Association between Preoperative Neutrophil-lymphocyte Ratio and All-cause Mortality in Patients Treated with Thoracic Endovascular Aortic Repair for Degenerative Thoracic Aortic Aneurysm

BACKGROUND

The neutrophil-lymphocyte ratio (NLR) has been increasingly recognized as a reliable surrogate marker for predicting mortality in clinical practice. This study determined the predictive ability of NLR for overall mortality after thoracic endovascular aortic repair (TEVAR) for degenerative thoracic aortic aneurysm (TAA).

METHODS

Data from patients treated with TEVAR for degenerative TAA at our university hospital from January 2013 to December 2021 were evaluated. The preoperative NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count.

RESULTS

One hundred-three patients were included in this study. During a 9-year follow-up, 32 patients (31.1%) died. Multivariable analyses showed that age (hazard ratio [HR], 1.06; 95% confidence interval [CI], 1.00-1.12; P = 0.021), ischemic heart disease (HR, 2.13; 95% CI, 1.05-4.36; P = 0.038), and NLR (HR, 1.36; 95% CI, 1.08-1.72; P = 0.009) predicted all-cause mortality after TEVAR. A receiver operating characteristic curve determined the optimal cutoff value of NLR to predict all-cause mortality was 3.48.

CONCLUSIONS

An elevated preoperative NLR is indicative of a higher likelihood of all-cause mortality in patients treated with TEVAR for degenerative TAA, suggesting that NLR could serve as a possible biomarker for stratifying patients at risk of overall mortality after TEVAR.

A Systematic Review on the Role of Neutrophil to Lymphocyte Ratio in Limb Ischemia

BACKGROUND

Limb ischemia is a severe vascular condition that can lead to critical complications, endangering both limbs and lives. The goal of this research was to explore the role of neutrophil to lymphocyte ratio (NLR) in limb ischemia.

METHODS

From inception to June 8, 2022, PubMed/MEDLINE, Institute for Scientific Information Web of Science, and Scopus were searched for articles comparing NLR in limb ischemia to healthy individuals.

RESULTS

Finally, a total of 23 studies were included in the review. There was a direct link between NLR and critical limb ischemia (CLI) development in peripheral arterial disease patients. Elevated NLR levels predict a higher risk of CLI among peripheral arterial disease patients. Also, it was concluded that NLR is a dependable predictor of survival in patients with limb ischemia, and higher NLR readings are linked to decreased survival rates. Moreover, the risk of amputation is related to the level of NLR in CLI patients. However, based on the data, NLR is not a reliable indicator of sarcopenia in CLI patients. More research is needed to determine the relationship between NLR and response to treatment in CLI patients. Also, we recommend investigating the effect of each treatment on NLR level in these patients.

CONCLUSIONS

Our results provide evidence that NLR level is associated with risk of amputation and mortality in patients with limb ischemia. It is a promising biomarker that can be easily incorporated into clinical practice to assist in the prediction and prevention of CLI.

Leukocyte Indices as Markers of Inflammation and Predictors of Outcome in Heart Failure with Preserved Ejection Fraction

Background: The pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF) is suggested to be influenced by inflammation. Leukocyte indices, including the neutrophil-lymphocyte ratio (NLR), the monocyte-lymphocyte ratio (MLR), and the pan-immune inflammation value (PIV), can be utilized as biomarkers of systemic inflammation. Their prognostic utility is yet to be fully understood. Methods: Between December 2010 and May 2023, patients presenting to a tertiary referral center for HFpEF were included into a prospective registry. The association of the NLR, MLR, and PIV with the composite endpoint of all-cause mortality and HF-related hospitalization was tested utilizing Cox regression analysis. Results: In total, 479 patients (median 74.3, interquartile range (IQR): 69.22-78.3 years, 27.8% male) were included. Patients were observed for 43 (IQR: 11-70) months, during which a total of 267 (55.7%) patients met the primary endpoint. In a univariate Cox regression analysis, an above-the-median NLR implied a hazard ratio (HR) of 1.76 (95%-confidence interval (CI): 1.38-2.24, p < 0.001), an MLR of 1.46 (95%-CI: 1.14-1.86, p = 0.003), and a PIV of 1.67, 95%-CI: 1.30-2.13, p < 0.001) for the composite endpoint. After adjustment in a step-wise model, the NLR (HR: 1.81, 95%-CI: 1.22-2.69, p = 0.003), the MLR (HR: 1.57, 95%-CI: 1.06-2.34, p = 0.026), and the PIV (HR: 1.64, 95%-CI: 1.10-2.46, p = 0.015) remained significantly associated with the combined endpoint. Conclusions: The NLR, the MLR, and the PIV are simple biomarkers independently associated with outcomes in patients with HFpEF.

Neutrophil-Lymphocyte Ratio as a Predictor of Persistent Type 2 Endoleak after Endovascular Aneurysm Repair

Objectives: One of the important postoperative complications of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is type 2 endoleak (T2EL). However, there is no well-established biomarker. We aimed to evaluate the validity of the neutrophil-lymphocyte ratio (NLR) as a predictor of T2EL. Methods: Data were retrospectively collected from 146 patients who underwent EVAR for AAA at our institution between April 1, 2008 and March 31, 2021. Within 90 days before surgery, preoperative NLR was calculated from the same blood sample. The receiver operating characteristic curve (ROC) was used to determine the cutoff NLR values for persistent T2EL. Univariate and multivariate analyses were performed. Results: Compared with patients without persistent T2EL, those who had persistent T2EL had lower preoperative NLR (P = 0.041), based on a cutoff value of 1.918, and the entire group was then divided into two groups based on these values for comparison. Univariate analysis showed significant differences in NLR, the white blood cell (WBC) count, the percentage of mural thrombus of aneurysm, history of the hypertension, follow-up term, and aneurysm diameter at final follow-up. Multivariate analysis showed that NLR and AAA diameter on the last follow-up were significantly associated with T2EL persistence. Conclusions: Preoperative low NLR can be a useful predictor of postoperative persistent T2EL.

Neutrophil-to-lymphocyte ratio as a predictor of all-cause and cardiovascular mortality in coronary heart disease and hypertensive patients: a retrospective cohort study

Background

To date, no studies have investigated the correlation between the neutrophil-to-lymphocyte ratio (NLR) and the long-term risk of mortality in individuals with both coronary heart disease (CHD) and hypertension. This study aims to evaluate the association between NLR and all-cause and cardiovascular mortality among this patient population.

Methods

National Death Index (NDI) and National Health and Nutrition Examination Survey (NHANES 2001-2018) were the data sources. A nonlinear association between the NLR and mortality risk was shown by restricted cubic spline (RCS) analysis. Using a weighted Cox proportional hazards model, we quantitatively evaluated the effect of NLR on mortality risk.The capacity of NLR to forecast survival was assessed by evaluating time-dependent receiver operating characteristic (ROC) curves. A mediating influence analysis was conducted to assess the influence of NLR on mortality through eGFR as a mediator.

Results

The study involved a total of 2136 individuals. During the median follow-up interval of 76.0 months, 801 deaths were recorded. The RCS analysis showed NLR and mortality risk to have a nonlinear relationship. Two groups were established based on the participants' NLR levels: a group with high NLR (NLR > 2.65) and a group with low NLR (NLR < 2.65). After adjusting for potential confounding factors, the Cox proportional hazards model revealed that participants with an increased NLR faced a significantly higher risk of cardiovascular mortality. (HR 1.58, 95% CI 1.33-1.82, p < 0.0001) and all-cause mortality (HR 1.46, 95% CI 1.30-1.62, p < 0.0001). An analysis of interactions and data stratification corroborated the validity of our findings. eGFR was identified as a partial mediator in the association between NLR and mortality rates, contributing 12.17% and 9.66% of the variance in all-cause and cardiovascular mortality, respectively. The predictive performance for cardiovascular mortality was quantified using ROC curves, with respective AUC values of 0.67, 0.65, and 0.64 for predictions over 3, 5, and 10 years. The AUC values for all-cause mortality were 0.66, 0.64, and 0.63 for the same time frames.

Conclusion

For patients with CHD and hypertension, an elevated NLR serves as an independent prognostic indicator for both all-cause and cardiovascular mortality.

Prognostic Value of Neutrophil/Lymphocyte Ratio for Pulmonary Embolism: A Meta-Analysis and External Validation

BACKGROUND

Prognostic value of neutrophil/lymphocyte ratio (NLR) for pulmonary embolism (PE) has been reported in several retrospective studies. The purpose of this investigation was to perform a pooled analysis and external validation of predictive value of NLR.

METHODS

PubMed, Embase, and Cochrane databases were searched from inception to November 5, 2022. A random effects model was used. Grade was used to evaluate the certainty of evidence. External validation was conducted in clinical cohorts before and after a propensity scoring matching (PSM). Covariates include basic clinical characteristics, such as age, gender, etc. The value of NLR in prediction model was also evaluated.

