The usefulness of C-reactive protein and neutrophil-to-lymphocyte ratio for predicting the outcome in hospitalized patients with liver cirrhosis

Relationship between the systemic immune-inflammatory index and overactive bladder risk: A cross-sectional assessment involving United States Adults

AIMS

This study aimed to evaluate the association between the systemic immune-inflammatory index (SII) and the risk of overactive bladder (OAB) in the adult United States population.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) 2005-2010 were analyzed. A non-pregnant cohort aged ≥20 years with available SII and OAB data was included. Weighted univariate and multivariate logistic regression analyses were performed to assess the association between SII and OAB risk. Additionally, subgroup, interaction, and restricted cubic spline analyses were conducted.

RESULTS

A total of 4,545 participants were included, of whom 16.13% had OAB, with a mean SII of 5.75 ± 0.07. OAB risk increased with higher SII tertiles. In the fully adjusted model (Model 2), individuals in the highest SII tertile exhibited a 41% higher risk of OAB compared to those in the lowest tertile (OR: 1.41, 95% CI: 1.13-1.76, P = 0.004). Two-piece-wise regression analysis identified an SII breakpoint at 3.40, where a significant positive association was found for SII ≥ 3.40 (OR = 1.06, P < 0.0001), whereas no significant association was detected for SII < 3.40 (P = 0.06). Subgroup and interaction analyses revealed a consistent relationship between SII and OAB across different population strata, except for diabetes mellitus.

CONCLUSION

SII, an easily accessible biomarker, was independently associated with an increased risk of OAB, highlighting its potential utility in diagnostic prediction.

The association between immunoinflammatory biomarkers NLR, PLR, LMR and nonalcoholic fatty liver disease: a systematic review and meta-analysis

Non-alcoholic fatty liver disease (NAFLD) is a chronic liver disorder closely linked to metabolic syndrome. Identifying novel, easily measurable biomarkers could significantly enhance the diagnosis and management of NAFLD in clinical settings. Recent studies suggest that immunoinflammatory biomarkers-specifically, the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR)-may offer diagnostic value for NAFLD. However, the effectiveness of these biomarkers has not been comprehensively assessed in this patient population. This systematic review and meta-analysis aimed to evaluate the association between these immunoinflammatory biomarkers and NAFLD. As of August 8, 2024, databases including PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus were systematically searched to compare NLR, PLR, and LMR levels in NAFLD patients and healthy controls. Study quality was assessed using the Newcastle-Ottawa Scale, and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated (PROSPERO registry number: CRD42024580812). A total of 20 studies were included in the meta-analysis. Results indicated that NAFLD patients had significantly higher NLR levels (SMD = 0.43; 95% CI 0.28-0.58; p < 0.001) and lower PLR levels (SMD = - 0.29; 95% CI - 0.41 to - 0.17; p < 0.001) compared to controls. However, no significant difference in LMR was observed between NAFLD patients and controls(SMD = 0.08; 95% CI - 0.00 to 0.17; p = 0.051). These findings suggest that NLR and PLR may hold promise as diagnostic markers for NAFLD, while LMR appears to have limited diagnostic utility. Further research is warranted to explore the potential role of these biomarkers in tracking disease progression.

Role of the Lymphocyte Count-to-C-Reactive Protein Ratio in the Risk Stratification for High EASE Scores After Living Donor Liver Transplantation: A Retrospective Observational Cohort Study

