C-Reactive Protein to Serum Albumin Ratio Is an Independent Predictor of All-Cause Mortality in Patients with ANCA-Associated Vasculitis

Potential biomarkers in Behçet's disease: monocyte, neutrophil, platelet, and C-reactive protein to albumin ratios

Introduction

The objective of this cross-sectional study was to evaluate the monocyte to albumin ratio (MAR), neutrophil to albumin ratio (NAR), platelet to albumin ratio (PAR), and C-reactive protein to albumin ratio (CAR) as potential biomarkers for disease activity in patients with Behçet's disease (BD).

Material and methods

Both BD cases and healthy controls were enrolled in this study. Demographic characteristics, disease duration, and current medications were recorded for all participants. The BD Current Activity Form (BDCAF) was utilized to assess the activity of BD. Additionally, erythrocyte sedimentation rate, CRP, and serum albumin levels were measured. The MAR, NAR, PAR, and CAR were compared between the two groups. Correlation analysis and receiver operating characteristic curves (ROC) were employed to establish cut-off points for these biomarkers.

Results

In the study, both BD cases and 45 controls were included, totaling 90 participants. Significant differences were observed in the mean ±SD values of ESR, MAR, PAR, CAR, and albumin between the BD cases and controls (p = 0.008, p = 0.009, p = 0.029, p = 0.034, p = 0.006, respectively). However, despite these differences, no significant correlation was detected between BDCAF and the parameters under investigation. The cut-off point was determined as 150.59 (sensitivity 46.67%, specificity 82.22%, p = 0.008, AUC = 0.655) for MAR; as 62,013.73 (sensitivity 60.00%, specificity 66.67%, p = 0.03, AUC = 0.629) for PAR; and as 1.16 (sensitivity 35.56%, specificity of 95.567%, p = 0.03, AUC = 0.629) for CAR. The results were not able to define any cut-off points for active-inactive BD.

Conclusions

Significantly higher levels of MAR, PAR, and CAR were observed in patients with BD than controls. Monocyte to albumin ratio, PAR, and CAR were notably elevated in patients with active BD. This finding suggests that these parameters possess discriminative ability and could potentially serve as biomarkers to aid in the clinical evaluation of BD.

Novel Inflammatory Markers Associated With Cutaneous Leukocytoclastic Vasculitis Etiology

Objectives

We aimed to compare inflammatory markers and determine their potential role in distinguishing secondary leukocytoclastic vasculitis (SLV) from idiopathic leukocytoclastic vasculitis (ILV).

Materials and Methods

We included in this cross-sectional study patients with cutaneous leukocytoclastic vasculitis (CLV) diagnosed on cutaneous biopsy. We assessed clinical and laboratory data and then calculated platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP)-to-albumin ratio (CAR), and fibrinogen-to-albumin ratio (FAR). We have also defined the number of positive etiological examination (NPE) as the sum in a unique patient of the positive paraclinical examinations involved in the etiological assessment of CLV.

Results

In total 77 patients were included, with 52 SLV group patients and 25 in the ILV group, mean age was 44+/-18 vs 49+/-21, and gender ratio was 29/23 vs 11/14. Comparison of PLR, NLR, CAR, and FAR showed significant differences in mean values between SLV and ILV groups with 199.1 (117.3-309.8) vs 126.8 (79-193) (P = 0.01) for PLR, 3.6 (1.9-5.1) vs 2.3 (1.7-3.4) (P = 0.048) for NLR, 1.9 mg.g-1 (0.4-3.6) vs 0.6 mg g-1 (0.2-1.9) (P = 0.043) for CAR, and 155.8 mg.g-1 (90.7-192.3) vs 108.7 mg.g-1 (82.2-148.1) (P = 0.034) for FAR. PLR, CAR, and FAR were positively correlated to NPE (r = 0.463, P < 0.001; r = 0.434, P < 0.001; and r = 0.411, P < 0.001, respectively), and there was no significant correlation between NLR and NPE (r = 0.165, P = 0.151).

Conclusion

This is the first study to investigate PLR, NLR, CAR, and FAR in CLV, and it demonstrates that elevation of these ratios is associated with SLV, which leads us to suggest to exhaustively explore patients with elevated ratios.

A predictive mortality score in ANCA-associated renal vasculitis

BACKGROUND

Several scores have been developed to predict mortality at anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) diagnosis. Their prognostic value in Caucasian patients with kidney involvement (AAV-GN) remains uncertain as none has been developed in this specific population. We aimed to propose a novel and more accurate score specific for them.

METHODS

This multicentric study included patients diagnosed with AAV-GN since January 2000 in four nephrology centers (recorded in the Maine-Anjou AAV-GN Registry). Existing scores and baseline characteristics were assessed at diagnosis before any therapeutic intervention. A multivariable analysis was performed to build a new predictive score for death. Its prognosis performance (area under receiving operating curve and C-index) and accuracy (Brier score) was compared with existing scores. One hundred and eighty-five patients with AAV-GN from the RENVAS registry were used as a validation cohort.

RESULTS

A total of 228 patients with AAV-GN from the Maine-Anjou registry were included to build the new score. It included the four components most associated with death: age, history of hypertension or cardiac disease, creatinine and hemoglobin levels at diagnosis. Overall, 194 patients had all the data available to determine the performance of the new score and existing scores. The new score performed better than the previous ones in the development and in the validation cohort. Among the scores tested, only Five-Factor Score and Japanese Vasculitis Activity Score had good performance in predicting death in AAV-GN.

CONCLUSIONS

This original score, named DANGER (Death in ANCA Glomerulonephritis-Estimating the Risk), may be useful to predict the risk of death in AAV-GN patients. Validation in different populations is needed to clarify its role in assisting clinical decisions.

Role of the C-reactive Protein-to-Albumin Ratio in Assessing Disease Activity in Elderly Patients With Rheumatoid Arthritis

OBJECTIVE

Nowadays, one measure that is more helpful in assessing the level of inflammation than either C-reactive protein (CRP) or albumin alone is the C-reactive protein-to-albumin ratio (CAR). Our study set out to assess the CAR in elderly individuals with rheumatoid arthritis (RA) and its correlation with other parameters.