RESULTS

A total of 15 studies comprising 5,874 patients were included. Pooled risk ratio of NLR was 2.33 (95% confidence interval [CI]: 1.97-2.75), with an area under the curve of 0.78 (95% CI: 0.74-0.81), a sensitivity of 0.75 (95% CI: 0.71-0.79), a specificity of 0.67 (95% CI: 0.61-0.73), and a median cut-off value of 5.7. Grade of Recommendations Assessment Development and Evaluation (GRADE) certainty analysis showed the quality of the evidence was moderate. Before (n = 336) and after (n = 152) propensity scoring matching, risk ratio of NLR was 2.69 (95% CI: 1.04-6.97) and 6.58 (95% CI: 1.99-17.75). A prediction model consisting of NLR, age, D-dimer, and simplified PE severity index had an area under the curve of 0.809 (95% CI: 0.738-0.88), a sensitivity of 0.638 (95% CI: 0.511-0.745), and a specificity of 0.851 (95% CI: 0.709-0.917). Net reclassification index (12%, P = 0.035) and integrated discrimination improvement (17%, P = 0.022) indicated an improvement caused by NLR.

CONCLUSIONS

Prognostic value of NLR for PE was confirmed by meta-analysis and validated in an independent cohort, deserving further clinical application.

Evaluation of systemic immune-inflammation index for predicting severity of lower extremity arterial disease

OBJECTIVE

Predictive value of systemic immune-inflammation index (SII) has been shown in clinical outcomes and complexity of coronary artery disease, acute coronary syndrome, and heart failure. We sight to evaluate value of SII in patients with lower extremity arterial disease (LEAD).

METHODS

A total of 271 patients diagnosed with LEAD were included to our study. Blood samples of the patients were collected and analyzed for biochemical variables and complete blood count parameters. SII value of each patient was calculated. The complexity of atherosclerotic disease was classified according to Trans-Atlantic Inter-Society Consensus (TASC II) classification.

RESULTS

Patients with TASC C-D were older than patients in TASC A-B group (63.06 ± 9.24 years and 60.85 ± 8.75 years, respectively). Other co-morbidities were comparable in both groups. Hemoglobin level and lymphocyte count were significantly lower, neutrophil, platelet counts, and SII values were significantly higher in patients with TASC C-D disease compared to that of patients with TASC A-B disease. SII showed significant correlation with the severity of LEAD (r = 0.363, p < .001). SII value of 664.24 predicted TASC C-D disease with a sensitivity and specificity of 60.8% and 73.3%, respectively. Results of multivariate logistic regression analysis showed that SII had higher odds ratio compared to platelet, neutrophil, and lymphocyte counts.

CONCLUSION

Higher SII may indicate probability of more complex LEAD. This relationship seems plausible in terms of similar pathophysiology of coronary artery disease and peripheral artery disease.

Significance of Neutrophil to Lymphocyte Ratio (NLR) and Platelet Lymphocyte Ratio (PLR) in Diabetic Foot Ulcer and Potential New Therapeutic Targets

Diabetic foot ulcer (DFU) is a well-known complication of diabetes and a significant burden on the national health systems. The neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio are inexpensive and easily accessible biomarkers that have proved to be useful in several inflammatory, infectious and cardiovascular diseases. We carried out a comprehensive review examining the association of NLR and PLR with the onset and progression of DFU. PLR and NLR were significantly increased in patients with DFU, compared with a control group of T2DM patients without DFU, and correlate well with DFU severity, evaluated by Wagner and IWGDF grading scales. In patients with diabetic foot infections (DFI), elevated NLR and PLR were correlated with osteomyelitis, increased risk of amputation, and septic complications. The significance of the elevated value of these biomarkers in DFU is related to chronic hyperglycemia and low-grade systemic inflammation, atherosclerotic and vascular complications, and also the associated septic factor. Serial, dynamic follow-up can provide useful information in planning and monitoring DFU treatment, as well as in risk stratification of these vulnerable patients. Further randomized studies are needed to set the cut-off values with clinical significance.

Peripheral immunity changes are associated with neurodegeneration and worse clinical outcome in idiopathic normal pressure hydrocephalus

BACKGROUND AND PURPOSE

Idiopathic normal pressure hydrocephalus (iNPH) pathogenesis is multifactorial. Systemic inflammation might have a role in gathering clinical-pathological trajectories. We aimed to shape the peripheral immune profile of iNPH and establish correlations with cerebrospinal fluid (CSF) markers, ventricular enlargement, and clinical outcomes.

METHODS

We conducted a single-center retrospective-longitudinal study, including 38 iNPH patients and 38 controls. Baseline iNPH Grading Scale and modified Rankin Scale (mRS) scores were collected with peripheral blood cell count, CSF amyloid-β42 (Aβ42), total tau (t-tau), phosphorylated-181-tau, and Evans index. Depending on 5-year outcome, iNPH patients were grouped into "poor outcome" (PO; mRS ≥ 5) and "favorable outcome" (FO; mRS < 5). Biomarkers were compared and correlated with each other. Receiver operating characteristic analysis was performed.

RESULTS

iNPH patients compared to controls had higher neutrophil-to-lymphocyte ratio (NLR; 2.43 ± 1.04 vs. 1.61 ± 0.47, p < 0.001), higher neutrophils (4.22 ± 0.86 1000/mL vs. 3.48 ± 1.34, p = 0.033), and lower lymphocytes (1.45 ± 0.55 1000/mL vs. 2.07 ± 0.86, p = 0.038), with the expected CSF biomarkers signature. In the patients' cohort, NLR was associated directly with t-tau and inversely with Aβ42. NLR directly correlated with Evans index. PO patients compared to those with FO had higher NLR (3.25 ± 1.40 vs. 2.01 ± 0.77, p = 0.035) and higher t-tau (274.76 ± 114.39 pg/mL vs. 150.28 ± 72.62, p = 0.017), with an area under the curve of 0.786 and 0.793, respectively.

CONCLUSIONS

iNPH patients present a proinflammatory state associated with neurodegeneration and predicting poor clinical outcome. Systemic inflammation represents a factor in the clinical-pathological progression of iNPH, and the NLR emerges as a potential prognostic index.

Dynamic NLR and PLR in Predicting COVID-19 Severity: A Retrospective Cohort Study

INTRODUCTION

The hyperinflammation phase of severe SARS-CoV-2 is characterised by complete blood count alterations. In this context, the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) can be used as prognostic factors. We studied NLR and PLR trends at different timepoints and computed optimal cutoffs to predict four outcomes: use of continuous positive airways pressure (CPAP), intensive care unit (ICU) admission, invasive ventilation and death.

METHODS

We retrospectively included all adult patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia admitted from 23 January 2020 to 18 May 2021. Analyses included non-parametric tests to study the ability of NLR and PLR to distinguish the patients' outcomes at each timepoint. Receiver operating characteristic (ROC) curves were built for NLR and PLR at each timepoint (minus discharge) to identify cutoffs to distinguish severe and non-severe disease. Their statistical significance was assessed with the chi-square test. Collection of data under the SMACORE database was approved with protocol number 20200046877.

RESULTS

We included 2169 patients. NLR and PLR were higher in severe coronavirus disease 2019 (COVID-19). Both ratios were able to distinguish the outcomes at each timepoint. For NLR, the areas under the receiver operating characteristic curve (AUROC) ranged between 0.59 and 0.81, and for PLR between 0.53 and 0.67. From each ROC curve we computed an optimal cutoff value.

CONCLUSION

NLR and PLR cutoffs are able to distinguish severity grades and mortality at different timepoints during the course of disease, and, as such, they allow a tailored approach. Future prospects include validating our cutoffs in a prospective cohort and comparing their performance against other COVID-19 scores.

Vascular surgery patients with elevated neutrophil-to-lymphocyte ratios have downregulated neutrophil complement RNA expression

Elevated neutrophil-to-lymphocyte ratio (NLR) in patients who undergo elective vascular surgery (EVS) have increased mortality independent of perioperative surgical outcome. To understand why high NLR is associated with higher mortality, we investigated neutrophil and lymphocyte transcriptome expression in patients undergoing EVS. Blood samples were collected from patients undergoing EVS and healthy donors for NLR calculation. RNA samples were isolated from patients' neutrophils and lymphocytes and divided into NLR_Low (<3) and NLR_High (≥3) groups (n = 6 each). Paired samples with the highest RNA integrity number (mean = 9.8 ± 0.4) were sequenced and analyzed for differential expression. Normalized data were inputted for downstream analysis using iPathwayGuide (AdvaitaBio) and gene set enrichment analysis using GenePattern and MSigDB (Broad Institute). There was no clinical difference between the patient groups with regard to clinical diagnosis, age, sex, history of hypertension, lipid abnormalities, diabetes mellitus, smoking, or statin use. The mean NLR was 4.37 ± 0.27 SEM in the NLR_High and 1.88 ± 0.16 for the NLR_Low groups. Significantly differentially expressed gene sets identified in the RNA sequence data were enriched highly (P = 1E-24) in the humoral immunity and complement systems. Neutrophils from NLR_High patients downregulated complement genes (C1QA, C1QB, C1QC, C1S, C2, CR2, C3AR1, C3, C8G, and C9 and complement regulatory genes CD59, SERPING1, C4BPA, CFH, and CFI). Downregulation of gene expressions of humoral immunity and complement within the neutrophils are associated with elevated NLR. It remains to be determined whether and how these changes contribute to increased late mortality previously observed in patients undergoing EVS.