Background: Early allograft failure (EAF) significantly contributes to mortality, necessitating re-transplantation following liver transplantation. The EAF simplified estimation (EASE) score has been recently developed to predict EAF. We aimed to assess the predictive capacity of high EASE scores for EAF and postoperative outcomes and to evaluate the association between the lymphocyte count-to-C-reactive protein ratio (LCR) and high EASE scores after living donor liver transplantation (LDLT). Methods: We retrospectively analyzed the data of 808 patients who underwent LDLT. After excluding 16 patients with incomplete laboratory data, the final cohort included 792 patients. Patients with EASE scores ≥-0.74 were categorized into the high EASE group. Multivariate logistic regression was used to examine the association between the LCR and high EASE scores. Results: High EASE scores demonstrated superior predictive accuracy for EAF development relative to that of the early allograft dysfunction (EAD) model (p = 0.018) and were more closely associated with overall mortality (p = 0.033). A preoperative LCR < 12.7 significantly increased the odds (odds ratio, 3.3; confidence interval, 1.997-5.493) of exhibiting high EASE scores post-LDLT, alongside preoperative hematocrit levels, operative duration, intraoperative continuous renal replacement therapy, administered calcium dose, mean heart rate, and donor age. Conclusions: The EASE score could offer enhanced utility for predicting EAF and overall mortality following LDLT relative to that of EAD. Identifying and managing risk factors, including low LCR values, for elevated EASE scores is essential for improving patient prognoses.

Revisiting septic shock in cirrhosis: a call for personalized management

INTRODUCTION

Patients with cirrhosis are known to be prone to infections. Infections can trigger organ failures and decompensations in cirrhosis. Septic shock can increase mortality by fourfold and cause hemodynamic imbalances, adding to the already hyperdynamic circulation. Management of septic shock in cirrhosis can be tricky due to this complex interplay of altered hemodynamics, immune function, and coagulation.

AREAS COVERED

In this review, we explore the pathophysiological basis, screening, monitoring and management of septic shock in cirrhosis. We also explore novel biomarkers, the growing challenge of multidrug-resistant pathogens and novel and adjunctive therapies. Finally, we propose an algorithm for the management of septic shock in cirrhosis. We conducted a comprehensive search of electronic databases such as PubMed, Web of Science, and Cochrane Library using the keywords and MeSH terms like 'septic shock,' 'cirrhosis,' 'liver disease,' 'sepsis' among others. The search was restricted to peer-reviewed articles in English.

EXPERT OPINION

The difficulties in managing septic shock in cirrhosis are discussed, emphasizing personalized approaches over protocol-driven care. Fluid and vasopressor management, antibiotic timing and selection, the role of adjunctive therapies, the importance of lactate clearance, gut failure, and the need for further research in this population are highlighted.

Role of Cardiac Biomarkers in Hepatic Disorders: A Literature Review

Various studies have reported the association between cardiac markers and hepatic disorders. The main objective of this review article was to elucidate the significance of important cardiac indicators such as ischemia-modified albumin, cardiac troponin, cardiac natriuretic peptides, creatine kinase, creatine kinase-MB, lactate dehydrogenase, heart-type fatty acid-binding protein, osteopontin, soluble suppression of tumorigenicity 2, C-reactive protein, and lipoprotein(a) in the development of hepatic disorders. In addition, it highlighted recent notable discoveries and accomplishments in this field and identified areas requiring further investigation, ongoing discussions, and potential avenues for future research. Early identification and control of these cardiac markers might be helpful to control the prevalence of hepatic disorders associated with cardiovascular diseases.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

Characteristics and Related Factors of Bacterial Infection Among Patients With Cirrhosis

Background

Infection causes cirrhosis to decompensate, affecting liver function and resulting in several complications, including esophageal variceal hemorrhage, hepatic encephalopathy, and hepatorenal syndrome. Objective: This study aimed to identify the prevalence, essential features, and related factors of bacterial infection among patients with cirrhosis in Vietnam.

Methods

This retrospective study included 317 patients diagnosed with cirrhosis, who were divided into two groups: group 1 including 125 patients with bacterial infection and group 2 including 192 patients without bacterial infection. Infection was diagnosed on the basis of its localization.

Results

Spontaneous bacterial peritonitis (SBP; 31.2%) and pneumonia (28.8%) were the most common infections identified. The procalcitonin (PCT) level had a strong diagnostic value with an area under the curve value of 0.868. The most common type of gram-negative bacteria was Escherichia coli, while the gram-positive bacteria seen were Staphylococcus, Enterococcus, and Streptococcus among the patients with infection. In the logistic regression analysis, Child-Pugh class B and C (p<0.001, OR=4.14, CI=1.90-9.03; OR=4.76, CI=2.03-11.16, respectively) and the presence of acute kidney injury (p=0.009, OR=2.57, CI=1.27-5.22) and gastrointestinal hemorrhage (p=0.035, OR=0.39, CI=0.16-0.94) significantly differed between the groups.

