Diagnostic accuracy of red blood cell distribution width to platelet ratio for predicting staging liver fibrosis in chronic liver disease patients: A systematic review and meta-analysis

Diagnostic Accuracy of Red Cell Distribution Width to Platelet Ratio for the Prediction of Liver Fibrosis in Patients With Chronic Liver Disease From Eastern India

Background Early diagnosis of liver cirrhosis in patients with chronic liver disease (CLD) can help delay/prevent complications and thereby improve survival. The currently available diagnostic modalities for the non-invasive assessment of hepatic fibrosis, especially FibroScan, are costly and not widely available, whereas various non-invasive scores for the assessment of fibrosis are cumbersome. Hence, we aimed to develop an easy and simple score for predicting cirrhosis in patients from Eastern India suffering from CLD with a better diagnostic accuracy. Methodology This cross-sectional, observational study was conducted between September 2019 and September 2021 in East India. Our study participants were patients who had CLD of etiologies such as alcohol-related liver disease, non-alcoholic fatty liver disease, chronic viral hepatitis B, chronic viral hepatitis C, primary biliary cholangitis, and autoimmune hepatitis, who had undergone FibroScan of the liver. All demographic details were noted, and the patients were subjected to physical examination, followed by hematological as well as biochemical investigations, including liver function tests. Non-invasive scores (such as aspartate aminotransferase (AST) to platelet ratio index (APRI) and Fibrosis-4 score (FIB-4) and red cell distribution width (RDW) to platelet ratio (RPR)) were computed, and their diagnostic accuracy for prediction of advanced fibrosis and cirrhosis were evaluated by receiver operating characteristic curve (ROC curve) analysis with comparison of area under the ROC curves. Pearson correlation and logistic regression analysis were also performed to study the association of these scores with advanced fibrosis and cirrhosis. Results The area under the ROC (AUROC) curve of the APRI score, FIB-4 score, RPR, and RPR × AST for prediction of advanced liver fibrosis was 0.817, 0.799, 0.706, and 0.811, respectively. Similarly, the AUROC of the above scores for the prediction of cirrhosis was 0.889, 0.858, 0.797, and 0.898. However, the product of RPR and AST was superior than APRI and FIB-4 for predicting cirrhosis. An RPR × AST value above the cut-off of 4.818 can help predict liver cirrhosis with 85.7% sensitivity and 85.5% specificity. Pearson correlation and logistic regression analysis also proved the association of these scores with liver fibrosis. Conclusions RPR is a simple, inexpensive, and easily available marker for predicting liver cirrhosis. Nevertheless, the variable RPR × AST can predict liver cirrhosis in patients with CLD with even greater diagnostic accuracy.

Predictive Value of Red Cell Distribution Width-to-Platelet Ratio Combined with Procalcitonin in 28-day Mortality for Patients with Sepsis

Objectives

The objective of this study was to investigate the predictive value of erythrocyte distribution width-to-platelet ratio (RPR) combined with procalcitonin (PCT) on 28-day mortality in patients with sepsis.

Methods

A total of 193 patients with sepsis admitted to the Affiliated Hospital of Southwest Medical University from January 2013 to January 2018 were selected as the study objects. Univariate and multivariate analyses were used to understand the indicators related to the 28-day prognosis of patients, and the ROC curve was further drawn. The Kaplan-Meier curve was used to evaluate the prognosis of patients.

Results

A total of 193 patients were enrolled and divided into the survivor group (=156) and nonsurvivor group (=37) according to the prognosis within 28 days. The median age was 62.5 years, and 64.7% were males. Multivariate analysis showed that PCT and RPR were independent risk factors for 28-day prognosis in sepsis patients. The area under the ROC curve of PCT and RPR were 0.894 and 0.861, respectively, and the cutoff values were 27.04 and 0.12, respectively. Survival curve analysis showed that PCT and RPR were associated with the 28-day prognosis of patients, and the combination of PCT and RPR had a better predictive effect.