Association of neutrophil-to-lymphocyte ratio with thirty-day mortality in acute peripheral arterial ischemia

BACKGROUND

Acute peripheral arterial ischemia (APAI) is an acute ischemic condition that develops as a result of embolism or thrombosis, and its morbidity and mortality are still high today. The objective of this study is to determine the effect of preoperative Neutrophil-to-Lymphocyte ratio (NLR) on mortality in patients admitted with the diagnosis of APAI.

METHODS

178 patients who were diagnosed with acute peripheral arterial occlusion and underwent emergency embolectomy were evaluated retrospectively over a 7-year period. Patient demographics, clinical history, risk factors, comorbidity, and hemogram sub-parameters were documented. The endpoint of the patients was determined as death.

RESULTS

A total of 178 patients were identified with a mean age 74.29±14.71 (range 28-111) years; among them, 105 (59%) were female. 18% patients (32/178) died within 30 days. Lower extremity involvement was present in 124 (69.7%) of the patients. A statistically significant difference was found between the mortality rates and blood parameters of the patients included in the study in terms of white blood count C-reactive protein (CRP), and age among those with normal distribution. Neutrophil, NLR, procalcitonin, lactate, aspartate aminotransferase, and urea; It was statistically significant in terms of mortality in our patients with APAI. NLR values of the deceased were determined as 7.98 ± 6.85.

CONCLUSIONS

APAI patients with high NLRs had significantly higher risks of 30-day mortality. The NLR can be used as a prognostic marker in these patients and warrants further investigation.

Proximal Femur Fractures in the Elderly-A Novel Modality to Predict Mortality: The Neutrophil-to-Lymphocyte Ratio

Background: The assessment and identification of elderly patients with proximal femur fractures (PFF) who are at high risk of postoperative mortality may influence the treatment decision-making process. The purpose of this study was to determine whether the neutrophil-to-lymphocyte ratio (NLR) could be used to predict postoperative mortality in the elderly population. Methods: A four-year retrospective cohort study of electronic medical records was conducted at a single tertiary care hospital between 2015 and 2018. Data from 1551 patients aged 65 years and older who underwent surgical treatment for PFF were collected and analyzed. The data included complete blood counts at admission, demographic information, underlying illnesses, type of surgery, and postoperative mortality and complications during the first year of follow-up. A survival analysis model was utilized. Results: The mean age was 90.76 ± 1.88 years, 1066 (68.7%) women. Forty-four (2.8%) patients experienced postoperative infection. A higher NLR0 was independently associated with higher all-cause mortality rates in patients who underwent surgical treatment for PFF (p = 0.041). Moreover, the mean NLR0 value was higher when the death occurred earlier after surgery (p < 0.001). Conclusions: When combined with other clinical and laboratory findings, NLR0 levels may serve as a potentially valuable, inexpensive, and reliable prognostic biomarker to improve risk stratification for elderly patients who are candidates for PFF surgery. Furthermore, with additional research, we could potentially develop a treatment algorithm to identify patients at high risk of postoperative mortality.

Evaluation of the relationship between monocyte to high-density lipoprotein cholesterol ratio and thrombus burden in patients with deep vein thrombosis

OBJECTIVE

The purpose of this study was to evaluate monocyte count and high-density lipoprotein cholesterol levels and their ratio (monocyte/high-density lipoprotein ratio) in patients with deep venous thrombosis as well as to determine whether this ratio at the time of diagnosis can be an indicator of thrombus burden in terms of thrombus location in deep venous thrombosis.

METHODS

We retrospectively analyzed the patient's diagnosis of deep venous thrombosis confirmed with venous Doppler ultrasound, using a database query for outpatients between 2018 and 2022. Of 378 patients included, blood count results at the time of diagnosis were available for 356. We recruited 300 age- and sex-matched patients with appropriate blood counts, without a diagnosis of deep venous thrombosis, as the control group, by querying the outpatient clinic database. The monocyte/high-density lipoprotein ratio was computed from the ratio of monocyte count to high-density lipoprotein-C. Patients were categorized based on the level of thrombus and the number of vein segments involved as evidenced by Doppler ultrasound findings.

RESULTS

The serum level of monocyte/high-density lipoprotein ratio was significantly higher in the patient group compared to the control group (p<0.01). Patients with proximal deep venous thrombosis had a higher mean monocyte/high-density lipoprotein ratio (19.6±5.1 vs. 17.1±5.5; p<0.01) than patients with distal deep venous thrombosis. Monocyte/high-density lipoprotein ratio increased with the number of vein segments involved (p<0.01).

CONCLUSION

Monocyte/high-density lipoprotein ratio is significantly elevated in patients with deep venous thrombosis when compared to the control group. Monocyte/high-density lipoprotein ratio levels were correlated with disease burden reflected by thrombus location and the number of vein segments involved in deep venous thrombosis patients.

Abnormal peripheral blood cell counts in neurofibromatosis type 1

Neurofibromatosis type 1 (NF1), also known as von Recklinghausen disease, is an autosomal dominant disease characterized by neurofibromas with infiltration of mast cells. Neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR) and basophil-to-lymphocyte ratio (BLR) are examined as markers for various diseases. However, these parameters have not yet been assessed for NF1. This study therefore examined these parameters in NF1 patients. We recruited 153 NF patients (78 males, 75 females) and 51 control patients (31 males, 20 females). Complete blood counts were performed, then NLR, LMR, PLR and BLR were calculated. Neutrophil count was significantly higher in male NF1 patients than in male controls. Lymphocyte count was significantly lower in NF1 patients than in controls for both sexes. Monocyte count was significantly higher in male NF1 patients than in male controls. Basophil count was significantly higher in male NF1 patients than in male controls. NLR, PLR and BLR were significantly higher in NF1 patients than in controls for both sexes. LMR was significantly lower in NF1 patients than in controls for both sexes. NF1 shows high NLR, PLR and BLR and low lymphocyte count and LMR.

Dysregulated Genes, MicroRNAs, Biological Pathways, and Gastrocnemius Muscle Fiber Types Associated With Progression of Peripheral Artery Disease: A Preliminary Analysis

Background Peripheral artery disease (PAD) is associated with gastrocnemius muscle abnormalities. However, the biological pathways associated with gastrocnemius muscle dysfunction and their associations with progression of PAD are largely unknown. This study characterized differential gene and microRNA (miRNA) expression in gastrocnemius biopsies from people without PAD compared with those with PAD. Participants with PAD included those with and without PAD progression. Methods and Results mRNA and miRNA sequencing were performed to identify differentially expressed genes, differentially expressed miRNAs, mRNA-miRNA interactions, and associated biological pathways for 3 sets of comparisons: (1) PAD progression (n=7) versus non-PAD (n=7); (2) PAD no progression (n=6) versus non-PAD; and (3) PAD progression versus PAD no progression. Immunohistochemistry was performed to determine gastrocnemius muscle fiber types and muscle fiber size. Differentially expressed genes and differentially expressed miRNAs were more abundant in the comparison of PAD progression versus non-PAD compared with PAD with versus without progression. Among the top significant cellular pathways in subjects with PAD progression were muscle contraction or development, transforming growth factor-beta, growth/differentiation factor, and activin signaling, inflammation, cellular senescence, and notch signaling. Subjects with PAD progression had increased frequency of smaller Type 2a gastrocnemius muscle fibers in exploratory analyses. Conclusions Humans with PAD progression exhibited greater differences in the number of gene and miRNA expression, biological pathways, and Type 2a muscle fiber size compared with those without PAD. Fewer differences were observed between people with PAD without progression and control patients without PAD. Further study is needed to confirm whether the identified transcripts may serve as potential biomarkers for diagnosis and progression of PAD.

Short- and Mid-Term Survival Prediction in Patients with Acute Type A Aortic Dissection Undergoing Surgical Repair: Based on the Systemic Immune-Inflammation Index

Purpose

The postoperative survival of patients with acute type A aortic dissection (aTAAD) remains unsatisfactory. The current study developed an easy-to-use survival prediction model and calculator.

Methods

A total of 496 patients with aTAAD undergoing surgical repair were included in this study. The systemic immune-inflammation index (SII) and other clinical features were collected and subjected to logistic and Cox regression analyses. The survival prediction model was based on Cox regression analyses and exhibited as a nomogram. For convenience of use, the nomogram was further developed into calculator software.

Results

We demonstrated that a higher preoperative SII was associated with in-hospital death (OR: 4.116, p < 0.001) and a higher postoperative overall survival rate (HR: 2.467, p < 0.001) in aTAAD patients undergoing surgical repair. A survival prediction model and calculator based on SII and four other clinical features were developed. The overall C-index of the model was 0.743. The areas under the curves (AUCs) of the 1- and 3-month and 1- and 3-year survival probabilities were 0.73, 0.71, 0.71 and 0.72, respectively. The model also showed good calibration and clinical utility.

Conclusion

Preoperative SII is significantly associated with postoperative survival. Based on SII and other clinical features, we created the first easy-to-use prediction model and calculator for predicting the postoperative survival rate in aTAAD patients, which showed good prediction performance.