Conclusion

The most prevalent type of bacterial infection in patients with cirrhosis is SBP, with gram-negative bacteria being the most common cause. The PCT level is useful in identifying infection in patients with cirrhosis. Decompensated cirrhosis is linked to a higher risk of infection.

Analysis of Efficacy and Safety of Small-Volume-Plasma Artificial Liver Model in the Treatment of Acute-On-Chronic Liver Failure

To explore the efficacy and safety of a small-volume-plasma artificial liver support system (ALSS) in the treatment of acute-on-chronic liver failure (ACLF). A retrospective analysis was performed. All ACLF patients received ALSS of plasma exchange & double plasma molecular absorb system (PE+DPMAS) treatment, and successfully completed this treatment. Patients were divided into small-volume and half-volume plasma groups. We compared the changes of the indicators on liver function, kidney function, blood coagulation function, and blood ammonia level before and after PE+DPMAS treatment; we compared the short-term and long-term curative effects between small-volume and half-volume plasma groups; and the factors influencing Week 4 and Week 12 mortality of ACLF patients were analyzed. The Week 4 improvement rates were 63.96 % and 66.86 % in the small-volume and half-volume plasma groups, respectively. The Week 12 survival rates in the small-volume-plasma and half-volume plasma groups were 66.72 % and 64.61 %, respectively. We found several risk factors affecting Week 4 and Week 12 mortality. Kaplan-Meier survival curves suggested no significant difference in Week 4 and Week 12 survival rates between the small-volume and half-volume plasma groups (P=0.34). The small-volume-plasma PE+DPMAS treatment could effectively reduce bilirubin and bile acids, and this was an approach with high safety and few complications, similar to the half-volume-plasma PE+DPMAS treatment. The small-volume-plasma PE+DPMAS has the advantage of greatly reducing the need for intraoperative plasma, which is especially of importance in times of shortage of plasma.

Sex-specific differences in the effect of lymphocyte-to-C-reactive protein ratio on subclinical myocardial injury in the general population free from cardiovascular disease

BACKGROUND AND AIM

The Lymphocyte-to-C-reactive protein ratio (LCR) combines information on immune and inflammatory status. Lymphocytes reflect immune health, while C-reactive protein (CRP) signals systemic inflammation. Some studies have linked LCR with cardiovascular outcomes, suggesting it could help identify at-risk individuals. However, its clinical utility needs further research validation. To investigate the association between lymphocyte-to-C-reactive protein ratio (LCR) and subclinical myocardial injury (SC-MI) in individuals who are free from cardiovascular disease (CVD) within the general population.

METHODS AND RESULTS

The study included individuals in the National Health and Nutrition Examination Survey (NHANES) III. SC-MI was defined as having a Cardiac Infarction Injury Score (CIIS) greater than 10 units on a 12-lead electrocardiogram. Logistic regression models were employed to investigate the association between LCR and SC-MI. In total, 5870 individuals were included in the study, among whom 3266 had a history of SC-MI. Compared with the lowest quartile (Q1) in male, the odds ratios (OR) of SC-MI in Q2, Q3, and Q4 were 0.67 (95%CI: 0.53-0.86), 0.66 (95%CI: 0.51-0.84), and 0.70 (95%CI: 0.55-0.89), respectively. The data shows a trend where the OR of SC-MI are lower in higher quartiles of LCR, compared to the lowest quartile, in the male population (P for trend = 0.006). In other words, the likelihood of SC-MI tends to be lower among males with higher LCR values. However, after adjusting for potential confounding variables, the relationship between LCR and SC-MI displays a pattern of an initial decline, followed by a minor upward shift.

CONCLUSION

LCR is independently and inversely associated with SC-MI risk in the general population free from CVD. Furthermore, the observed association is exclusive to males, indicating a need for further randomized controlled trials to substantiate the efficacy of implementing LCR reduction as a means of CVD prevention in the male population.

