hematological abnormalities were found in 92.5% of cirrhotic patients and in 55.1% of patients with NCPHT (p < 0.001). While thrombocytopenia was the most common HI in patients with cirrhosis, anemia was the most prevalent HI in NCPHT group. In the cirrhotic group, the NLR was the only parameter to differentiate each CTP group from two others. The NLR value increased with the severity of cirrhosis (2.28 ± 0.14 in CTP-A, 2.85 ± 0.19 in CTP-B and 3.26 ± 0.37 in CTP-C). The AUROC of NLR was 0.692 for differentiating compensated cirrhotic patients from decompensated. Hematological abnormalities are more prevalent and more severe in cirrhotic patients compared to patients with NCPHT. NLR may be used to assess the severity of cirrhosis.

Giant gastric lipoma successfully removed by endoscopic submucosal dissection: case report and systematic review

OBJECTIVES

Gastric lipomas are rare adipose tumors that constitute less than 1% of gastric tumors. While lipomas generally do not need removal unless symptomatic, endoscopic resection has been proposed as safe for gastric lipomas smaller than 2 cm. Yet, there is no consensus on the optimal treatment method for larger lipomas. We report a case of a giant 7-cm gastric lipoma successfully removed by endoscopic submucosal dissection (ESD) and systematically review the literature for gastric lipomas removed by ESD.

METHODS

Systematic review was conducted by searching PubMed and Scopus databases, up to 15 February 2018, using combinations of relevant terms.

RESULTS

We report a 55-year-old male with known gastroesophageal reflux disease and asthma, who sought medical attention due to chronic heartburn and asthma exacerbations. These symptoms were attributed to a large 7 cm × 3 cm gastric lipoma that caused gastric outlet obstruction. The lipoma was safely removed by ESD, allowing quick recovery and alleviation of symptoms. In our review, we identified 20 gastric lipomas treated with ESD, with 15 (75%) being 2 cm or larger. The average size of the lipomas was 4 cm (range: 1.2-9 cm). All lipomas were limited to the submucosa, with 80% of the tumors located in the antrum. Three lipomas were removed by submucosal tunneling. All tumors were successfully removed en bloc and no major complications were reported.

CONCLUSION

Our findings support the conclusion that ESD may be a safe alternative to conventional surgery for removal of large symptomatic gastric lipomas.

Profiling Neutrophil-to-Lymphocyte Ratio Changes in Response to Nucleoside Analog Therapy for Chronic Hepatitis B Infection

BACKGROUND/AIM

The neutrophil-lymphocyte ratio (NLR) has gained attention as an index of inflammation in patients with chronic hepatitis B virus (HBV); however, changes with nucleoside analog therapy require investigation.

PATIENTS AND METHODS

We carried out a retrospective study identifying monoinfected HBV patients initiated on therapy with NLR follow-up over 1 year. Biochemistries recorded at treatment initiation and 1 year included alanine aminotransferase (ALT), Model for End Stage Liver Disease (MELD) score, and NLR.

RESULTS

A total of 67 patients were initiated on therapy and had baseline characteristics including e-antigen (eAg) (50, 74.6%) and cirrhosis (19, 28.4%). On subgroup analysis among those with HBV-associated cirrhosis, the NLR decreased over 1 year (3.08±0.39 vs. 1.77±0.18, p<0.001) as did MELD and ALT. Among the non-cirrhotic cohort, there was no difference in NLR (1.99±0.89 vs. 2.14±1.03, p=0.134) despite a decrease in ALT.

CONCLUSION

Nucleoside analog therapy in HBV cirrhosis is associated with a decrease in NLR over 1 year that tracks with changes of established indices of inflammation/global hepatic function.

The role of neutrophil to lymphocyte ratio for the assessment of liver fibrosis and cirrhosis: a systematic review

Neutrophil to lymphocyte ratio (NLR) is widely used to assess inflammatory diseases. We performed a systematic review to explore the prognostic role of NLR for the assessment of liver fibrosis and cirrhosis. Areas covered: We searched the PubMed and EMBASE databases for the eligible papers which explored the association between NLR and liver fibrosis/cirrhosis or investigated the prognostic value of NLR in cirrhotic patients. Expert commentary: In accordance with assessment of liver fibrosis stage, we classified papers into four subgroups by etiology. For the patients with nonalcoholic fatty liver disease (NAFLD) there was a significant association between NLR and fibrosis stage and nonalcoholic fatty liver disease activity score (NAS), while NLR had a negative correlation with fibrosis stage for the patients with chronic hepatitis B (CHB). As for the patients with and chronic hepatitis C (CHC), NLR might not be significantly associated with fibrosis stage. Moreover, NLR seemed to be significantly useful for predicting outcomes in cirrhotic patients. Hence, NLR might be associated with liver fibrosis stage, especially in patients with NAFLD. Furthermore, NLR might be a useful biomarker for evaluating the prognosis in cirrhotic patients.