A Prediction Model Based on Blood Biomarker for Mortality Risk in Patients with Acute Venous Thromboembolism

Background

Most studies to date have focused on predicting the risk of venous thromboembolism (VTE), but prediction models about mortality risk in VTE are rarely reported. We sought to develop and validate a multivariable model to predict the all-cause mortality risk in patients with acute VTE in emergency settings.

Methods

A total of 700 patients were included from Qilu Hospital of Shandong University and were randomly assigned into training set (n=490) and validation set (n=210) in an 7:3 ratio. Multivariate logistics regression analysis was performed to identify independent variables and develop a prediction model, which was validated internally using bootstrap method. The discrimination, calibration and clinical utility were evaluated by receiver operating characteristic curve (ROC) analysis, Hosmer-Lemeshow (HL) test, Kaplan-meier (KM) analysis and decision curve analysis (DCA).

Results

There were 52 patients (10.6%) dying and 437 (89.4%) surviving in training set. Age (odds ratio [OR]: 4.158, 95% confidence interval [CI]: 2.426–7.127), pulmonary embolism (OR: 1.779, 95% CI: 1.124–2.814), platelet count (OR: 0.507, 95% CI: 0.310–0.830), D-dimer (OR: 1.826, 95% CI: 1.133–2.942) and platelet/lymphocyte ratio (OR: 2.166, 95% CI: 1.259–3.727) were independent risk variables associated with all-cause mortality. The model had good predictive capability with an AUC of 0.746 (95% CI: 0.668,0.825), a sensitivity of 0.769 (95% CI: 0.607,0.889), a specificity of 0.672 (95% CI: 0.634,0.707). The validation model had an AUC of 0.739 (95% CI: 0.685,0.793), a sensitivity of 0.690 (95% CI: 0.580,0.787), a specificity of 0.693 (95% CI: 0.655,0.729). The model is well calibrated and the HL test showed a good fit (χ²=5.291, p=0.726, Nagelkerke R²=0.137). KM analysis and DCA showed a good clinical utility of the nomogram.

Conclusion

This study identified independent variables affecting all-cause mortality in patients with acute VTE, and developed a prediction model and provided a nomogram with good prediction capability and clinical utility.

Serum inflammatory marker levels in serous macular detachment secondary to diabetic macular edema

PURPOSE

To evaluate the serum inflammatory marker levels in serous macular detachment (SMD) secondary to diabetic macular edema (DME).

MATERIAL AND METHODS

Patients with DME were divided into two groups according to the presence of SMD. Group 1 consisted of 40 patients with SMD, Group 2 consisted of 40 patients without SMD, and Group 3 consisted of 40 healthy subjects. Neutrophil and mean platelet volume (MPV) were obtained from blood samples. The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and the systemic immune inflammation index (SII) were calculated. In Group 1 and 2 sub-group analysis was done according to grade of diabetic retinopathy (DR) and the results were analyzed in these subgroups.

RESULTS

The neutrophils, MPV, NLR, and SII levels were significantly higher in Group 1 (p = 0.000, p = 0.004, p = 0.000, p = 0.001, respectively). In subgroup analysis; the neutrophils, NLR, and SII levels were significantly higher in patients with proliferative DR (p = 0.044, p = 0.046, p = 0.046, respectively) and the SII levels were significantly higher in patients with severe nonproliferative DR in Group 1 (p = 0.039). The mean CMT values were 548.8 ± 138.3 µm in Group 1 and 420.1 ± 112.7 µm in Group 2. The CMT values were significantly higher in Group 1 (p: 0.000). However, there was no significant correlation between the CMT values and the systemic inflamatuar markers levels (p>0.05) in both of the groups.

CONCLUSIONS

NLR and SII levels were significantly higher in DME with SMD, especially in advanced cases. Elevated serum inflammatory markers might be associated with a higher incidence of SMD.

Association between neutrophil-to-lymphocyte ratio and major postoperative complications after carotid endarterectomy: A retrospective cohort study

BACKGROUND

Carotid artery cross-clamping during carotid endarterectomy (CEA) may damage local cerebral perfusion and induce cerebral ischemia–reperfusion injury to activate local inflammatory responses. Neutrophil-to-lymphocyte ratio (NLR) is an indicator that reflects systemic inflammation. However, the correlation between NLR and complications after CEA remains unclear.

AIM

To investigate the association between NLR and major complications after surgery in patients undergoing CEA.

METHODS

This retrospective cohort study included patients who received CEA between January 2016 and July 2018 at Beijing Tiantan Hospital. Neutrophil and lymphocyte counts in whole blood within 24 h after CEA were collected. The primary outcome was the composite of major postoperative complications including neurological, pulmonary, cardiovascular and acute kidney injuries. The secondary outcomes included infections, fever, deep venous thrombosis, length of hospitalization and cost of hospitalization. Statistical analyses were performed using EmpowerStats software and R software.

RESULTS

A total of 224 patients who received CEA were screened for review and 206 were included in the statistical analyses; of whom, 40 (19.42%) developed major postoperative complications. NLR within 24 h after CEA was significantly correlated with major postoperative complications (P = 0.026). After confounding factors were adjusted, the odds ratio was 1.15 (95%CI: 1.03–1.29, P = 0.014). The incidence of major postoperative complications in the high NLR group was 8.47 times that in the low NLR group (P = 0.002).

CONCLUSION

NLR is associated with major postoperative complications in patients undergoing CEA.

The role of the multi-inflammatory index as a novel inflammation-related index in the differential diagnosis of massive and non-massive pulmonary embolism

OBJECTIVE

Systemic inflammatory response and pro-coagulator factors are critical in acute pulmonary embolism. Recently, there is increasing evidence that the multi-inflammatory index (MII) may be prognostic in many clinical situations. The study investigated whether MII-1 and MII-2 can distinguish massive (MPE) and non-massive pulmonary embolism (NMPE).

METHODS

A total of 146 patients (73 MPE and 73 NMPE) were included in the study that was designed as a retrospective cross-sectional analysis. Following haemogram analysis, MII-1 (platelet-to-lymphocyte x CRP) and MII-2 (neutrophil-to-lymphocyte x CRP) were calculated manually.

RESULTS

MII-1 and 2 showed a positive significant correlation with PLR and NLR, moderate positive correlation with CPR, and weak positive correlation with PAP (P < .001). CRP, MII-1, MII-2, PAP and systolic BP variables showed strong diagnostic value in distinguishing MPE and NMPE [AUC (SE): 0.816 (0.037), 0.811 (0.038), 0.810 (0.037), 0.870 (0.032) and 0.864 (0.032); respectively] (P < .001). MPR, MPV, RDW, and PLR in distinguishing MPE and NMPE groups did not show significance (P > .05).

CONCLUSION

Although MII-1 and MII-2 are simple, cheap, and easy indexes to calculate, they showed a strong ability to distinguish MPE and NMPE compared with the previously studied classical inflammatory indexes.

Cytogenetic follow-up studies on humans with internal and external exposure to ionizing radiation

Cells exposed to ionizing radiation have a wide spectrum of DNA lesions that include DNA single-strand breaks, DNA double-strand breaks (DSBs), oxidative base damage and DNA-protein crosslinks. Among them, DSB is the most critical lesion, which when mis-repaired leads to unstable and stable chromosome aberrations. Currently, chromosome aberration analysis is the preferred method for biological monitoring of radiation-exposed humans. Stable chromosome aberrations, such as inversions and balanced translocations, persist in the peripheral blood lymphocytes of radiation-exposed humans for several years and, therefore, are potentially useful tools to prognosticate the health risks of radiation exposure, particularly in the hematopoietic system. In this review, we summarize the cytogenetic follow-up studies performed by REAC/TS (Radiation Emergency Assistance Center/Training site, Oak Ridge, USA) on humans exposed to internal and external radiation. In the light of our observations as well as the data existing in the literature, this review attempts to highlight the importance of follow-up studies for predicting the extent of genomic instability and its impact on delayed health risks in radiation-exposed victims.

Diagnostic and Prognostic Value of Immune/Inflammation Biomarkers for Venous Thromboembolism: Is It Reliable for Clinical Practice?

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), has been an important cause of sudden in-hospital death. Studies have shown that the immune/inflammatory response plays an important role in the pathogenesis of vascular disease, with representative markers in the blood including the neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), monocyte/lymphocyte ratio (MLR), systemic immune/inflammatory index (SII), etc. However, there is a variety of immune/inflammatory indicators. Moreover, most previous studies have been single-center investigations involving one or two indicators, with varying nature of cases, number of cases and study objectives, thereby making it difficult to reach consensus conclusions with good clinical guidelines. This article reviews the clinical value of immunoinflammatory indicators for VTE based on previous studies, including the diagnostic and prognostic capabilities. In conclusion, NLR provides promising predictive capability for the onset and prognosis of VTE and deserves extensive application in clinical practice. PLR also has certain diagnostic and prognostic value, but further studies are warranted to identify its reliability and stability. Monocytes, eosinophils and platelet-related indicators show some clinical association with VTE, although the predictive capabilities are mediocre. SII is of promising potential value for VTE and deserves further investigations. This review will provide new clues and valuable clinical guidance for the diagnosis and therapy of VTE.