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

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

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

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

Hematological parameters and their predictive value for assessing disease severity in laboratory-confirmed COVID-19 patients: a retrospective study

BACKGROUND

The coronavirus disease 19 (COVID-19) infection has spread globally and caused a substantial amount of mortality and morbidity. Early detection of severe infections will improve care and reduce deaths. The use of hematological parameters in predicting COVID-19 disease severity, patient outcomes, and early risk stratification is limited. Therefore, the study was aimed at determining hematological parameters and their predictive value for assessing disease severity in laboratory-confirmed COVID-19 patients in Northwest Ethiopia.

METHODS

A retrospective cross-sectional study was conducted at the University of Gondar comprehensive specialized hospital and Tibebe Ghion comprehensive specialized referral hospital on 253 patients diagnosed with COVID-19 and admitted between March 2021 and February 2022. Data were extracted, and entered into Epi-data 4.2.0.0, and analyzed using SPSS version 25 software. Hematological parameters were provided as the median and interquartile range (IQR). Categorical variables were represented by their frequency, and the χ2 test was applied to compare observed results with expected results. The receiver-operating curve (ROC) was used to establish the predictive value of hematological parameters for COVID-19 severity. A p-value < 0.05 was considered statistically significant.

RESULTS

On a total of 253 patients, there were 43.87% severe cases, with a mortality rate of 26.9%. The ROC analysis showed the optimal cutoff values for hematological parameters were ANC (3370), lymphocyte (680), NLR (9.34), PLR (290.77), platelets (332,000), and WBCs (4390.65). The area under the curve (AUC) values for NLR (0.679) and ANC (0.631) were high, with the highest sensitivity and specificity, and could potentially be used to predict COVID-19 severity.

CONCLUSION

This study proved that high NLR and high ANC have prognostic value for assessing disease severity in COVID-19. Thus, assessing and considering these hematological parameters when triaging COVID-19 patients may prevent complications and improve the patient's outcome.

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

Background

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

Methods

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

Results

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

Conclusion

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

The relationship between C-reactive protein to lymphocyte ratio and the prevalence of myocardial infarction in US adults: A cross-sectional study

Objective

C-reactive protein to lymphocyte ratio (CLR) has been identified as a novel inflammatory biomarker. However, the role of CLR in myocardial infarction is unclear. Thus, this study designs to investigate the association of CLR with the prevalence of myocardial infarction in a large multiracial population in the United States.

Methods

Participants from the National Health and Nutrition Examination Survey (NHANES) 2017-March 2020 Pre-pandemic were included in this cross-sectional study. Multivariable regression and subgroup analyses, controlling for demographic variables, were performed to examine the association between CLR and its quintiles and myocardial infarction. A smooth curve fitting was used to model the non-linear relationship between them.

Results

A total of 12,615 participants aged ≥18 years were recruited, of whom 609 (4.83%) self-reported a history of myocardial infarction. Compared to those in the lowest quartile of ln-transformed CLR (Q1), the myocardial infarction risks for subjects in Q2, Q3, and Q4 were 1.64, 1.71, and 1.79 times, respectively. Obvious upward trends were observed when ln-transformed CLR increased (P for trend <0.01). In continuous analyses, the fully adjusted odds ratios (OR) for myocardial infarction prevalence per ln-transformed increment in CLR was 1.46 (95% CI: 1.16-1.84, P < 0.01). Furthermore, a linear association was detected for ln-transformed CLR with the risk of myocardial infarction. Interaction test showed that the effect of CLR on myocardial infarction was significantly affected by age (P for interaction = 0.04).

Conclusions

Data from a large, cross-sectional cohort program show that CLR is positively associated with myocardial infarction prevalence. Our findings highlight that CLR may be a novel inflammation warning biomarker for myocardial infarction.

A novel prognostic nomogram for older patients with acute-on-chronic liver diseases (AoCLD): a nationwide, multicentre, prospective cohort study

BACKGROUND

the incidence of acute-on-chronic liver disease (AoCLD) is increasing.

OBJECTIVE

to investigate the clinical features and risk factors of AoCLD and construct an effective prognostic nomogram model for older patients with AoCLD.