METHODS

Included in the research were patients who were being followed up on for RA between January 2021 and January 2024 and categorized according to their age at the time of enrolment and assigned to one of two groups: younger patients, defined as <60 years of age, and those aged ≥60 years, who were recorded as elderly patients. The clinical evaluation of the patients and laboratory data measured for each patient included age, gender, disease duration, medications, CRP, erythrocyte sedimentation rate (ESR), albumin, neutrophil-to-lymphocyte ratio (NLR), and CAR. Disease activity was assessed with the disease activity score 28 (DAS 28)-ESR. The health assessment questionnaire was used to measure the functional status.

RESULTS

Ninety-four patients (<60 years: 58 and ≥60 years: 36) were included. The mean age of the elderly patients was 65.80 ± 5.33 years. Female predominance was similar in both the RA groups (<60 years: 50 patients (86.2%) vs. ≥60 years: 31 (86.1%)). The distribution of biological and disease-modifying drugs did not significantly differ between the groups. With the exception of albumin, there was no statistically significant difference between the groups for ESR, CRP, CAR, NLR, or DAS28-ESR. Elderly patients with a DAS28-ESR of 2.6 and above had a statistically significant higher CAR than the remission group (3.44±3.73 vs. 2.71±5.73, respectively). There was no statistically significant difference in the NLR value of elderly patients with a DAS28-ESR of 2.6 and above compared to the remission group (3.06 ± 2.95 vs. 2.65 ± 1.38, respectively). In addition, CAR was positively correlated with ESR, CRP, and DAS28-ESR (r = 0.726, p < 0.001; r = 0.954, p < 0.001; r = 0.339, p = 0.043, respectively). However, there was no discernible correlation between CAR and HAQ, NLR, or disease duration.

CONCLUSION

In elderly RA patients, our study demonstrated the correlation between CAR and inflammatory biomarkers and the DAS28-ESR. According to this, CAR may prove to be a useful biomarker for assessing inflammation and disease activity in clinical settings.

The Efficacy of C-Reactive Protein (CRP) to Albumin Ratio (CAR) and Fibrinogen to CRP Ratio (FCR) in Predicting the Latent Period of Preterm Labor

OBJECTIVE

To investigate the role of inflammatory markers, including neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and monocyte to lymphocyte ratio (MLR), c-reactive protein (CRP) to albumin ratio (CAR), fibrinogen to albumin ratio (FAR), and fibrinogen to CRP ratio (FCR) in predicting the latency period (≤72 vs. >72 hours) before preterm birth.

MATERIALS AND METHODS

In a retrospective study, we assessed 135 patients meeting the specified criteria with signs of preterm labor (<34 weeks). The patients were categorized into two groups: 71 patients giving birth within 72 h (latency ≤ 72 h) and 64 patients giving birth after 72 h (latency > 72 h). We examined the demographic and medical characteristics and perinatal outcomes of all participants. Categorical variables between groups were compared using the Chi-square test. The Student's t-test was utilized for normally distributed continuous variables, and the Mann-Whitney U test was applied for non-normally distributed data. Receiver operating characteristic (ROC) curve analysis was conducted to identify the optimal cut-off levels for inflammatory markers in predicting the latency period before birth.

RESULTS

Among the parameters examined, significant differences were observed between the groups only in terms of CAR and FCR. While CAR showed a significantly higher value in the group with latency period ≤72 h (0.537 ± 1.239 vs. 0.247 ± 0.325, p = 0.022), FCR showed a significantly lower value in the group with latency period ≤72 h (63.58 (2.99-1165) vs. 88.93 (9.35-1165), p = 0.013). The identified cut-off value for CAR was 0.190, providing a sensitivity of 57.7% and a specificity of 56.3% (p = 0.022). The cut-off value for FCR was 71.67, with a sensitivity of 42.3% and a specificity of 42.2% (p = 0.013).

CONCLUSIONS

The CAR and the FCR, serving as predictive markers for preterm labor, may offer a simple, cost-effective, and easily accessible approach, particularly in resource-limited settings.

Time to normalisation of C-reactive protein and incidence of relapse in microscopic polyangiitis: A medical records review study in Japan

OBJECTIVES

Despite the identification of risk factors for relapses in antineutrophil cytoplasmic antibody-associated vasculitis, the relationship between changes in C-reactive protein (CRP) levels after the initial treatment and the incidence of relapse remains unknown. This study aimed to assess the association between the time taken for normalisation of CRP levels and the incidence of relapse in Japanese adult patients with microscopic polyangiitis.

METHODS

This study included 85 consecutive patients with newly diagnosed microscopic polyangiitis who achieved remission after 6 months of immunosuppressive treatment at the Aichi Medical University Hospital between 2009 and 2017. The relationship between the time to normalisation of CRP after the initial immunosuppressive treatment and relapse incidences was evaluated using multivariable Cox proportional hazard models.

RESULTS

During the follow-up period, 13 (30.2%), 7 (41.2%), and 16 (64.0%) patients relapsed (P = .025) within 1-14, 15-28, and ≥29 days of normalisation, respectively. The hazard ratios [95% confidence intervals (CIs)] for the time to normalisation of CRP of 1-14, 15-28, and ≥29 days were 1.00 (reference), 2.42 (95% CI: 0.92-6.39), and 3.48 (95% CI: 1.56-7.76), respectively.

CONCLUSIONS

A significant association between the time to normalisation of CRP and the relapse incidence in Japanese patients with microscopic polyangiitis was observed.