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.

Blood Cell Count Indexes of Systemic Inflammation in Carotid Artery Disease: Current Evidence and Future Perspectives

Carotid artery disease is commonly encountered in clinical practice and accounts for approximately 30% of ischemic strokes in the general population. Numerous biomarkers have been investigated as predictors of the onset and progression of carotid disease, the occurrence of cerebrovascular complications, and overall prognosis. Among them, blood cell count (BCC) indexes of systemic inflammation might be particularly useful, from a pathophysiological and clinical point of view, given the inflammatory nature of the atherosclerotic process. The aim of this review is to discuss the available evidence regarding the role of common BCC indexes, such as the neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), platelet to lymphocyte ratio (PLR), mean platelet volume (MPV), platelet distribution width (PDW), and red cell distribution width (RDW), in the diagnosis and risk stratification of carotid artery disease, and their potential clinical applications.

Research progress on biomarkers of pulmonary embolism

OBJECTIVES

To present a review on the traditional and new biomarkers of pulmonary embolism (PE).

DATA SOURCE

A systematic search has been carried out using keywords as PE, biomarker, diagnosis and risk stratification.

RESULTS

The results of this work have been structured into three parts: first, conventional biomarkers for vascular, cardiac and inflammation, including static markers and dynamic markers for measuring the time course; next, a review of new biomarkers in recent years, such as RNAs and markers obtained through proteomics and mass spectrometry; finally, use of new detection methods to directly detect the activity of existing markers, such as the determination of coagulation factor II and plasmin activities based on the proteolytic activation of an engineered zymogen.

CONCLUSIONS

This work summarized the characteristics of current traditional biomarkers for clinical diagnosis and risk stratification of PE, as well as a series of newly discovered biomarkers obtained through various clinical experimental methods.

Elevated neutrophil to lymphocyte ratio is associated with decreased amputation-free survival after femoropopliteal percutaneous revascularization

BACKGROUND

An elevated neutrophil-lymphocyte ratio (NLR) is a biomarker associated with adverse outcomes after cardiovascular surgery. This study evaluates the association of preoperative NLR with clinical outcomes after peripheral vascular intervention (PVI) of the femoropopliteal segments.

METHODS

A retrospective review identified 488 patients who underwent percutaneous interventions of femoropopliteal arteries between 2011 and 2018 and had a pre-procedural complete blood count with differential with normal white blood cell count within 30 days prior to intervention. Amputation-free survival (AFS), survival, and freedom from major amputation were assessed using Kaplan-Meier methods. Cohorts of patients with NLR <3 (Low), 3-4 (Mid), and >4 (High) were compared using univariate and multivariable statistical models. In these analyses NLR was analyzed as a continuous variable to correlate with clinical outcomes.

RESULTS

Mean age was 71.7 ± 12.8 years and males constituted 55.5%. The majority of patients presented with chronic limb threatening ischemia (CLTI, 78.5%). Increasing NLR was correlated with increasing rates of comorbidities, except for smoking history. The 30-day mortality rates increased with increasing NLR: 1.4%, 4.3%, and 7.0% for Low (<3), Mid (3-4) and High (>4) NLR groups, respectively (P =.005). Patients with a lower pre-operative NLR achieved significantly greater amputation-free survival at 4-year follow-up: low NLR, 65.5%; mid NLR, 37.5%; and high NLR, 17.6% (P <.0001). By multivariable analysis, increasing NLR, advanced age, CLTI, and dialysis-dependent renal failure reduced AFS.

CONCLUSIONS

Elevated NLR is an independent predictor of decreased AFS following percutaneous interventions of femoropopliteal segments. Further research on identification and modulation of risk factors for high NLR are warranted.

Pre-operative Neutrophil to Lymphocyte Ratio is Associated With 30 Day Death or Amputation After Revascularisation for Acute Limb Ischaemia

OBJECTIVE

Inflammation is an early feature of acute limb ischaemia (ALI), hence the potential prognostic significance of inflammatory biomarkers. This study aimed to assess the value of pre-operative inflammatory biomarkers, specifically the neutrophil to lymphocyte ratio (NLR) and the platelet to lymphocyte ratio (PLR), for predicting an adverse outcome after revascularisation for ALI.

METHODS

All patients submitted to lower limb revascularisation for Rutherford IIa or IIb ALI at the authors' institution between 2009 and 2019 were screened retrospectively. Pre-operative NLR and PLR were analysed, along with other known prognostic factors. Primary outcome was the composite endpoint of 30 day death or amputation.

RESULTS

A total of 345 patients were included, 84 of whom suffered the primary outcome (24.3%). The median follow up was 23.1 months (3.1 - 52.2). Higher age (OR 1.05 per year increase, 95% CI 1.01 - 1.09), diabetes (OR 2.63, 95% CI 1.14 - 6.06), Rutherford grade IIb vs. IIa (OR 5.51, 95% CI 2.11 - 14.42), higher NLR (OR 1.28 per unit increase, 95% CI 1.12 - 1.47), and fasciotomy need (OR 3.44, 95% CI 1.14 - 10.34) were independently associated with 30 day death or amputation, whereas pre-operative statin or anticoagulant medication were associated with a risk reduction (OR 0.23, 95% CI 0.53 - 0.96 and OR 0.20, 95% CI 0.05 - 0.84, respectively). PLR did not show an independent effect on this population. Pre-operative NLR presented a good discriminative ability (AUC 0.86, 95% CI 0.82 - 0.90). A cut off NLR level ≥ 5.4 demonstrated a 90.5% sensitivity and 73.6% specificity for 30 day death or amputation. Kaplan-Meier analysis showed that patients with pre-operative NLR ≥ 5.4 had significantly lower 30 day, six month and one year amputation free survival when compared with those with NLR < 5.4 (64.8 ± 4.0%, 44.1 ± 4.1%, and 37.5 ± 4.1% vs. 98.5 ± 0.9%, 91.9 ± 2.0%, and 85.9 ± 2.5%, log rank p < .001).

CONCLUSION

In this study, higher pre-operative NLR was associated with 30 day death or amputation following intervention for Rutherford grade IIa or IIb ALI. NLR potentially stands as a simple, widely available and inexpensive biomarker that can refine decision making and possibly contribute to ALI morbidity and mortality reduction.

Neutrophil-to-lymphocyte ratio associated with an increased risk of mortality in patients with critical limb ischemia

Purpose

Association of the neutrophil-to-lymphocyte ratio (NLR) with mortality has not been comprehensively explored in critical limb ischemia (CLI) patients. We investigated the association between the NLR and clinical outcomes in CLI.

Materials and methods

We retrospectively enrolled consecutive CLI patients between 1/1/2013 and 12/31/2018. Receiver operating characteristic curve analysis determined NLR cutoffs for 1-year in-hospital, all-cause and cardiac-related mortality; major adverse cardiovascular events (MACEs); and major adverse limb events (MALEs).

Results

Among 195 patients (age, 74.0 years, SD: 11.5; 51.8% male; body mass index, 23.4 kg/m², SD: 4.2), 14.4% exhibited acute limb ischemia. After 1 year, patients with NLR>8 had higher in-hospital mortality (21.1% vs. 3.6%, P<0.001), all-cause mortality (54.4% vs. 13.8%, P<0.001), cardiac-related mortality (28.1% vs. 6.5%, P<0.001), MACE (29.8% vs. 13.0%, P = 0.008), and MALE (28.1% vs. 13.0%, P = 0.021) rates than those with NLR<8. In multivariate logistic regression, NLR≥8 was significantly associated with all-cause (P<0.001) and cardiac-related (adjusted HR: 5.286, 95% CI: 2.075–13.47, P<0.001) mortality, and NLR≥6 was significantly associated with MALEs (adjusted HR: 2.804, 95% CI: 1.292–6.088, P = 0.009). Each increase in the NLR was associated with increases in all-cause (adjusted HR: 1.028, 95% CI: 1.008–1.049, P = 0.007) and cardiac-related (adjusted HR:1.027, 95% CI: 0.998–1.057, P = 0.073) mortality but not in-hospital mortality or MACEs.

Conclusion

CLI patients with high NLRs had significantly higher risks of 1-year all-cause and cardiac-related mortality and MALEs. The NLR can be used for prognostic prediction in these patients.

The relation between neutrophil/lymphocyte and platelet/lymphocyte ratios with mortality and limb amputation after acute limb ischaemia

OBJECTIVE

Acute limb ischaemia is still considered a significant event, with considerable early- and long-term amputation and mortality risk. Our study aims to investigate the predictive role of pre-operative neutrophil/lymphocyte and platelet/lymphocyte ratios in terms of mortality and amputation risk in patients with acute limb ischaemia.