METHODS

data from 3,970 patients included in the CATCH-LIFE study were used, including 2,600 and 1,370 patients in the training and validation sets, respectively. Multivariate Cox regression analyses were performed to identify predictive risk factors in older individuals, and an easy-to-use nomogram was established. Performance was assessed using area under the curve, calibration plots and decision curve analysis (DCA).

RESULTS

of the 3,949 patients with AoCLD, 809 were older with a higher proportion of autoimmune-related abnormalities, hepatitis C viral infection and schistosomiasis. In the older patient group, the incidence of cirrhosis, hepatic encephalopathy (HE), infection, ascites and gastrointestinal bleeding; neutrophil-to-lymphocyte ratio (NLR), aspartate-to-alanine transaminase ratio (AST/ALT), creatinine and blood urea nitrogen levels were higher, whereas incidence of acute-on-chronic liver failure, white blood cell, platelet and haemoglobin levels; albumin, total bilirubin (TB), AST and ALT levels; international normalised ratio (INR), estimated glomerular filtration rate and blood potassium levels were lower than in the younger group. The final nomogram was developed based on the multivariate Cox analysis in training cohort using six risk factors: ascites, HE grades, NLR, TB, INR and AST/ALT. Liver transplantation-free mortality predictions were comparable between the training and validation sets. DCA showed higher net benefit for the nomograph than the treat-all or treat-none strategies, with wider threshold probabilities ranges.

CONCLUSIONS

our analysis will assist clinical predictions and prognoses in older patients with AoCLD.

Neutrophil to Lymphocyte Ratio and Spontaneous Bacterial Peritonitis among Cirrhotic Patients: A Systematic Review and Meta-analysis

BACKGROUND

The goal of this systematic review and meta-analysis was analyzing published studies on the role of neutrophil to lymphocyte ratio (NLR) in infection and spatially spontaneous bacterial peritonitis (SBP) among cirrhotic patients.

METHODS

PubMed, Web of Science, and Scopus were searched until May 24, 2022. The Newcastle-Ottawa scale was used for quality assessment.

RESULTS

Of 14 studies included in our study, six studies were on infection with 2786 hospitalized cirrhotic patients, of whom 934 developed an infection. Other studies were on SBP with 1573 cirrhotic patients with ascites, of whom 557 developed SBP. The pooled results showed that there was no difference in NLR levels between hospitalized cirrhotic patients who developed infection compared to those who did not (random-effects model: SMD = 0.63, 95% CI = -0.01-1.27, p=0.054). However, cirrhotic patients with ascites who developed SBP had elevated levels of NLR compared to those who did not (random-effects model: SMD = 1.05, 95% CI = 0.52-1.57,p < 0.001). This difference remained significant in prospective studies (SMD = 0.94, 95% CI = 0.51-1.38,p < 0.001) but not in retrospective studies (SMD = 1.37, 95% CI = -0.56-3.29,p=0.165), in the subgroup analysis according to the study design. The pooled sensitivity of NLR was 92.07% (95% CI = 74.85%-97.84%) and the pooled specificity was 72.58% (95% CI = 57.72%-83.69%). The pooled positive likelihood ratio, negative likelihood ratio, DOR of NLR were 3.35(95%CI = 2.06-5.46), 0.10 (95%CI = 0.03-0.38), and 30.78 (95%CI = 7.01-135.04), respectively.

CONCLUSION

Our results support NLR to be a valid biomarker that can be readily integrated into clinical settings to help in the prevention and prediction of SBP among cirrhotic patients.