C-Reactive Protein Levels Are Associated with Complement C4 Deposits and Interstitial Arteritis in ANCA-Associated Renal Vasculitis

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a potentially life-threatening systemic small-vessel vasculitis that is characterized by pauci-immune glomerulonephritis in case of kidney involvement, representing a major denominator of AAV mortality. Innate immunity with complement system activation is increasingly recognized in the pathogenesis of AAV and as an attractive therapeutic target. Although C-reactive protein (CRP) was thought to be a passive, nonspecific marker of inflammation, recent studies indicate that CRP plays a key role in the innate immune system by recognizing pathogens and altered self-determinants. Elevated baseline CRP at disease onset of AAV has already been described as a determinant of poor long-term outcomes. However, its clinical implications at disease onset of AAV, with respect to vasculitis manifestations and complement system activation that might also affect long-term outcomes, remain elusive. CRP levels were retrospectively analyzed in 53 kidney-biopsy-confirmed cases of ANCA-associated renal vasculitis; a total of 138 disease controls were also evaluated. Univariate and multivariate regression analysis was performed on clinicopathological parameters associated with CRP levels in ANCA-associated renal vasculitis. Results: Compared to disease controls, CRP elevation was common in ANCA-associated renal vasculitis and associated with de novo disease (p = 0.0169), critical illness (p = 0.0346), and severe deterioration of kidney function (p = 0.0167), independent of extrarenal disease manifestations. As confirmed by multiple regression analysis, CRP levels were correlated with active lesions predominated by interstitial arteritis in renal vasculitis, specifically with MPO-ANCA seropositivity (p = 0.0017). Based on analysis of systemic complement system activation and intrarenal complement deposits, CRP elevation was correlated specifically with complement C4 deposits in interstitial arteries in the subgroup with myeloperoxidase (MPO)-ANCA seropositivity (p = 0.039). Finally, this association was independent of systemic complement system activation, as reflected by the consumption of respective complement components. Here, we expand our current understanding of CRP in ANCA-associated renal vasculitis not only as an inflammatory marker, but potentially also as being involved in the pathogenesis of kidney injury by interaction with the complement system.

Predictivity of CRP, Albumin, and CRP to Albumin Ratio on the Development of Intensive Care Requirement, Mortality, and Disease Severity in COVID-19

BACKGROUND

The C-reactive protein (CRP) to albumin ratio (CAR) is a new index calculated by dividing CRP by the albumin level. It has been claimed to have predictive value in determining morbidity and mortality in many critical diseases Aim: In this research, we aimed to elucidate the importance of CRP, albumin, and CAR as parameters that can predict the clinical course in COVID-19 patients.

MATERIALS & METHOD

In this retrospective analysis, the clinical, laboratory, and radiological findings of patients over the age of 18 who were diagnosed with SARS-CoV-2 infection with a positive reverse transcription-polymerase chain reaction (RT-PCR) test were evaluated. Age, gender, laboratory examinations at admission, and CRP and albumin values at the time of diagnosis have been recorded. The relationship of these parameters with the requirement for intensive care, exitus, and serious illness in the clinical follow-up of the patients was investigated. The baseline hospitalization parameters of the patients were compared between the severe and non-severe groups.

RESULTS

Individuals with severe disease had a higher rate of additional disease than those with non-severe disease. It was observed that the mean laboratory values ​​of patients with severe disease had a statistically higher level of D-dimer, CRP, aspartate aminotransferase (AST), platelet distribution width (PDW), CRP-albumin ratio, and ferritin, compared to mild to moderate cases (p<0.05). The rate of additional disease in deceased patients was higher than in patients who were alive (p<0.05). The CAR value was found to be moderately predictive in our study revealing the severity of the disease, and the possibility that the severity of the disease might be higher in patients with a CAR value above 21.47.

CONCLUSION

The results of this study revealed that CAR is a potential parameter in distinguishing critically ill COVID-19 patients in need of intensive care. Therefore, one can say that CAR is an important biomarker in clinically determining COVID-19.

The prognostic value of C-reactive protein to albumin ratio in patients undergoing transcatheter aortic valve implantation

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a less invasive and safe therapeutic alternative in patients who are at very high surgical risk or in whom there are contraindications to open surgery. On the other hand, allocating transcatheter therapy to the adequate candidates and identifying a reliable and validated risk stratification tool for mortality prediction is still lacking. The C-reactive (CRP) to albumin ratio (CAR) is a novel inflammation-based prognostic tool and it is strongly associated with inflammation severity and mortality. In this study, we aimed to elucidate the predictive significance of CAR for mortality in patients who underwent TAVI.

METHODS

The records of 321 consecutive patients who underwent TAVI due to symptomatic aortic stenosis between 1 January 2015 and 31 December 2020 were analysed. Patients were divided into two groups based on the CAR values. For each group, all-cause, cardiovascular, and non-cardiovascular mortality occurring >72 h after the index procedure and at maximum follow-up was documented.

RESULTS

The mean follow-up time was 40 (22-63) months. A total of 180 (56.1%) patients died during long-term follow-up. According to our study, median CAR values were significantly higher among patients who died during follow-ups compared to survivors [1.13 (0.69-2.21) vs 3.56 (1.53-10.00), p < 0.001].

CONCLUSION

Our data showed that CAR is an independent predictor of long-term mortality in patients undergoing TAVI due to symptomatic aortic stenosis.

The Association Between High-Sensitivity C-Reactive Protein/Albumin Ratio and Cardiovascular Prognosis in Patients Undergoing Percutaneous Coronary Intervention

Limited studies have focused on the impact of high-sensitivity C-reactive protein (hsCRP) to albumin ratio (CAR) on cardiovascular outcomes in patients undergoing percutaneous coronary intervention (PCI). Hence, the present study evaluates the association between CAR and cardiovascular outcomes in patients undergoing drug-eluting stent (DES) implantation. We consecutively enrolled 9375 CHD patients undergoing DES implantation. All patients were divided into 3 groups according to their CAR: tertile 1 (CAR ≤.02, n=3125), tertile 2 (.02<CAR≤.06, n = 3125), and tertile 3 (CAR >.06, n = 3125). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE). Kaplan-Meier analysis indicated that the incidences of MACCE and MI increased with high tertiles of the CAR (MACCE: 8.7 vs 10.5 vs 12.3%, log-rank P < .001; MI: 3.3 vs 4.0 vs 4.7%, long-rank P = .015). Cox regression analysis suggested that CAR was an independent risk factors for MACCE (HR per standard deviation (SD) increase: 1.07, 95% CI, 1.01-1.14, P = .024), and MI (HR per SD increase: 1.11, 95% CI, 1.01-1.22, P = .028). In conclusion, the CAR is an independent predictor of MACCE and MI in CHD patients.

Relationship Between C-Reactive Protein/Serum Albumin Ratio, Neutrophil/Lymphocyte Ratio, and ANCA-Associated Vasculitis Activity: A Retrospective Single Center Cohort Study

Objectives

To evaluate the role of C-reactive protein/albumin ratio (CAR), neutrophil/lymphocyte ratio (NLR), and mean platelet volume (MPV) in newly diagnosed AAV patients and examine their clinical significance.