Clinical Predictors for Neutrophil-to-Lymphocyte Ratio Changes in Patients with Chronic Hepatitis B Receiving Peginterferon Treatment

BACKGROUND

A lower neutrophil-to-lymphocyte ratio (NLR) was found to be associated with better clinical outcomes in hepatitis B-related liver cirrhosis and hepatocellular carcinoma. We aimed to identify pre-therapeutic variables capable of predicting NLR changes in patients with hepatitis B receiving peginterferon therapy.

PATIENTS AND METHODS

The baseline clinicopathological data were analyzed to correlate with NLR changes before and 1 year after peginterferon treatment in 71 patients with hepatitis B.

RESULTS

Univariate analysis revealed that pre-treatment NLR itself negatively predicted NLR changes following peginterferon treatment (odds ratio(OR)=0.320, p=0.013). Further analysis identified pre-treatment NLR, hemoglobin and hepatitis B surface antigen level as independent predictors for NLR changes (adjusted p=0.028, 0.005, and 0.028, respectively). A predictive score composed of these three factors had an area under the curve of 76.5% (p<0.001).

CONCLUSION

Pretreatment NLR, hemoglobin and hepatitis B surface antigen level in combination, effectively predicted NLR changes following peginterferon treatment.

What's new in the diagnosis of pancreatic cancer: a patent review (2011-present)

INTRODUCTION

Pancreatic cancer (PC) is the fourth leading cause of cancer-related death in the US with a 5-year survival rate of about 5%. Most patients have advanced metastatic disease mainly due to the lack of an effective early detection, and an extremely poor prognosis. Advancing in the fight against PC requires developing novel observable biomarkers at preclinical stages for early detection. Areas covered: This manuscript is an overview of different PC diagnostic modalities and the latest innovations made to enhance early PC detection through the patents published from 2011 to 2017. It also comments on the ongoing clinical trials and highlights the main challenges to be addressed in the future. Expert opinion: At present, real efforts are being made to identify new specific biomarkers with a potential clinical applicability, and to develop new devices that integrate several biomarkers in order to be more sensitive and specific for the early detection of PC. Although many biomarkers have been patented recently, they will not reach the clinic until they have been validated by clinical trials. We believe that the high-throughput screening of '-omic' technologies to detect tumor-specific molecular alterations can lead to an enhanced understanding of the disease mechanisms and the discovery of new clinical diagnostic biomarkers.

A nomogram for predicting prognostic value of inflammatory response biomarkers in decompensated cirrhotic patients without acute-on-chronic liver failure

BACKGROUND

Inflammation plays a vital role in liver cirrhosis progression and prognosis.

AIM

To investigate the prognostic significance of inflammatory response markers in decompensated cirrhotic patients without acute-on-chronic liver failure (ACLF).

METHODS

Independent predictors were identified using multivariate Cox model and then assembled into a nomogram to predict survival. Concordance index (C-index) and time-dependent receiver operating characteristics (td-ROC) analysis were adopted to evaluate and compare the performance of nomogram, model for end-stage liver disease (MELD) scores, MELD-Na and Chronic Liver Failure-consortium score for acute decompensated (CLIF-C ADs).

RESULTS

A total of 902 decompensated cirrhotic patients with different aetiologies were enrolled, with 6-month, 1-year and 3-year mortality of 18.6%, 24.4% and 34.8%, respectively. The cut-off values for neutrophil-to-lymphocyte ratio (NLR) and lymphocyte-to-monocyte ratio (LMR) determined by X-tile program were 5.7 and 1.1 respectively. Patients with NLR>5.7 or LMR≤1.1 had significantly higher mortality (P < 0.001). Independent factors derived from multivariable Cox analysis of development cohort to predict mortality were age, NLR and LMR (hazard ratio (HR): 1.064, 95% confidence interval (CI): 1.045-1.084, P < 0.001; HR: 1.124, 95%CI: 1.091-1.158, P < 0.001; HR: 0.794, 95%CI: 0.702-0.898, P < 0.001, respectively). The C-indexes of nomogram were higher than that of MELD score, MELD-Na and CLIF-C ADs for predicting survival. The tdROC and decision curves showed that nomogram was superior to MELD score, MELD-Na and CLIF-C ADs. Similar results were observed in validation cohort.

CONCLUSION

The proposed nomogram with neutrophil-to-lymphocyte ratio and lymphocyte-to-monocyte ratio resulted in accurate prognostic prediction for decompensated cirrhotic patients without ACLF.