The Usefulness of Extended Inflammation Parameters and Systemic Inflammatory Response Markers in the Diagnostics of Autoimmune Hepatitis

(1) Introduction: Autoimmune hepatitis (AIH) is a chronic disease. A persistent autoimmune reaction in the liver is significantly related to the systemic inflammatory response. Extended Inflammation Parameters (EIP) can be used to assess the activation of immune cells such as activated neutrophils (NEUT-RI and NEUT-GI) and activated lymphocytes (RE-LYMP and AS-LYMP) in the phase of active inflammation. The role of the systemic inflammatory response markers should also be emphasised, especially: NLR, PLR, and RLR, which have recently been widely studied as markers in autoimmune skin diseases or liver diseases. (2) Materials and Methods: The study included 30 patients with AIH and 30 healthy volunteers. The parameters of the EIP group (RE-LYMP, AS-LYMP, NEUT-RI, NEUT-GI), calculated haematological indices Red Blood Cell Distribution Width-to-Platelet Ratio (RPR), Mean Platelet Volume-to-Platelet Ratio (MPR), Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), Red Blood Cell Distribution Width-to-Lymphocyte Ratio (RLR), and selected blood morphological and biochemical indices were analysed. The aim of the study was to assess the usefulness of the EIP and systemic inflammatory response markers in the diagnostics of AIH. (3) Results: Compared to the controls, the patients with AIH showed significantly higher EIP values: NEUT-RI (48.05 vs. 43.30), NEUT-GI (152.65 vs. 147.40), RE-LYMP (0.07 vs. 0.03), and the inflammatory response markers: MPR (0.05 vs. 0.04), RPR (0.07 vs. 0.05), and NLR (2.81 vs. 1.42. Among the examined markers, EIP has significant diagnostic potential: NEUT-RI (AUC = 0.86), NEUT-GI (AUC = 0.80), and RE-LYMP (AUC = 0.78), and so do calculated haematological indices, i.e., MPR (AUC = 0.75), PLR (AUC = 1.00), and RLR (AUC = 1.00) Moreover, the importance of NEUT-GI (AUC = 0.89), MPR (AUC = 0.93), PLR (AUC = 0.86), RPR (AUC = 0.91), and FIB-4 (AUC = 0.83) in the detection of liver fibrosis in the course of AIH has also been proven. (4) Conclusions: EIP and systemic inflammatory response markers may turn out to be useful in detecting AIH and in looking for features of already developed liver cirrhosis in its course.

Genotypes and Variants of BKPyV in Organ Donors after Brain Death

Kidney transplantation from a donor with latent BKPyV might be the cause of serious complications, such as BK virus-associated nephropathy. The aim of the study was to determine the prevalence of BKPyV infection in donors after brain death (DBDs), to analyse the molecular variation of BKPyV and to compare clinical and inflammation parameters of DBDs infected with various genotypes of BKPyV. BKPyV was investigated in blood and urine samples of 103 DBDs using PCR followed by sequencing and bioinformatic analysis, and the viral load was assessed by qPCR. Clinical parameters, including cellular markers of inflammation were assessed. The results confirm high prevalence of BKPyV (48%),and genotype IV (49%) over genotype I (43%) and the co-infection with genotypes I and IV in 8.2%. Viral load ranged from 102 to 107 copies/mL, with an average of 1.92 × 106 copies/mL. No specific markers for BKPyV infection were detected among the parameters tested. Infection with genotype I may be associated with the adverse impact on thekidney function, while infection with genotype IV was associated with the anemia Not only the viral load but also the genotype of BKPyV may have an impact on the course of infection.

Early Diagnosis and Prevention of Infections in Cirrhosis

Strategies to prevent infection and improve outcomes in patients with cirrhosis. HAV, hepatitis A virus; HBV, hepatitis B virus; COVID-19, novel coronavirus disease 2019; NSBB, nonselective β-blocker; PPI, proton pump inhibitors.Cirrhosis is a risk factor for infections. Majority of hospital admissions in patients with cirrhosis are due to infections. Sepsis is an immunological response to an infectious process that leads to end-organ dysfunction and death. Preventing infections may avoid the downstream complications, and early diagnosis of infections may improve the outcomes. In this review, we discuss the pathogenesis, diagnosis, and biomarkers of infection; the incremental preventive strategies for infections and sepsi; and the consequent organ failures in cirrhosis. Strategies for primary prevention include reducing gut translocation by selective intestinal decontamination, avoiding unnecessary proton pump inhibitors' use, appropriate use of β-blockers, and vaccinations for viral diseases including novel coronavirus disease 2019. Secondary prevention includes early diagnosis and a timely and judicious use of antibiotics to prevent organ dysfunction. Organ failure support constitutes tertiary intervention in cirrhosis. In conclusion, infections in cirrhosis are potentially preventable with appropriate care strategies to then enable improved outcomes.