Methods

Data from 79 untreated newly diagnosed AAV patients were collected and 76 health examination subjects were included in the healthy control group. All clinical characteristics of AAV patients were extracted from their medical records. The NLR, CAR, and MPV levels of AAV patients and the healthy controls were compared and the correlation between these markers and clinical characteristics was analyzed. Patients were then divided into two groups based on the 2003 Birmingham Vasculitis Activity Score (BVAS). The correlation between NLR, CAR, and MPV and disease activity was analyzed and their effects on the cumulative survival rate were analyzed.

Results

Compared with the healthy control group, elevated CAR, NLR, and MPV were observed in AAV patients. CAR (r = 0.701, P < 0.0001) and NLR (r = 0.369, P < 0.05) were positively correlated with the BVAS while MPV did not show any significant correlation (P = 0.85). The optimal cutoff value for disease activity evaluation using CAR was 0.80 (sensitivity: 85% and specificity: 82%, P < 0.05). The optimal cutoff value for disease activity evaluation using NLR was 5.15 (sensitivity: 66% and specificity: 72%, P < 0.05). Kaplan–Meier survival analysis revealed that the all-cause mortality rate was higher in patients with CAR ≥ 0.8 than in patients with CAR < 0.8 (P < 0.05). Patients with low NLR also showed a lower cumulative survival rate (P < 0.05).

Conclusions

NLR and CAR can reflect the inflammatory response and disease activity in AAV patients, while MPV is not significantly correlated with disease activity in AAV patients. The all-cause mortality rate was higher in patients with high CAR and NLR than in patients with low CAR and NLR.

Identification of differentially expressed genes and pathways in kidney of ANCA-associated vasculitis by integrated bioinformatics analysis

The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a systematic of relatively rare autoimmune diseases with unknown cause. Kidney involvement is one of the most common clinical manifestations, and the degree of renal damage is closely associated with the development and prognosis of AAV. In this study, we utilized the Robust Rank Aggreg (RRA) method in R to integrate GSE104948, GSE104954, GSE108109, GSE108112, and GSE108113 profile datasets loaded from Gene Expression Omnibus (GEO) database and identified a set of differentially expressed genes (DEGs) in kidney between AAV patients and living donors. Then, the results of gene ontology (GO) functional annotation showed that immunity and metabolism involved process of AAV both in glomerulus and tubulointerstitial. The Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis revealed that following pathways, such as complement and coagulation cascades pathway; Staphylococcus aureus infection; disease-COVID-19; and systemic lupus erythematosus (SLE) pathway play a crucial role in AAV. Next, the results analyzed by protein–protein interaction (PPI) network and Cytoscape software exhibited the hub genes ALB, TYROBP, and CYBB existed in both glomerular and tubulointerstitial compartments datasets. Finally, KEGG analysis using genes of two most important modules also further validated complement and coagulation cascades pathway and S. aureus infection existed both in glomerulus and tubulointerstitial compartments datasets. In conclusion, this study identified key genes and pathways involved in kidney of AAV, which was benefit to further uncover the mechanisms underlying the development and progress of AAV, biomarkers, and potential therapeutic targets as well.

Are inflammatory and malnutrition markers associated with metabolic syndrome in patients with sarcoidosis?

OBJECTIVE

The study aimed to investigate the use of Neutrophil/lymphocyte ratio, C-reactive protein/albumin ratio, controlling nutritional status, and prognostic nutritional index immune, inflammatory, and malnutrition markers Metabolic syndrome+ in sarcoidosis patients, as an early-stage marker.

METHOD

This is a single-center and cross-sectional study that determines the association of Metabolic syndrome in patients with sarcoidosis. Patients were evaluated based on the National Cholesterol Education Program's Adult Treatment Panel III criteria. Neutrophil/lymphocyte ratio, C-reactive protein/albumin ratio, controlling nutritional status, and prognostic nutritional index values were simultaneously determined through blood test.

RESULTS

A total of 253 patients diagnosed with sarcoidosis were included in this study. Metabolic syndrome- was detected in 37.2% of patients. The prevalence was significantly higher in females (p<0.001). Any degree of malnutrition assessed by controlling nutritional status had higher Metabolic syndrome (p=0.035). The Neutrophil/lymphocyte ratio cutoff value was 2.24, sensitivity was 70.53, specificity was 60.13, and Area Under the Curve value was 0.663 for predicting Metabolic syndrome in sarcoidosis patients.

CONCLUSION

Neutrophil/lymphocyte ratio and controlling nutritional status are associated with the Metabolic syndrome+ in sarcoidosis patients. Thus, close monitoring of Neutrophil/lymphocyte ratio and controlling nutritional status increase in terms of Metabolic syndrome and immune malnutrition may be important in sarcoidosis patients.

C-reactive protein-to-albumin ratio and 8-year incidence of type 2 diabetes: the Korean genome and epidemiology study

AIMS

The C-reactive protein-to-albumin ratio (CAR) has been reported as a novel prognostic marker in serious illness and various inflammatory diseases. The aim of this study is to investigate the association of CAR with incidence risk of type 2 diabetes in adults without chronic disease.

METHODS

A total of 5904 participants aged 40 to 69 years were selected from the Korean Genome and Epidemiology Study who were observed over 12 years. Multivariable logistic regression was analyzed to examine the relationship between CAR tertiles and incident diabetes. The predictive power of new-onset diabetes by CAR and homeostasis model assessment-insulin resistance (HOMA-IR) were also measured using the random forest model.

RESULTS

During a mean follow-up period of 7.6 years, 701 subjects (11.9%) developed diabetes. Compared with the lowest CAR group, the highest CAR group was associated with incidence of diabetes (OR 1.60; 95% CI 1.24-1.89) after adjustment for other potential confounding factors. In the random forest model, CAR did not show a significant difference in prediction of new-onset diabetes compared with HOMA-IR (p = 0.561).

CONCLUSIONS

CAR, which is a ratio of commonly used biomarkers and reflects both oxidative stress and antioxidants, is suggested as a predictor of incident diabetes.