Conclusions

PCT and RPR are independent predictors of sepsis prognosis. The combined application of PCT and RPR (PCT-RPR) can further improve the predictive performance and provide a reference for the clinical diagnosis, treatment, and prognosis evaluation of sepsis patients.

Red Cell Distribution Width-to-Platelet Count Ratio: A Promising Predictor of In-Hospital All-Cause Mortality in Critically Ill Patients with Acute Ischemic Stroke

INTRODUCTION

The red blood cell distribution width-to-platelet ratio (RPR), a novel inflammatory index, has already been proven as a prognostic factor in some other diseases, but its prognostic effect on critically ill patients with acute ischemic stroke (AIS) has been rarely investigated. This study aimed to investigate the association between RPR and in-hospital mortality in these patients.

METHODS

We extracted clinical data from the Medical Information Mart for Intensive Care IV 1.0 database. The primary outcome was in-hospital all-cause mortality of patients with critical AIS. The main independent variable was RPR. To investigate the association between RPR and in-hospital all-cause mortality in patients with critical AIS, multivariable logistic analyses, smooth curve fitting, and stratified analyses were conducted.

RESULTS

In total, 2,673 patients with AIS who were admitted to the intensive care unit were included in the study. In the multivariable analysis, in-hospital mortality was positively related to RPR (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.02-1.59). According to the two-piecewise logistic regression model, we found that the inflection point of RPR was 1.89%. To the left of the inflection point (RPR ≤1.89%), we did not detect any relationship between RPR and in-hospital all-cause mortality (OR [95% CI]: 0.73 [0.41, 1.31], p = 0.2884). In contrast, to the right of the inflection point (RPR >1.89%), RPR was positively related to in-hospital all-cause mortality (OR [95% CI]: 1.61 [1.18, 2.19], p = 0.0027).

CONCLUSIONS

RPR showed a nonlinear relationship with in-hospital all-cause mortality in patients with critical AIS.

Red blood cell distribution width derivatives in alcohol-related liver cirrhosis and metabolic-associated fatty liver disease

BACKGROUND

Looking for undiscovered blood markers of liver fibrosis and steatosis still remains an issue worth exploring. There are still plenty of unresolved issues related to the actual role of hematological indices as potential markers of liver function.

AIM

To study red blood cell distribution width (RDW), RDW-to-platelet ratio (RPR) and RDW-to-lymphocyte ratio (RLR) in alcohol-related liver cirrhosis (ALC) and metabolic-associated fatty liver disease (MAFLD).

METHODS

The study group was composed of 302 people: 142 patients with ALC and 92 with MAFLD; 68 persons were included as controls. RDW, RPR and RLR were measured in each person. Indirect and direct parameters of liver fibrosis were also assessed [aspartate transaminase to alkaline transaminase ratio, aspartate transaminase to platelet ratio index (APRI), fibrosis-4 (FIB-4), gamma-glutamyl transpeptidase to platelet ratio (GPR), procollagen I carboxyterminal propeptide, procollagen III aminoterminal propeptide, transforming growth factor-α, platelet-derived growth factor AB, laminin]. MELD score in ALC patients and non-alcoholic fatty liver disease (NAFLD) fibrosis score together with BARD score were obtained in the MAFLD group. The achieved results were compared to controls. Then a correlation between assessed markers was done. Diagnostic value of each investigated parameter and its suggested cut-off in the research group were evaluated with area under the curve (AUC).