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

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

Update on blood-based biomarkers for chronic liver diseases prognosis: Literature review and institutional experience

Liver cirrhosis is the final stage of chronic liver disease (CLD) and is associated with high morbidity and mortality. Various complications such as portal hypertension, ascites retention, hepatic encephalopathy, and hepatorenal syndrome deeply affect patient outcome. The most common tools to predict the outcome of a CLD patient include the following: assessing severity of portal hypertension; scoring systems such as the model of end-stage liver disease and Child-Pugh score and blood biomarkers related to complications and/or survival rate. In this article, we summarize recent studies of noninvasive markers for predicting impending complications related to CLD and discuss the clinical value of currently available blood biomarkers based on evidence from the literature. In addition, noninvasive blood biomarker assays for different prognostic functions were validated on 113 liver cirrhosis patients at our institution using Kaplan-Meier curve analysis to confirm that these markers can satisfactorily predict CLD-related patient death.

Neutrophil-to-lymphocyte ratio: an accurate method for diagnosing infection in cirrhosis

BACKGROUND

Early diagnosing bacterial infection in cirrhotic patients is critical but challenging. Neutrophil-to-lymphocyte ratio (NLR) reflects systemic inflammation and is an emerging biomarker that replicates cirrhosis' imbalanced immune response.

AIM

Assess whether NLR levels associate with higher risk of infection in patients admitted with first cirrhosis decompensation.

METHODS

Retrospective, unicenter study, including patients with cirrhosis, admitted to the hospital at first decompensation. NLR was calculated at admission. Applying logistic regression models and testing for discriminative power, we correlated NLR with the outcome infection.

RESULTS

We included 139 patients. Forty-four infections to report (31.7%), 18 (12.9%) community infections and 26 (18.7%) hospital-acquired infections.Higher NLR values at admission were associated with increased infection risk in univariable and multivariable models - for each unit increase of NLR, infection odds increased 1.29 times (95%CI = 1.09-1.53; p = 0.003), after adjusting for covariates. We performed a classification tree based only on NLR to evaluate the risk of infection. A high-risk group (proportion of patients with infection = 87%) was identified, corresponding to NLR>14; patients with NLR <3.6 presented lower infection risk (17%).Regarding hospital-acquired infection, we were not able to discriminate groups of patients based on classification trees.

CONCLUSION

NLR is a straightforward approach to attest the individual infection risk on cirrhotic patients. We report NLR cutoffs 3.6 and 14 as optimal for overall infection diagnosing, mainly due to community infection.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Associations between hematological parameters and disease severity in patients with SARS-CoV-2 infection

Background

The emergence and rapid spread of the deadly novel coronavirus disease caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) is a swiftly evolving public health crisis worldwide. SARS‐CoV‐2 infection is characterized by the development and progression of inflammatory responses. Hematological parameters, such as white blood cells (WBCs) and their subpopulations, red cell distribution width, platelet count, mean platelet volume, plateletcrit, and derived markers such as neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR), and lymphocyte‐to‐monocyte ratio, are established biomarkers of inflammatory responses. We aimed to investigate associations between hematological parameters and disease severity in patients with SARS‐CoV‐2 infection.

Methods

We retrospectively analyzed data from 68 patients with confirmed SARS‐CoV‐2 infection. Twenty‐two patients had mild illness, and 46 had moderate or severe illness at the time of admission. Univariate and multivariate regression analyses were used to identify correlates of disease severity. The areas under receiver operating characteristic curves were calculated to estimate and compare the predictive values of different diagnostic markers.

Results

Mean lymphocyte and monocyte counts were lower while WBC counts, neutrophil counts, NLR, and PLR were higher in patients with severe disease compared with those with mild disease (all P < .01). Univariate analysis revealed that older age, high WBC counts, high neutrophil counts, high NLR, high PLR, low monocyte counts, and low lymphocyte counts were independent correlates of severe illness. Multivariate analysis identified high NLR as the only independent correlate of severe illness. Receiver operating characteristic curve analysis showed that NLR had the highest area under curve of all hematological parameters.