Association between biopsies for anti-neutrophil cytoplasmic antibody-associated vasculitis and prognosis: a retrospective cohort study

OBJECTIVES

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a systemic vasculitis with unknown aetiology. Although biopsies are helpful for diagnosing AAV, whether they improve the outcomes of AAV patients remains unknown. The objective of this study was to elucidate the association between biopsies and prognosis.

METHOD

This retrospective cohort study analysed health care records that were routinely collected at 190 hospitals in Japan from April 2005 to March 2019. Patients who were 18 years or older and hospitalized for AAV were eligible for inclusion. The primary outcome was the composite outcome of death and renal replacement therapy (RRT) during the first admission. We compared the outcome between the biopsy group and the no-biopsy group. The chi-square test was performed as a univariable analysis, and logistic regression analysis was performed as a multivariable analysis.

RESULTS

Three hundred and eighty-six patients were assessed in this study. One hundred fifty-four (39.9%) patients underwent biopsy, and 232 (60.1%) patients did not undergo biopsy during the first admission with AAV. In univariable analysis, the composite outcome of death and RRT were observed in 7 (4.5%) patients in the biopsy group and 25 (10.8%) patients in the no-biopsy group (OR 0.39 [95% CI 0.17, 0.94], P = 0.01). The result was consistent in the multivariable analysis (OR 0.31 [95% CI 0.12, 0.79], P = 0.01) after adjusting for potential confounders.

CONCLUSIONS

We showed that patients who underwent biopsy had a better prognosis in the composite outcome of mortality and RRT during admission using a Japanese healthcare record database. Key Points • This is the first study to elucidate the association between undergoing biopsy and prognosis. • Patients undergoing biopsy had a better prognosis in the composite outcome of mortality and RRT. • The proportion of patients who received transfusions was not significantly different between the two groups.

Novel mortality-predicting index at diagnosis can effectively predict all-cause mortality in patients with antineutrophil cytoplasmic antibody-associated vasculitis

Background

This study investigated whether the inflammation prognostic index (IPI) and the mortality predicting index (MPI) at diagnosis could predict all‐cause mortality in patients with antineutrophil cytoplasmic antibody (ANCA)‐associated vasculitis (AAV).

Methods

We included 223 AAV patients and reviewed their medical records. Clinical and laboratory data and AAV‐specific indices at diagnosis were assessed. The IPI was calculated as neutrophil‐to‐lymphocyte ratio (NLR) × C‐reactive protein to albumin ratio (CAR). Here, we newly developed an MPI (NLR × CAR × monocyte counts).

Results

The mean age of 223 patients (122 MPA, 57 GPA and 44 EGPA patients) was 59 years. The rate of mortality was 11.2%. Using the receiver operator characteristic curve for all‐cause mortality, the cut‐offs were calculated as NLR: 3.22, CAR: 3.25, IPI: 18.53 and MPI: 8367.82. In the univariable Cox hazard analysis, age, gender, smoking history, BVAS, FFS and over the cut‐off of each index showed statistical significance. As the indices share at least two mutual variables, the multivariable analysis was conducted four times based on each index. An IPI ≥18.53 (HR 3.162) and MPI ≥8367.82 (HR 3.356) were significantly associated with all‐cause mortality.

Conclusions

This study developed a novel indicator, MPI, that uses the existing NLR and CAR indices and proved that it could predict all‐cause mortality in AAV patients.

An independent indicator of erectile dysfunction is C-reactive protein/albumin ratio

Research has found that, instead of passive lipid-accumulated vascular damage, atherosclerosis which is the primary cause of erectile dysfunction (ED) can be seen as an active inflammatory cycle and that inflammation has a central role in the entire atherosclerotic process. As an inflammatory marker, serum C-reactive protein (CRP)/albumin ratio (CAR) may link to ED and ED severity. The CAR, demographic features and other criteria of 198 patients with ED who visited our outpatient clinic during March 2019-April 2020 were prospectively evaluated. The research also included healthy control subjects without systemic or infectious diseases. The mean difference of CAR between ED and no ED was statistically significant (0.55 ± 0.27 and 0.79 ± 0.49, p = .002 respectively). On the basis of the ROC analysis, CAR has a good ED diagnostic value with an area under the curve (AUC) of 0.63 (95% CI:0.541-0.714) and better diagnostic performance to distinguish ED severity (AUC:0.73, 95% CI:0.620-0.842). Additionally, mean CAR gradually increased with increasing severity of ED (for all p < .001). The CAR has been described as an independent ED indicator in the multivariate analysis (p = .001OR = 8.934; 95% CI:2.449-32.583). Increased CAR is associated with ED severity and increased ED risk. For CAR predicting ED and ED severity, a considerable cut-off point was identified.

Male Sex Is a Significant Predictor of All-cause Mortality in Patients with Antineutrophil Cytoplasmic Antibody-associated Vasculitis

BACKGROUND

We investigated and compared the initial clinical features at diagnosis and the poor outcomes during follow-up in Korean patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) based on sex.

METHODS

The medical records of 223 immunosuppressive drug-naïve patients with AAV were reviewed. Age, body mass index (BMI), smoking history, AAV subtypes, ANCA positivity, clinical manifestations, Birmingham vasculitis activity score (BVAS), five-factor score (FFS), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) at diagnosis were collected. All-cause mortality, end-stage renal disease (ESRD), cerebrovascular accident (CVA) and cardiovascular disease (CVD) were assessed as the poor outcomes of AAV during follow-up.

RESULTS

The median age was 59.0 years and 74 of 223 AAV patients (33.2%) were men. Among variables at diagnosis, male patients exhibited higher BMI than female. However, there were no differences in other demographic data, AAV subtypes, ANCA positivity, BVAS, FFS, ESR and CRP between the two groups. Male patients received cyclophosphamide more frequently, but there were no significant differences in the frequencies of the poor outcomes of AAV between the two groups. Male patients exhibited a significantly lower cumulative patients' survival rate than female patients during the follow-up period based on all-cause mortality (P = 0.037). In the multivariable analysis, both male sex (hazard ratio [HR], 2.378) and FFS (HR, 1.693) at diagnosis were significantly and independently associated with all-cause mortality during follow-up.

CONCLUSION

Male sex is a significant and independent predictor of all-cause mortality in AAV patients.