RESULTS

RDW, RPR and RLR values turned out to be significantly higher in ALC and MAFLD groups compared to controls (ALC: P < 0.0001; NAFLD: P < 0.05, P < 0.0001 and P < 0.0001, respectively). RPR correlated positively with MELD score (P < 0.01) and indirect indices of liver fibrosis (FIB-4 and GPR; P < 0.0001) in ALC patients; negative correlations were found between PDGF-AB and both: RDW and RPR (P < 0.01 and P < 0.0001, respectively). RPR correlated positively with NAFLD fibrosis score and APRI (P < 0.0001) in the MAFLD group; a positive relationship was observed between RDW and FIB-4, too (P < 0.05). AUC values and suggested cut-offs for RDW, RPR and RLR in ALC patients were: 0.912 (> 14.2%), 0.965 (> 0.075) and 0.914 (> 8.684), respectively. AUC values and suggested cut-offs for RDW, RPR and RLR in MAFLD patients were: 0.606 (> 12.8%), 0.724 (> 0.047) and 0.691 (> 6.25), respectively.

CONCLUSION

RDW with its derivatives appear to be valuable diagnostic markers in patients with ALC. They can also be associated with a deterioration of liver function in this group.

Diagnostic Accuracy of Red Cell Distribution Width to Platelet Ratio for Detection of Liver Fibrosis Compared with Fibroscan in Chronic Hepatitis B Egyptian patients

Background and Aims:

The decision to treat chronic hepatitis B Virus infection (CHB) may necessitate an assessment of the degree of liver fibrosis. Guidelines recommend Fibroscan examination in such cases. However, it is costly and not widely available. Red cell distribution width (RDW) and platelet count are simple parameters obtained from the blood pictures; and their ratio RDW to platelet ratio (RPR) was claimed to correlate with liver fibrosis. We aimed to assess the ability of RPR to replace the costly fibroscan in the detection of significant fibrosis in chronic hepatitis B patients.

Patients and Methods:

This cross-sectional study was conducted in the Tropical medicine department, Tanta University, Egypt, between December 2018 and September 2019. One hundred and twenty-five patients with CHB were included and divided according to the fibroscan examination into: Group I: patients with no significant fibrosis (n=66), Group II: patients with significant (≥ F2) fibrosis (n=59). RPR was calculated for all patients and tested against Fibroscan results.

Results:

Both groups were matched in regards to age, sex, viral load, and steatosis. There was a significant positive correlation between the degree of stiffness measured by FibroScan in patients with a significant degree of fibrosis and serum bilirubin, a quantitative polymerase chain reaction of hepatitis B virus DNA (HBV DNA PCR), and fibrosis-4 score (FIB-4 score) (P value= 0.020, 0.049, and 0.0402, respectively). However, RPR was not correlated to the degree of fibrosis in fibroscan examination.

Conclusions:

The accuracy of RDW to platelet ratio (RPR) for the detection of fibrosis in CHB patients is questionable. FIB-4 is correlated with liver stiffness measurement (LSM) in patients with significant fibrosis (F2 or more). Neither RPR, AST to Platelet Ratio Index (APRI) or FIB4 can replace fibroscan for grading of fibrosis in CHB patients for evaluation to start therapy.

Association of Red Cell Distribution Width-to-Platelet Ratio and Mortality in Patients with Sepsis

Background

As a novel inflammatory index, the ratio of red cell distribution width (RDW) to platelet count (RPR) may have prognostic value in some critical illnesses. However, studies on the prognostic influence of RPR in patients with sepsis are few. This study is aimed at investigating the association between RPR levels and 28-day mortality in patients with sepsis.

Methods

Data of patients with sepsis were obtained from the Medical Information Mart for Intensive Care III database. The best cut-off value was calculated by establishing the receiver operating characteristic curve (ROC), and the predictive ability of different indicators was compared through the area under the curve (AUC). The association between RPR levels and 28-day mortality was assessed using the Cox proportional hazards model. Restrictive cubic spline analysis was applied to the multivariable Cox model to investigate the nonlinear relationship between RPR and 28-day mortality.