METHODS

Pre-operative blood samples of all patients admitted with acute limb ischaemia were used to calculate neutrophil/lymphocyte and platelet/lymphocyte ratios. Population was subdivided into quartiles by platelet/lymphocyte ratio and neutrophil/lymphocyte ratio values, and Kaplan-Meier life tables were obtained for overall survival and limb salvage. The optimal neutrophil/lymphocyte ratio and platelet/lymphocyte ratio cut-offs were obtained from receiver operating characteristic curves with all-cause mortality and all kinds of amputation. Stepwise multivariate analysis was performed in order to identify independent risk and protective factors for mortality and amputations.

RESULTS

A total of 168 patients were included in the analysis. Receiver operating characteristic curves identified cut-off values for neutrophil/lymphocyte ratio and platelet/lymphocyte ratio: neutrophil/lymphocyte ratio ≥5.57 for mortality; neutrophil/lymphocyte ratio ≥6.66 and platelet/lymphocyte ratio ≥269.9 for all amputations. Kaplan-Meier analysis revealed that survival rate in group neutrophil/lymphocyte ratio <5.57 was 83.4%, 78.9%, 73.7%, and 59.8%, respectively, at 12, 24, 36, and 48 months; in neutrophil/lymphocyte ratio ≥5.57 group was 62.4%, 51.3%, 47.8, and 43.7%, respectively (p < 0.0001). Freedom from all amputations was significantly higher in case of neutrophil/lymphocyte ratio and platelet/lymphocyte ratio below the identified cut-off values (p < 0.0001). Neutrophil/lymphocyte ratio and platelet/lymphocyte ratio were found as independent risk factors.

CONCLUSION

Neutrophil/lymphocyte ratio and platelet/lymphocyte ratio are reliable markers for stratification of mortality and limb amputations in patients with acute limb ischaemia. The inexpensive nature and ready availability of these biomarkers' values reinforced their usefulness in everyday clinical practice.

Neutrophil to Lymphocyte Ratio as a Predictor of Long-Term Outcome in Peritoneal Dialysis Patients: A 5-Year Cohort Study

INTRODUCTION

The mortality of peritoneal dialysis (PD) patients remains high. The neutrophil to lymphocyte ratio (NLR), as an indicator of systemic inflammation, has been considered to be a predictor of cardiovascular and all-cause mortality in hemodialysis patients. The present study aims to investigate the relationship between NLR and long-term outcome in PD patients.

MATERIALS AND METHODS

The study included patients who initiated PD for at least 3 months between January 1, 2013, and December 31, 2015. All the patients were followed up until death, cessation of PD, or to the end of the study (June 31, 2018). NLR was calculated as the ratio of neutrophils to lymphocytes.

RESULTS

A total of 140 patients were included in this study. The median NLR reported was 2.87. Patients with lower NLR showed a higher survival rate than patients with higher NLR (log rank 6.886, p = 0.009). Furthermore, patients with higher NLR had a significantly higher cardiovascular mortality (log rank 5.221, p = 0.022). Multivariate Cox proportional hazards model showed that older age (HR 1.054, 95% CI 1.017-1.092, p = 0.004), higher Ca × P (HR 1.689, 95% CI 1.131-2.523, p = 0.010), and higher NLR (HR 2.603, 95% CI 1.037-6.535, p = 0.042) were independent predictors of increased all-cause mortality. NLR was also independently associated with cardiovascular mortality (HR 2.886, 95% CI 1.005-8.283, p = 0.039). Higher NLR (HR 2.667, 95% CI 1.333-5.337, p = 0.006), older age (HR 1.028, 95% CI 1.005-1.052, p = 0.016), and history of cardiovascular disease (HR 1.426, 95% CI 1.195-3.927, p = 0.031) were significantly independently associated with poor peritonitis-free survival in this study.

CONCLUSIONS

NLR could be a strong predictor of long-term outcome in PD patients.

Critical limb ischemia patients clinically improving with medical treatment have lower neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios

OBJECTIVES

Inflammation is a component in the pathogenesis of critical limb ischemia. We aimed to assess how inflammation affects response to treatment in patients treated for critical limb ischemia using neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocytes ratios (PLR) as markers of inflammation.

METHODS

Patients in a single tertiary cardiovascular center with critical limb ischemia unsuitable for surgical or interventional revascularization were retrospectively identified. Data were collected on medical history for risk factors, previous surgical or endovascular revascularization, and outcome. A standard regimen of low molecular weight heparin, aspirin, statins, iloprost infusions, and a standard pain medication protocol were applied to each patient per hospital protocol. Patients with improvement in ischemic pain and healed ulcers made up the responders group and cases with no worsening pain or ulcer size or progression to minor or major amputations made up the non-responders group. Responders and Non-responders were compared for risk factors including pretreatment NLR and PLR.

RESULTS

268 included patients who were not candidates for surgical or endovascular revascularization were identified. Responders had significantly lower pretreatment NLR (4.48 vs 8.47, p < 0.001) and PLR (162.19 vs 225.43, p = 0.001) values. After controlling for associated risk factors NLR ≥ 4.63 (p < 0.001) and PLR ≥ 151.24 (p = 0.016) were independently associated with no response to treatment.

CONCLUSIONS

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocytes ratio are markers of inflammation that are reduced in patients improving with medical treatment suggesting a decreased state of inflammation before treatment in responding patients.

Characteristics and clinical indicators of concomitant venous thromboembolism in acute limb ischemia

BACKGROUND

Venous thromboembolism (VTE) concomitant to acute limb ischemia (ALI) is rarely reported. The aim of the study was to investigate characteristics and identify clinical indicators of VTE in patients with ALI.

METHODS

Electronic medical record was used to identify patients diagnosed with ALI from January 2013 to June 2019. Eligible patients were categorized as VTE or non-VTE based on the presence or absence of concomitant VTE. Univariate analysis and multivariate analysis for indicators of VTE were performed.

RESULTS

A total of 153 patients with 161 ischemic limbs were enrolled. Venous duplex ultrasound (DUS) for 149 patients (157 ischemic limbs) revealed deep vein thrombosis (DVT) in 38 (24.2%) ischemic limbs of 37 (24.8%) patients. Five femoral DVTs were found intraoperatively. Six patients had pulmonary embolism (PE) and three of them died. In all, 43 (28.1%) ALI patients were diagnosed with VTE. They were treated with trans-arterial catheter-directed thrombolysis (N.=22), embolectomy (N.=9), primary amputation (N.=4) and anticoagulation alone (N.=8). The univariate analysis indicated that symptoms ≥ 2 days [odds ratio (OR): 3.42, 95%CI:1.54-7.62], Rutherford classification IIb-III (OR: 9.17, 95%CI: 2.10-40.12), leg swelling (OR: 4.44, 95%CI: 2.07-9.53), neutrophil ratio ≥0.80 (OR: 3.92, 95%CI: 1.72-8.93) and positive D-dimer (OR: 8.44, 95%CI: 3.65-19.53) were indicators of VTE concomitant to ALI. In the multivariate analysis, leg swelling and positive D-dimer appeared to be independent indicators.

CONCLUSIONS

VTE commonly occurs to ALI. Venous DUS for DVT screening should be considered for ALI patients who present one or more of these indicators.

New inflammatory and oxidative stress-based biomarker changes in response to a half-marathon in recreational athletes

BACKGROUND

Modulation of oxidative stress/inflammation during exercise may have both positive and negative health effects, depending by a number of factors (e.g. training status, and exercise type, intensity and duration) and the oxidative stress or inflammation-related biomarkers considered, which may reflect different levels of the oxidative stress/inflammatory multi entities. The aim of this study was to evaluate oxidative stress and inflammatory multi-biomarker panel in response to a half-marathon during early and delayed recovery.

METHODS

Blood samples (baseline, postrace within 20 min after the race end, and 24 h and 48 h after the run) from runners (N.=31, 20 males, mean age 47±6 years) were assessed for reactive oxygen species (ROM assay) and total antioxidant capacity (OXY test), leukocyte telomere length (LTL), procoagulant activity of circulating microparticles (MP-PCA), inflammatory parameters obtained by hemocrome, and irisin.

RESULTS

A significant decrease for OXY (from 375±71 to 280±66, 239±54, 239±45 µmolHClO/mL) after the half-marathon and during recovery was observed. A reduction for ROMs was also evidenced respect to baseline (from 328±46 to 301±39, 290±56, 320±55 AU). Instead, MP-PCA increased after the race (from 6.2±6 to 10.5±6, 7±4.3 and 5.8±2.1 nmol/L), whereas the other biomarkers did not significantly change.

CONCLUSIONS

The oxidant counterpart did not increase in response to the half-marathon, likely counteracted by antioxidants, which appeared greatly worn out. MP-PCA and WBC increase, always within the normality range, may represent an adaptation to regular chronic endurance training. In any case, antioxidant supply could be considered and tailored for each athlete in this exercise setting.

Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio in Patients with Retinal Artery Occlusion

Purpose

This study aimed to compare the neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios in patients with retinal artery occlusion (RAO) with those from a healthy control population and to identify the relationship between them.

Methods

Forty-six patients with RAO and fifty-one healthy control subjects were included in this retrospective case-control study. RAO was diagnosed following an ophthalmic examination and fluorescein angiography (FA). Blood neutrophil, lymphocyte, and platelet counts were recorded for each of the 97 subjects, from which NLR and PLR values were calculated.