Clinical features of Korean elderly patients with antineutrophil cytoplasmic antibody-associated vasculitis

BACKGROUND/AIMS

We compared the clinical and laboratory data between elderly and non-elderly patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) at diagnosis; further, we investigated the predictors at diagnosis for all-cause mortality and end-stage renal disease (ESRD) occurrence during follow-up in Korean elderly patients with AAV.

METHODS

We reviewed the medical records of 191 AAV patients regarding clinical manifestations and laboratory results at diagnosis and during follow-up. The follow-up duration was defined as the period from diagnosis to death for deceased patients or to the time of dialysis for ESRD patients, or to the last visit. Elderly (n = 67) and non-elderly (n = 124) patients were grouped based on an age threshold of 65 years.

RESULTS

At diagnosis, elderly patients exhibited higher median Birmingham Vasculitis Activity Score (BVAS) and higher frequencies of ANCA positivity and pulmonary manifestations than non-elderly patients. Furthermore, elderly patients exhibited increased median white blood cell count, blood urea nitrogen (BUN), alkaline phosphatase, erythrocyte sedimentation rate, and C-reactive protein and decreased median hemoglobin. However, there were no significant differences in all-cause mortality and ESRD occurrence between elderly and non-elderly patients. Meanwhile, elderly patients exhibited lower cumulative patients' and ESRD-free survival rates than non-elderly patients. In the multivariable Cox hazards model, BUN, creatinine and serum albumin at diagnosis were independent predictors for ESRD occurrence, whereas there were no independent predictors at diagnosis for all-cause mortality.

CONCLUSION

Elderly AAV patients exhibited substantially higher rates of all-cause mortality and ESRD occurrence during follow-up compared than non-elderly AAV patients.

Serological Biomarkers and Indices for the Current Activity and Prognosis of ANCA-Associated Vasculitis: Experience in a Single Centre in Korea

Small vessel vasculitis is composed of two types of vasculitis based on immune-complex deposits, immune-complex vasculitis and antineutrophil cytoplasmic antibody-associated vasculitis (AAV) according to the 2012 Chapel Hill Consensus Conferences Nomenclature of Vasculitis. In general, the current disease-states are assessed in three ways in real clinical practice such as activity, damage and functional status. Birmingham vasculitis activity score (BVAS, version 3) and five-factor score were calculated for assessing the cross-sectional activity and for predicting the prognosis of AAV, respectively. Since BVAS includes a wide spectrum of nine systemic items with differently weighted scores based on new-onset/worsening or persistent each symptom, it has been considered as the most reliable tool to assess AAV activity to date. However, since BVAS represents both cross-sectional and chronic clinical features, it has a limitation in flexibly reflecting the cross-sectional activity or severity of AAV. In addition, the heterogeneous items of BVAS are difficult to reflect the close correlation between BVAS and AAV pathogenesis. It is practically difficult to discover new biomarkers or indices that exceed the reliability of AAV-specific indices or acute-phase reactants established by long clinical experience. However, efforts to discover and develop new biomarkers or indices are expected to complement the clinical unmet need of existing AAV-specific indices and acute-phase reactants. In this review, we reviewed the serological biomarkers and indices that have been reported to date and introduced studies that investigated serological biomarkers and indices in Korean patients with AAV.

Relationship between C-reactive Protein/Albumin Ratio and Subclinical Inflammation in Patients with Familial Mediterranean Fever

Background Familial Mediterranean Fever (FMF), which is characterised by recurrent episodes of fever with serositis, is associated with ongoing inflammation without clinical findings during attack-free periods, leading to amyloidosis, the most important complication of FMF. The objective of this study was to investigate the C-reactive protein/albumin ratio (CAR) as a marker to identify subclinical inflammation in symptom-free FMF children and compare the CAR with other systemic inflammatory markers such as mean platelet volume (MPV), red cell distribution width (RDW), neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR).

Material and Methods We included 100 patients and 70 healthy subjects. Hospital records were obtained to collect data on laboratory findings and genetic mutations.

Results We found that the CAR levels of our FMF patients were significantly higher than those of the control group. We also evaluated that the CAR values had a higher area-under-the-curve value than the other systemic inflammation parameters including CRP, MPV, RDW, NLR, PLR based on Receiver-Operating Characteristics (ROC) analysis.

Conclusion It is important to identify subclinical inflammation in FMF patients with simple, reliable, easily accessible markers to avoid amyloidosis. Although the CAR might be used to assess subclinical inflammation in paediatric FMF patients, the prognostic value of CAR is not superior to CRP. Merging CRP and albumin into a single index thus provides no additional benefit in detecting subclinical inflammation in FMF.

Clinicopathological characteristics and outcomes of anti-neutrophil cytoplasmic autoantibody-related renal vasculitis with hyperuricemia: a retrospective case-control study

The objective of the study was to evaluate the clinicopathological characteristics and investigate the clinical determinants of patient and renal survival in the first 12 months after diagnosis in anti-neutrophil cytoplasmic antibody (ANCA)-associated renal vasculitis (AAV) patients with hyperuricemia. This was a retrospective case-control study in patients with AAV-related renal injury in the First Affiliated Hospital of Zhengzhou University from January 2014 to April 2019. Patients who met the study criteria were divided into two groups: patients without hyperuricemia (n = 92) and patients with hyperuricemia (n = 55). Participants were followed-up for 12 months, and progressing to end-stage renal disease (ESRD) and death was treated as the endpoint event. We found that the level of serum creatinine was an independent risk factor for hyperuricemia, and the level of serum uric acid was an independent risk factors for renal survival and patient survival in ANCA-associated renal vasculitis patients. The crescents formation and the proportion of fibrous crescent likely contributed to severe clinical characteristics and renal pathological changes in ANCA-associated renal vasculitis patients with hyperuricemia. Hyperuricemia has an important influence on the progression of ANCA-associated renal vasculitis. A good control of serum uric acid may improve the prognosis.

Clinical value of C-reactive protein/albumin ratio in Guillain-Barré syndrome

BACKGROUND

Respiratory failure in patients with Guillain-Barré syndrome (GBS) can lead to serious complications and dysfunctions, emphasizing the importance of early detection. The C-reactive protein-to-albumin ratio (CAR) is emerging as a novel inflammatory marker for predicting neurological outcome. We aimed to identify the association of CAR with respiratory failure and short-term outcome in GBS patients.