Results

A total of 3367 patients with sepsis were included in the study. A nonlinear relationship was observed between RPR and 28-day mortality, showing a trend of a first rapid increase and a gradual increase. For the prediction of mortality, the best cut-off value for RPR was 0.109, with an AUC of 0.728 (95% confidence interval [CI]: 0.709–0.747). The predictive capability of RPR was superior to those of RDW, platelet, SOFA score, and SAPS II score. After adjusting for various confounding factors, high RPR was significantly associated with increased mortality with adjusted hazard ratios of 1.210 (95% CI: 1.045–1.400) for categorical variables and 2.826 (95% CI: 2.025–3.944) for continuous variables.

Conclusion

Elevated RPR level is significantly correlated with a high risk of 28-day mortality in patients with sepsis and can be a new predictor of patient prognosis.

Blood-Based Non-Invasive Tests of Hepatic Fibrosis in Autoimmune Hepatitis: Application among Selected Patients Leads to Higher Accuracy

Background. Assessment of liver fibrosis is essential to guide treatment in autoimmune hepatitis (AIH), but non-invasive tests (NITs) showed poor accuracy. Our study aims to evaluate the performance of NITs among different AIH presentations. Methods. Monocentric retrospective study among 122 AIH patients. NITs were compared to histological grading of liver fibrosis. We performed an accuracy analysis among acute (jaundice and/or transaminases > 10 times upper limit of normal) and non-acute patients. Results. A significant difference in the distribution of NIT values for each Ishak stage was found for spleen-diameter-to-platelet-count ratio (SD/PC) (p < 0.001), fibrosis-4-score (FIB-4) (p = 0.002), AST-to-ALT ratio (AAR) (p = 0.002), red-blood-cell-width-distribution-to-platelet-count ratio (RDW/PC) (p = 0.008) and AST-to-platelet-count ratio (APRI) (p = 0.029). The AUC for advanced fibrosis of SD/PC, FIB-4, RDW/PC, APRI and AAR were, respectively, 0.814, 0.770, 0.768, 0.708 and 0.694. The AUC of SD/PC, FIB-4 and APRI in non-acute subgroup were 0.902, 0.834 and 0.758, while in acute patients they were 0.754, 0.724 and 0.716. RDW/PC and AAR weren’t different among the two subgroups. Conclusions. For SD/PC, FIB-4 and APRI, diagnostic accuracy is higher in patients with non-acute presentation. In this context, SD/PC and FIB-4 showed an overall performance that could be of interest in clinical practice alongside other non-invasive techniques.

Diagnostic accuracy of red blood cell distribution width to platelet ratio for predicting liver fibrosis in patients with chronic hepatitis B: A meta-analysis

OBJECTIVE

This study aims to systematically review the performance of red blood cell distribution width to platelet ratio (RPR) in the diagnosis of significant or advanced fibrosis, and cirrhosis associated with Hepatitis B virus (HBV).

METHODS

The relevant studies were comprehensively searched in English databases such as Web of Science, PubMed, EMBASE, Cochrane Library, as well as Chinese databases such as China National Knowledge Infrastructure, Wanfang Data from the inception to March 2021. Accuracy of RPR in diagnosing significant or advanced fibrosis and liver cirrhosis was assessed by area under the curve (AUC), pooled sensitivity and specificity, as well as positive and negative likelihood ratios. Stata 15.0 software was applied to analyze the data.

RESULTS

In total, 13 literature met the requirements, including patients with significant fibrosis (n=1890), advanced fibrosis (n=645), and cirrhosis (n=499). The prevalence rates of significant fibrosis, advanced fibrosis and cirrhosis were 49.31% (range: 17.25%-84.21%), 37.07% (range: 9.60%-58.20%) and 2.18% (range: 2.78%-44.19%), respectively. The AUCs for predicting significant fibrosis, advanced fibrosis, and cirrhosis by RPR were 0.73 (95%CI: 0.69-0.76),0.80 (95%CI: 0.77-0.84) and 0.80 (95%CI: 0.76-0.83), respectively.

CONCLUSION

RPR is of some diagnostic value to the prediction of HBV-related significant fibrosis, advanced fibrosis and cirrhosis.This conclusion is urgently needed to be verified by further multi-center studies of large sample size and rigorous design.