Results

There were 46 patients (28 male [M], 18 female [F]) in the RAO group and 51 patients (27 M, 24 F) in the control group. No significant differences were found between patients with RAO and the control subjects in terms of gender and age (P > 0.05). Patients with RAO had significantly increased NLR values (2.85 ± 1.70) than the control subjects (1.63 ± 0.59, P < 0.001). The mean PLR in patients with RAO was 123.69 ± 64.98, while that in control subjects was 103.08 ± 36.95; there was no significant difference between the two groups (P = 0.055). A logistic regression analysis revealed that NLRs were 3.8 times higher in patients with RAO than in control subjects (odds ratio = 3.880; 95% confidence interval = 1.94 to 7.74; P < 0.001).

Conclusion

NLRs were significantly increased in patients with RAO compared to the control subjects.

Elevated neutrophil-lymphocyte ratio predicts mortality following elective endovascular aneurysm repair

OBJECTIVE

The neutrophil-lymphocyte ratio (NLR) is an inexpensive and useful inflammatory marker that incorporates the balance of the innate (neutrophil) and adaptive (lymphocyte) immune responses. Data exist on the association between NLR and mortality in various coronary diseases and in cancer surgery, but there is a paucity of data on the impact of preoperative NLR on vascular surgical outcomes. The aim of this study was to evaluate the relationship between preoperative NLR and elective endovascular aortic aneurysm repair (EVAR) outcome.

METHODS

A retrospective review of all patients who underwent elective EVAR at a single institution between 2010 and 2018 was conducted (n = 373). Only patients who had a preoperative complete blood count with differential within 30 days of their operation were included. The NLR was computed by dividing the absolute neutrophil count by the absolute lymphocyte count. A receiver operating characteristic curve was used to determine the optimal cutoff value of NLR with the strongest association with mortality. NLR was dichotomized so that patients with NLR above the threshold were at increased risk of mortality compared with those below it. Continuous variables were analyzed using Wilcoxon nonparametric signed-rank test and categorical variables with the Fisher exact test. A comparison of NLR and mortality was completed using Kaplan-Meier survival analysis. Cox regression analysis was used to evaluate factors associated with mortality through 5-year follow-up.

RESULTS

Overall, 108 patients were included in this study. An NLR ≥ 4.0 was found to be associated with mortality (P < .0001). Thirty-two patients composed the High-NLR (NLR ≥ 4.0) group and the remaining 76 patients formed the Low-NLR (NLR < 4.0) group. Baseline characteristics were similar between groups, except that the High-NLR group was older (77.9 vs 74.4; P = .047). At a mean of 36.4 months follow-up, the overall mortality rate was 32.4%. Although there were no differences in the perioperative period, the Kaplan-Meier estimates of mortality were significantly greater in the High-NLR group at 1, 2, and 5 years postoperatively (P < .0001). The mean preoperative NLR of the deceased was higher (5.94 ± 5.20; median, 4.75; interquartile range, 3.17-7.83) than those who survived (2.87 ± 1.61; median, 2.53; interquartile range, 1.97-3.49) (P < .0001). Secondary interventions and sac enlargement rates were similar between groups. On univariable analysis, NLR (hazard ratio [HR], 1.17; 95% confidence interval [CI], 1.10-1.23; P < .0001), age (HR, 1.06; 95% CI, 1.02-1.11; P = .004), and aneurysm diameter (HR, 1.04; 95% CI, 1.01-1.07; P = .003) were associated with mortality. On multivariable analysis, NLR (HR, 1.19; 95% CI, 1.12-1.27; P < .0001), age (HR, 1.06; 95% CI, 1.01-1.11; P = .026), and aneurysm diameter (HR, 1.04; 95% CI, 1.02-1.07; P = .003) were associated with mortality.

CONCLUSIONS

Patients with an elevated preoperative NLR, irrespective of other comorbidities, may represent a previously unrecognized subset of patients who are at heightened risk of mortality after elective EVAR. A complete blood count with differential is an inexpensive test that may be used as a prognostic indicator for outcome after EVAR. Further research is warranted to identify clinical, pathological, or anatomical factors associated with an elevated NLR and to determine modifiable factors, which may help improve long-term survival.

Fibrinogen, Neutrophil-to-Lymphocyte Rate and Platelet-to-Neutrophil Rate as Novel Acute Phase Indicators in Patients with Thromboangiitis Obliterans

BACKGROUND/OBJECTIVES

The acute exacerbations and progressive deterioration seen in thromboangiitis obliterans (TAO) have been related to poor clinical outcomes. Here, we have studied the association of laboratory biomarkers with the acute phase of TAO (AP-TAO).

METHODS/RESULTS

We conducted a retrospective case-control study on 112 patients with TAO and 98 healthy controls; comparing the neutrophil-to-lymphocyte rate (NLR), lymphocyte-to-monocyte rate (LMR), platelet-to-neutrophil rate (PNR), fibrinogen (FIB), and apolipoprotein A-I (ApoA-I). Significantly higher NLR level, as well as lower LMR, PNR, and ApoA-I levels were observed in patients with TAO, particularly the acute phase. Significantly increased FIB was only observed in AP-TAO. A positive correlation was found between NLR and with C-reactive protein (CRP) in the acute phase (r = 0.817, P < 0.001). Moreover, NLR, PNR, and FIB levels of 3.38, 45.12, and 3.69 were shown to be the predictive cut-off values for the AP-TAO (sensitivity 72.5, 82,4, and 66,7%, specificity 92.2, 78.4, and 96.1%; area under the curve [AUC] 0.875, 0.855, and 0.872), respectively. The FIB level was independently associated with the AP-TAO (OR = 11.420, P = 0.007).

CONCLUSIONS

NLR, PNR, and FIB may be useful markers for the identification of inflammation and the AP-TAO. FIB may be an independent risk factor for the acute phase.

Associations of left ventricular systolic dysfunction with the factors among Thai patients on peritoneal dialysis: a cross-sectional study

Background

Factors associated with left ventricular systolic dysfunction (LVSD) of peritoneal dialysis (PD) patients are limited. We aim to explore and quantify the associated factors of LVSD among PD patients.

Methods

Participants from a PD clinic treated between 2012 and 2014 at the HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakhon Nayok, Thailand were recruited and divided into 2 groups according to their left ventricular ejection fraction (LVEF) (< 50% vs. ≥ 50%) with LVEF < 50% considered as LVSD. Correlations among the clinical, laboratory and echocardiographic variables were analyzed. The factors associated with LVSD were explored with univariate and multivariate logistic regression analyses. Beta coefficient along with odds ratio and 95% confidence interval (CI) were calculated and the P value < 0.05 was considered significant.

Results

Among 103 subjects stratified as LVSD (n = 18, 17.5%). The mean (SD) age was 59.3 (12.7) years, and nearly halves were males. Preexisting CAD, diabetes (DM) and current smoking were 20 (19.4%), 63 (61.2%) and 23 (22.3%) patients, respectively. The median time of dialysis vintage was 12 (3, 24) months. Factors associated with LVSD and corresponding ORs with 95% CI by multivariate analysis were prior coronary artery disease (CAD) [5.08 (1.16, 22.19)], DM [6.36 (1.29, 31.49)], smoking [10.62 (2.17, 51.99)], neutrophil to lymphocyte ratio (NLR) > 3.6 [6.77 (1.41, 32.52)], and high serum phosphate [9.39 (2.16, 40.92)] were significantly associated with LVSD.

Conclusions

Prior history of CAD, DM, smoking, high NLR and serum phosphate levels were found to be associated with LVSD for our PD patients. The evidence from prospective study is needed to confirm the predictive value of these variables.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1418-7) contains supplementary material, which is available to authorized users.

Neutrophil-to-lymphocyte ratio for early renal failure under extracorporeal membrane oxygenation support for postcardiotomy shock

Background

This study aims to investigate the relationship between the neutrophil-to-lymphocyte ratio and renal injury in patients under extracorporeal membrane oxygenation support for postcardiotomy shock.

Methods

Between January 2007 and July 2018, a total of 119 patients (38 males, 81 females; mean age 54.4±13.0 years; range, 24 to 74 years) who received extracorporeal membrane oxygenation support for postcardiotomy shock and survived at least 48 hours in our center were retrospectively analyzed. Pre- and postoperative neutrophil-to-lymphocyte ratios, demographic characteristics, renal function parameters, and extracorporeal membrane oxygenationrelated data of the patients were recorded. Occurrence and stages of renal injury was determined using the revised Acute Kidney Injury Network and Kidney Disease Improving Global Outcomes criteria.

Results

No significant relationship was found between preoperative neutrophil-to-lymphocyte ratio and renal injury (p>0.05). Postoperative neutrophil-to-lymphocyte ratio was higher in patients who developed renal injury, compared to patients without renal injury (8.68 [0.84-42.00] vs. 4.02 [1.04-21.21], respectively, p=0.004). When patients were grouped for renal injury stage according to the revised Acute Kidney Injury Network (p=0.015) and Kidney Disease Improving Global Outcomes (p=0.006) criteria, the patients with more severe renal injury had higher neutrophil-to-lymphocyte ratio. The receiver operating characteristics analysis revealed a cut-off value of 6.71 for the neutrophil-to-lymphocyte ratio for the detection of renal injury. Patients with a value above 6.71 had an odds ratio of 5.941 for occurrence of renal injury.