METHODS

A total of 200 patients diagnosed with GBS were retrospectively analyzed. Data were collected from an electronic database. The associations of C-reactive protein (CRP), albumin, and CAR at admission with outcomes were evaluated by logistic regression analysis. Using receiver operating characteristic curves, we calculated the cutoff value for the CAR and compared its discriminatory power with that of C-reactive protein alone.

RESULTS

Fifty-two (26%) patients showed poor short-term outcome, and 50 (25%) developed respiratory failure. CAR > 0.21 was an independent predictor of respiratory failure, and CAR > 0.19 was an independent predictor of poor short-term outcome. CAR showed a better predictive value than CRP alone. In addition, the c-index of the predictive nomogram for respiratory failure was higher when it included CAR (0.962) than when it did not (0.958). A similar result was observed for the predictive nomogram for poor short-term outcome (0.953 vs 0.947).

CONCLUSION

CAR > 0.21, a novel inflammatory biomarker, is independently associated with the occurrence of respiratory failure in GBS patients, while CAR > 0.19 is independently associated with poor short-term outcome. CAR may help identify GBS patients at high risk of poor prognosis.

Serum C-reactive protein to albumin ratio and mortality associated with peritoneal dialysis

Background: Serum C-reactive protein to albumin ratio (CAR) was recently identified as a poor marker of prognosis among various populations. The current study aimed to examine the association between CAR and all-cause mortality among patients undergoing peritoneal dialysis (PD).Methods: A total of 758 patients with PD were included in this study during the period from 1 November 2005 to 28 February 2017 and followed up until 31 May 2017. The primary outcome was all-cause mortality. We used multivariate Cox proportional hazard models and Kaplan-Meier survival curves to assess the relationship between CAR and all-cause mortality in these patients.Results: Among 758 participants, mean age was 49.1 ± 14.2 years, with 56% males and 18.6% prevalence of diabetes. Median CAR was 0.13 (interquartile range [IQR], 0.07-0.34). After 27 months (IQR, 14-40 months) of follow-up, 157 deaths had been reported. After adjusting for confounding factors, we found a significant association between serum CAR and all-cause mortality among those in the highest CAR group (hazard ratio 1.91, 95% confidence interval 1.05- 3.47, p = 0.034).Conclusions: In patients undergoing PD, an increase in serum CAR is independently associated with increased risk for all-cause mortality.

The Prognostic Value of C-reactive Protein to Albumin Ratio in Patients with Isolated Degenerative Aortic Valve Stenosis Undergoing Surgical Aortic Valve Replacement

Objective

To evaluate the prognostic value of C-reactive protein to albumin ratio (CAR) in patients with severe aortic valve stenosis undergoing surgical aortic valve replacement (AVR).

Methods

Four hundred seventy-six patients with severe degenerative aortic stenosis who underwent successful isolated surgical AVR were enrolled. Hospitalization due to heart failure, surgical aortic reoperation, paravalvular leakage rates, and long-term mortality were evaluated in the whole study group. The participants were divided into two groups, as 443 patients without mortality (group 1) and 33 patients with mortality (group 2) during the follow-up time.

Results

CAR was lower in patients without mortality than in those with mortality during the follow-up time (0.84 [0.03-23.43] vs. 2.50 [0.22-26.55], respectively, P<0.001). Age (odds ratio [OR]: 1.062, confidence interval [CI]: 1.012-1.114, P=0.014), CAR (OR: 1.221, CI: 1.125-1.325, P<0.001), ejection fraction (OR: 0.956, CI: 0.916-0.998, P=0.042), and valve type (OR: 2.634, CI: 1.045-6.638, P=0.040) were also found to be independent predictors of long-term mortality. Additionally, rehospitalization (0.86 [0.03-26.55] vs. 1.6 [0.17-24.05], P=0.006), aortic reoperation (0.87 [0.03-26.55] vs. 1.6 [0.20-23.43], P=0.016), and moderate to severe aortic paravalvular leakage (0.86 [0.03-26.55] vs. 1.86 [0.21-19.50], P=0.023) ratios were associated with higher CAR.

Conclusion

It was firstly described that CAR was strongly related with increased mortality rates in patients with isolated severe aortic stenosis after surgical AVR. Additionally, rehospitalization, risk of paravalvular leakage, and aortic reoperation rates were higher in patients with increased CAR than in those without it.

Serum C-Reactive Protein/Albumin Ratio in Rheumatoid Arthritis and its Relationship With Disease Activity, Physical Function, and Quality of Life

Objectives

This study aims to evaluate the relationship between C-reactive protein (CRP)/albumin ratio (CAR) and disease activity, quality of life (QoL), and physical function in rheumatoid arthritis (RA).

Patients and methods

A total of 121 RA patients (22 males, 99 females; mean age 57.6±11.2 years; range, 32 to 85 years) applying to Ankara University School of Medicine Rheumatology Outpatient Clinic between January 2019 and February 2019 were included in this cross-sectional study. The inclusion criteria were fulfilling the American College of Rheumatology/European League Against Rheumatism 2010 RA classification criteria, being over 18 years and accepting to participate in the study. Demographic and clinical parameters including serum erythrocyte sedimentation rate (ESR), CRP and albumin levels were recorded. Disease activity was measured using Disease Activity Score 28 (DAS28)-ESR. General health, fatigue, and pain were questioned by means of a 100 mm visual analog scale (VAS). The QoL was assessed with the Rheumatoid Arthritis Quality of Life (RAQoL) Questionnaire. The functional status was determined using the Health Assessment Questionnaire (HAQ).

Results

Rheumatoid factor (RF) was positive in 56.2% of the patients. The median ESR was 19.0 mm/hour [interquartile range (IQR): 19.5] and median CRP was 5.6 (IQR: 9) mg/L. The median CAR was 1.3 (IQR: 2.1) and median DAS 28-ESR was 3.6 (IQR: 1.5). There was a significant but weak correlation between CAR and DAS28-ESR [p<0.001, Spearman's correlation coefficient (rs)=0.327]. Moreover, CAR was positively correlated with ESR, CRP, and VAS physician's global assessment (p<0.001, rs=0.497; p<0.001, rs=0.987, p<0.001, rs=0.401, respectively). However, no correlation was observed between CAR, HAQ, and RAQoL. In the RF positive group, there was a significant but weak correlation between CAR and RF titers (p=0.016, rs=0.292).