Novel peripheral blood cell ratios: Effective 3-month post-mechanical thrombectomy prognostic biomarkers for acute ischemic stroke patients

BACKGROUND

Red blood cell distribution width to platelet ratio (RPR), Monocyte to high-density lipoprotein ratio (MHR), and Neutrophil to lymphocyte ratio (NLR) are novel inflammatory biomarkers in laboratory tests, which are associated with clinical outcomes in malignancy, cardiovascular and cerebrovascular diseases. This study aimed to determine their predictive value for the prognosis of acute ischemic stroke after mechanical thrombectomy (MT).

METHODS

A total of 286 patients with acute ischemic stroke (AIS) admitted to a tertiary stroke center in China between January 2018 and February 2020 were treated by MT. Demographic characteristics, risk factors, clinical data, laboratory parameters, and clinical outcomes were recorded. The clinical outcome was disability or death at discharge or 90 days (defined as a modified Rankin Scale score of 3-6). The relationship between RPR, MHR, and NLR and functional outcomes was investigated by binary Logistic regression analysis, and further assessed by receiver operating characteristic curve (ROC). The Kaplan-Meier method was used to analyze the survival rate of prognosis factors.

RESULTS

A total of 286 patients with AIS underwent MT (median age, 70.00; Interquartile range [IQR], 63.00-77.00; 41.6% female). Patients with unfavorable outcome showed higher RPR, MHR, and NLR than those with favorable outcome (RPR, [8.63; IQR, 6.30-10.78] vs [6.17; IQR, 5.11-7.35], P < 0.001; MHR, [0.40; IQR, 0.31-0.53] vs [0.34; IQR, 0.27-0.47], P = 0.005; NLR, [5.28; IQR, 3.63-8.02] vs [3.44; IQR, 2.63-4.63], P < 0.001). In multivariate and ROC curve analysis, higher RPR (>8.565) (odds ratio [OR], 1.671; 95% confidence interval [CI], 1.127-2.479; P = 0.011) and higher MHR (>0.368) (OR, 9.374; 95% CI, 1.160-75.767; P = 0.036), higher NLR (>4.030) (OR, 1.957; 95% CI, 1.382-2.770; P < 0.001) were independently associated with unfavorable outcome. The combined predictive value of the three indexes was higher than that of a single index. Kaplan-Meier survival curve analysis showed that the 90-day survival rate (82.1% vs 66.2%) was significantly different between the low RPR group and the high RPR group (χ² = 4.960, P = 0.026).

CONCLUSION

Higher RPR, MHR, and NLR might be independent risk factors for predicting 3-month poor prognosis in patients with AIS who underwent MT.

The Association of Red Blood Cell Distribution Width to Platelet Count Ratio and 28-Day Mortality of Patients with Sepsis: A Retrospective Cohort Study

BACKGROUND

Sepsis is a life-threatening and inflammatory disease with high morbidity and mortality. Red blood cell distribution width to platelet count ratio (RPR) was known as an inflammatory biomarker and was related to poor outcomes of various diseases.

AIM

This study was intended to explore the association between RPR and mortality of sepsis patients.

METHODS

A retrospective cohort study was undertaken in patients with sepsis, and the data were collected from a public database called Medical Information Mart for Intensive Care III (MIMIC-III). The primary outcome was 28-day mortality while the secondary outcomes were 90-day mortality and ICU mortality. Multivariable regression analyses, as well as interaction and stratified analyses, were conducted to investigate the relation between RPR and sepsis mortality.

RESULTS

In total, we enrolled 7531 patients with 1316 deaths. RPR was independently correlated with 28-day mortality (per 0.1 increase: HR=1.04; 95% CI 1.02-1.06), 90-day mortality (per 0.1 increase: HR=1.04; 95% CI 1.03-1.06) and ICU mortality (per 0.1 increase: OR=1.06; 95% CI 1.02-1.10). Twenty-eight-day survival was worse in the high RPR (≥0.134) group according to the Kaplan-Meier curve analyses (Log rank test, p<0.001). In stratified analyses, Sequential Organ Failure Assessment (SOFA) score and length of ICU stay had interactive effects with the high RPR (≥0.134) group on 28-day mortality.