Conclusion

Postoperative, but not preoperative neutrophil-tolymphocyte ratio is associated with presence and severity of renal injury in patients under extracorporeal membrane oxygenation support for postcardiotomy shock. Neutrophil-to-lymphocyte ratio is a simple and inexpensive marker of inflammation in this patient population.

Combined assessment of peritumoral Th1/Th2 polarization and peripheral immunity as a new biomarker in the prediction of BCG response in patients with high-risk NMIBC

Intravesical Bacille Calmette-Guérin (BCG) remains the most effective treatment for high-risk non-muscle-invasive bladder cancer (NMIBC), unfortunately there is no validated biomarker to predict clinical outcome. Here we tried to explore the possibility that a combination of the density of peritumoral infiltrating cells (Th1, Th2 and PD-L1) and the composition of peripheral immune cells (neutrophil and lymphocyte counts) could generate a more reliable prognostic biomarker. Twenty-two patients with high-risk NMIBC treated with BCG (10 BCG nonresponders and 12 BCG responders) were selected. BCG responders had significantly lower level of peritumoral T-bet⁺ cells with an associated higher GATA-3⁺/T-bet⁺ ratio (p = 0.04, p = 0.02, respectively). Furthermore, the immune polarization in tissue (GATA-3⁺/T-bet⁺ ratio) adjusted for the systemic inflammation (neutrophil-to-lymphocyte ratio) showed a significantly higher association with the BCG response (p = 0.004). A survival analysis demonstrated prolonged recurrence-free survival (RFS) in patients with a lower T-bet⁺/Lymphocyte ratio and higher GTR/NLR (p = 0.01). No association was observed between peritumoral PD-L1⁺ expression and the BCG response. In conclusion, alterations in overall immune function, both local and systemic, may influence the therapeutic response to BCG, therefore a combined analysis of tumoral (Th2/Th1 ratio) and peripheral (NLR) immune composition prior to treatment may be a promising approach to predict the BCG response in high-risk NMIBC patients.

Mediation Effect of Neutrophil Lymphocyte Ratio on Cardiometabolic Risk Factors and Cardiovascular Events

Neutrophil to lymphocyte ratio (NLR), an inflammatory biomarker, is associated with cardiovascular events (CVEs), but its causal pathway is unknown. We aimed to explore the extent to which NLR is directly associated with CVEs or mediated through diabetes mellitus (DM), hypertension (HT) and creatinine (Cr). The study used data on 2,501 subjects from the Electricity Generating Authority of Thailand cohort 2002-2012. Two causal pathways A: NLR→(DM→Cr→HT)→CVEs and B: NLR→(DM → HT→Cr)→CVEs were constructed. A generalized structural equation model and 1,000-replication bootstrapping were applied. The incidence rate of CVE was 8.8/1000/year. Prevalence rates of HT, DM, and chronic kidney disease were 45.1%, 23.6%, and 16.5%, respectively. The total effect of NLR on CVEs was explained partly (44%) by a direct effect and partly (56%) by an indirect effect through DM, HT and Cr. For pathway A, the direct OR of NLR on CVE was 1.25 (95% CI: 1.13, 1.39); the ORs for the indirect effects of NLR on CVEs mediated through DM, Cr, and poor-controlled HT were 1.06 (95% CI: 1.01, 1.11), 1.01 (95% CI: 1.00, 1.02), and 1.07 (95% CI: 1.01, 1.14) respectively. Results were similar for pathway B. Our findings demonstrate that roughly half of the relationship between NLR and CVEs may be mediated through DM, HT and Cr.

Blood Cell Parameters and Predicting Coronary In-Stent Restenosis

Major advances in coronary interventional techniques and pharmacotherapy as well as the use of drug-eluting stents (DESs) have considerably reduced the risk of in-stent restenosis (ISR). However, ISR remains a major clinical challenge. Inflammation and platelet activation are important processes that underlie the pathophysiology of ISR. Parameters related to blood cells, entailing both cell count and morphology, are useful markers of the inflammatory response and platelet activation in clinical practice. Recent studies have highlighted several new combined or derived parameters related to blood cells that independently predict ISR after DES implantation. The neutrophil/lymphocyte ratio, an inflammatory marker, is regarded as a predictor of the risk of ISR and the stability of atherosclerotic plaques. The mean platelet volume, a widely used platelet activation parameter, has been shown to be a predictor of the risk of ISR and the efficacy of antiplatelet therapy. Other markers considered include the platelet/lymphocyte ratio, red blood cell distribution width, and platelet distribution width. This review provides an overview of these parameters that may help stratify the risk of coronary angiographic and clinical outcomes related to ISR.

Relationship Between Postoperative Neutrophil-Lymphocyte Ratio and 6-Month Primary Patency of Percutaneous Transluminal Angioplasty in Femoropopliteal disease With Drug-Coated and Uncoated Balloons

We investigated the relationship of postoperative neutrophil-lymphocyte ratio (NLR) with 6-month primary patency of percutaneous transluminal angioplasty (PTA) in femoropopliteal disease using drug-coated balloon (DCB) or uncoated balloon (UCB). This retrospective study included 106 patients who received DCB (n = 44) or UCB (n = 62). The postoperative NLR was lower in the DCB group than that in the UCB group (2.60 vs 3.23; P = .004), and 6-month primary patency rate was significantly higher in DCB group than that in the UCB group (77.3% vs 53.2%; P = .011). Multivariate logistic analysis showed that the postoperative NLR was an independent predictor of 6-month primary patency after PTA in patients with femoropopliteal disease (odds ratio: 1.589, 95% confidence interval: 1.078-2.343; P = .019). The cutoff value of postoperative NLR was 3.05 for prediction of 6-month primary patency, with a sensitivity of 64.1% and specificity of 65.7%. The 6-month primary patency rate in the NLR ≤3.05 group was higher than that in the NLR >3.05 group (75.9% vs 47.9%; P = .003). In conclusion, DCB may improve early primary patency by inhibiting inflammation. A higher postoperative NLR was associated with early restenosis.

Neutrophil to lymphocyte ratio at diagnosis can estimate vasculitis activity and poor prognosis in patients with ANCA-associated vasculitis: a retrospective study

BACKGROUND

Neutrophil to lymphocyte ratio (NLR) was introduced to predict poor prognosis in various diseases, but not all variants of ANCA-associated vasculitis (AAV). In this study, we aimed to investigate whether NLR at diagnosis can estimate vasculitis activity at diagnosis and poor prognosis during follow-up in patients with AAV.

METHODS

We retrospectively reviewed the medical records of 160 patients with AAV. We collected clinical and laboratory data at diagnosis and obtained remission and death as poor prognosis. We stratified AAV patients into three groups according to tertile and defined the lower limit of each highest tertile as the optimal cut-off (5.9 for NLR and 15.0 of Birmingham vasculitis activity score [BVAS] for severe AAV).

RESULTS

The mean age at diagnosis was 55.2 years and 48 patients were men. In the univariable linear regression analysis, BVAS was negatively correlated with lymphocyte count and positively correlated with erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and NLR. In the multivariable linear regression analyses of ESR and CRP with either lymphocyte count or NLR, lymphocyte count (β = - 0.160) and NLR (β = 0.169) were associated with BVAS. Patients having NLR ≥ 5.9 exhibited severe AAV more frequently than those having NLR < 5.9 at diagnosis (relative 2.189, P = 0.023). Patients having NLR ≥ 5.9 exhibited a higher frequency of AAV relapse, but not death, than those having NLR < 5.9 (P = 0.016).

CONCLUSIONS

NLR at diagnosis can estimate vasculitis activity at diagnosis and predict relapse during follow-up in patients with AAV.

Prognostic role of neutrophils to lymphocytes ratio in patients with acute pulmonary embolism: a systematic review and meta-analysis of the literature

The prognostic assessment of patients with acute pulmonary embolism (PE) is essential to drive its management. The search for new prognostic factors is a central issue for a more accurate estimate of short-term adverse events. Circulating neutrophils/lymphocytes ratio (NLR) has been suggested as prognostic biomarker for different cardiovascular diseases. Given the central role of inflammation, and in particular of neutrophils in the pathogenesis of VTE and its clinical history, NLR might represent a prognostic tool also in this setting. We performed a systematic review and meta-analysis of the literature to assess the prognostic role of NLR in patients with acute PE. MEDLINE and EMBASE were searched up to 2017, week 21. A bivariate random-effects regression approach was used to obtain summary estimate of accuracy of the high NLR adjusting for inter-study variability. Six studies for a total of 1424 patient are included. High NLR has a weighted mean sensitivity of 77% (95% CI 68-83) and a weighted mean specificity of 74% (95% CI 68-79). High NLR positive and negative predictive values are 24.4% (95% CI 20.4-28.3) and 96.7% (95% CI 95.6-97.8), respectively. The relevant impact of NLR on short-term mortality after an acute PE makes it a promising biomarker to better stratify patient prognosis.