Conclusion

We observed a positive but weak correlation between CAR and DAS28-ESR, ESR, and the RF titer. Further studies are warranted to investigate the role of CAR in RA.

Controlling Nutritional Status Score is Associated with All-Cause Mortality in Patients with Antineutrophil Cytoplasmic Antibody-Associated Vasculitis

PURPOSE

The controlling nutritional status (CONUT) score was developed to detect undernutrition in patients. Here, we investigated whether the CONUT score estimated at diagnosis could help predict poor outcomes [all-cause mortality, relapse, and end-stage renal disease (ESRD)] of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).

MATERIALS AND METHODS

We retrospectively reviewed and collated data, including baseline characteristics, clinical manifestations (to calculate AAV-specific indices), and laboratory results, from 196 newly diagnosed AAV patients. Serum albumin, peripheral lymphocyte, and total cholesterol levels (at diagnosis) were used to calculate CONUT scores.

RESULTS

In total, 111 patients had high CONUT scores (≥3), which showed higher frequency of myeloperoxidase-ANCA and ANCA positivity, and demonstrated higher AAV-specific indices. The optimal cut-offs of CONUT score (at diagnosis) for predicting all-cause mortality and ESRD were ≥3.5 and ≥2.5, respectively. Patients with CONUT scores higher than the cut-off at diagnosis exhibited lower cumulative and ESRD-free survival rates compared to those with lower scores than the cut-off. In multivariable analyses, diabetes mellitus [hazard ratio (HR): 4.394], five-factor score (HR: 3.051), and CONUT score ≥3.5 (HR: 4.307) at diagnosis were independent predictors of all-cause mortality, while only serum creatinine (HR: 1.714) was an independent predictor of ESRD occurrence.

CONCLUSION

CONUT score at diagnosis is associated with all-cause mortality in AAV patients.

Predictive value of C-Reactive Protein/Albumin ratio in patients with chronic complicated diabetes mellitus

Objective:

To investigate the relationship between serum C-reactive protein (CRP)/albumin (ALB) ratio and complication occurrence in patients with Type-II diabetes mellitus with at least one chronic complication.

Methods:

The CAR, demographic characteristics, and other parameters of 108 patients with at least one chronic diabetic complication who attended to the internal medicine outpatient clinic between January 1, 2017, and September 1, 2018, were retrospectively evaluated. Healthy control subjects who did not have any systemic or infectious diseases were also included in the study. I compared the CAR, demographics, and other blood parameters between the two groups were compared.

Results:

The mean CAR levels were significantly higher in diabetic patients with at least one complication compared to the control group (0.15 [0.07 - 0.29] vs 0.07 [0.07 - 0.07], respectively, p<0.001). There was no significant correlation between CAR and diabetic complications, including neuropathy, nephropathy, coronary artery disease, and retinopathy in the patient group (p>0.05 for all). In the receiver operating curve (ROC) analysis, there was no significant cut-off point for CAR predicting diabetic complications.

Conclusions:

Although serum CAR levels were significantly higher in complicated diabetic patients compared to controls, any validated CAR value for predicting diabetic complications were not observed.

Biomarkers in Vasculitides of the Nervous System

Besides being affected by the rare and severe primary angiitis of the central nervous system (PACNS) the nervous system is also affected by primary systemic vasculitides (PSV). In contrast to PACNS, PSV affect not only the central but also the peripheral nervous system, resulting in a large array of potential symptoms. Given the high burden of disease, difficulties in distinguishing between differential diagnoses, and incomplete pathophysiological insights, there is an urgent need for additional precise diagnostic tools to enable an earlier diagnosis and initiation of effective treatments. Methods available to date, such as inflammatory markers, antibodies, cerebrospinal fluid (CSF) analysis, imaging, and biopsy, turn out to be insufficient to meet all current challenges. We highlight the use of biomarkers as an approach to extend current knowledge and, ultimately, improve patient management. Biomarkers are considered to be useful for disease diagnosis and monitoring, for predicting response to treatment, and for prognosis in clinical practice, as well as for establishing outcome parameters in clinical trials. In this article, we review the recent literature on biomarkers which have been applied in the context of different types of nervous system vasculitides including PACNS, giant-cell arteritis, Takayasu's arteritis, polyarteritis nodosa, ANCA (anti-neutrophil cytoplasm antibody)-associated vasculitides, cryoglobulinemic vasculitis, IgA vasculitis, and Behçet's disease. Overall, the majority of biomarkers is not specific for vasculitides of the nervous system.

Antineutrophil Cytoplasmic Antibody-Associated Vasculitis in Korea: A Narrative Review

Antineutrophil cytoplasmic antibody-associated vasculitis (AAV) is a group of systemic necrotising vasculitides, which often involve small vessels, and which lead to few or no immune deposits in affected organs. According to clinical manifestations and pathological features, AAV is classified into three variants: microscopic polyangiitis, granulomatosis with polyangiitis (GPA), and eosinophilic GPA. The American College of Rheumatology 1990 criteria contributed to the classification of AAV, although currently the algorithm suggested by the European Medicines Agency in 2007 and the Chapel Hill Consensus Conference Nomenclature of Vasculitides proposed in 2012 have encouraged physicians to classify AAV patients properly. So far, there have been noticeable advancements in studies on the pathophysiology of AAV and the classification criteria for AAV in Western countries. However, studies analysing clinical features of Korean patients with AAV have only been conducted and reported since 2000. One year-, 5 year-, and 10 year-cumulative patient survival rates are reported as 96.1, 94.8, and 92.8%. Furthermore, initial vasculitis activity, prognostic factor score, age and specific organ-involvement have been found to be associated with either all-cause mortality or poor disease course. The rate of serious infection is 28.6%, and 1 year-, 5 year- and 10 year-cumulative hospitalised infection free survival rates range from 85.1% to 72.7%. The overall standardised incidence ratio of cancer in AAV patients was deemed 1.43 compared to the general Korean population.