CONCLUSION

RPR is a novel biomarker that indicates poor prognosis of sepsis patients. Clinicians are required to pay more attention to those patients with high RPR.

Red cell distribution width to platelet ratio predicts liver fibrosis in patients with autoimmune hepatitis

Noninvasive tests for the assessment of liver fibrosis are highly needed for the management of patients with autoimmune hepatitis (AIH). We aimed to investigate the accuracy of red cell distribution width to platelet ratio (RPR) in predicting liver fibrosis in AIH patients. One hundred nineteen AIH patients who underwent liver biopsy were enrolled. Liver fibrosis stage was diagnosed using the Scheuer scoring system. The diagnostic accuracy was evaluated by the area under the receiver operating characteristic curve (AUROC). RPR values in AIH patients with S2-S4 (0.10, interquartile range [IQR] 0.08-0.15), S3-S4 (0.10, IQR 0.09-0.14), and S4 (0.14, IQR 0.09-0.19) were significantly higher than patients with S0-S1 (0.07, IQR 0.06-0.08, P < .001), S0-S2 (0.08, IQR 0.06-0.12, P = .025) and S0-S3 (0.09, IQR 0.07-0.13, P = .014), respectively. The RPR was positively correlated with fibrosis stages (r = 0.412, P < .001), while aspartate transaminase to platelet ratio index (APRI) and fibrosis-4 score (FIB-4) were not significantly associated with fibrosis stages in AIH patients. The AUROCs of RPR in identifying significant fibrosis (S2-S4), advanced fibrosis (S3-S4), and cirrhosis (S4) were 0.780 (95% confidence interval [CI] 0.696-0.865), 0.639 (95% CI 0.530-0.748), and 0.724 (95% CI 0.570-0.878), respectively. The AUROCs of RPR were significantly higher than APRI and FIB-4 in diagnosing significant fibrosis, advanced fibrosis, and cirrhosis. Our study demonstrates that the RPR is a simple predictor of liver fibrosis and is superior to APRI and FIB-4 in identifying liver fibrosis in AIH patients.

Relationship between Neutrophil-to-Lymphocyte Ratio and Systemic Lupus Erythematosus: A Meta-analysis

Systemic lupus erythematosus (SLE) is a chronic systematic autoimmune disease. Current methods of diagnosing SLE or evaluating its activity are complex and expensive. Numerous studies have suggested that neutrophil-to-lymphocyte ratio (NLR) is closely correlated with the presence of SLE and its activity, suggesting that it may serve as a diagnostic and monitoring indicator for SLE. Therefore, we performed a meta-analysis to systematically assess the association between NLR and SLE. We performed a literature search until 12 April 2019 in the PubMed, Web of Science, and China National Knowledge Infrastructure databases. Cross-sectional studies comparing the NLR of SLE patients versus those of healthy controls, of active versus inactive SLE patients, and of SLE patients with versus without lupus nephritis were considered for inclusion. Mean intergroup NLR differences were estimated using standardized mean differences and their 95% confidence intervals. Study quality was assessed using the Agency for Healthcare Research and Quality instrument for cross-sectional studies. Fourteen studies with 1,781 SLE patients and 1,330 healthy controls were included in this meta-analysis. The pooled results showed that the NLR was significantly higher in SLE patients than in healthy controls, in active SLE patients than in inactive SLE patients, and in SLE patients with lupus nephritis than in those without lupus nephritis. NLR may be an indicator for monitoring disease activity and reflecting renal involvement in SLE patients. Nevertheless, more high-quality studies are warranted to further validate our findings.

Haematologic indices in hepatitis B virus-related liver disease

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