Conclusion

Among hematological parameters, the NLR showed superior prediction of disease severity in patients with SARS‐CoV‐2 infection. Thus, the NLR could be a valuable parameter to complement conventional measures for identification of patients at high risk for severe disease.

The significance of C-reactive protein to albumin ratio in patients with decompensated cirrhosis

Background

Prognostic indicators in patients with decompensated cirrhosis are vital for the estimation of death risk. The ratio of C-reactive protein to albumin (CAR) has been verified as a prognostic marker in patients with hepatocellular carcinoma and decompensated cirrhosis related to hepatitis B virus. Neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and gamma globulins have been separately studied in cirrhosis. We evaluated the predictive role of CAR and other inflammatory markers in decompensated patients.

Methods

We prospectively studied 159 patients with stable decompensated cirrhosis, calculating the following indexes: CAR, NLR, LMR, Child-Turcotte-Pugh (CTP), and model for end-stage liver disease (MELD).

Results

MELD (area under the curve [AUC] 0.814) and CTP score (AUC 0.752) were superior to the other markers above in predicting patients’ mortality (P<0.05). Patients with CAR<2.17 (median value) presented better times of survival: 20 months (12-27) vs. 14 months (10-17) (log rank P=0.015). NLR and LMR barely discriminated patients’ prognosis. In multivariate analysis, only MELD and CTP scores were significant risk factors, whether using the proposed cutoff of 1.3 (hazard ratio [HR] 1.17 [1.106-2.44], P<0.001) or the median 2.17 CAR categorical variable (HR 1.17 [1.104-1.243], P<0.001). When patients who underwent liver transplantation were excluded, apart from the MELD and CTP scores CAR 2.17 was the only significant factor associated with the outcome (HR 3.61 [0.96-13.6], P=0.05) and detected different survival times: 10 (1-48) vs. 11 (2-38) months, log rank P=0.003. Patients with LMR≥1.9 presented significantly better renal function, in terms of true glomerular filtration rate (80±34 vs. 64±33 mL/min, P=0.004) and creatinine levels: 0.84 (0.1-1.8) vs. 0.98 (0.59-3.3) mg/dL (P=0.001).

Conclusion

Our findings demonstrate the significance of CAR and LMR in the outcome and renal function of decompensated patients.

A novel predictive model based on inflammatory markers to assess the prognosis of patients with HBV-related acute-on-chronic liver failure: a retrospective cohort study

Background

Systemic inflammatory response is closely related to the development and prognosis of liver failure. This study aimed to establish a new model combing the inflammatory markers including neutrophil/lymphocyte ratio (NLR) and red blood cell distribution width (RDW) with several hematological testing indicators to assess the prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF).

Methods

A derivation cohort with 421 patients and a validation cohort with 156 patients were recruited from three hospitals. Retrospectively collecting their clinical data and laboratory testing indicators. Medcalc-15.10 software was employed for data analyses.

Results

Multivariate analysis indicated that RDW, NLR, INR, TBIL and Cr were risk factors for 90-day mortality in patients with HBV-ACLF. The risk assessment model is COX_RNTIC = 0.053 × RDW + 0.027 × NLR + 0.003 × TBIL+ 0.317 × INR + 0.003 × Cr (RNTIC) with a cut-off value of 3.08 (sensitivity: 77.89%, specificity: 86.04%). The area under the receiver operating characteristics curve (AUC) of the RNTIC was 0.873 [95% CI(0.837–0.903)], better than the predictive value of MELD score [0.732, 95% CI(0.687–0.774)], MELD-Na [0.714, 95% CI(0.668–0.757)], CTP[0.703, 95% CI(0.657–0.747)]. In the validation cohort, RNTIC also performed a better prediction value than MELD score, MELD-Na and CTP with the AUC of [0.845, 95% CI(0.778–0.898)], [0.768, 95% CI (0.694–0.832)], [0.759, 95% CI(0.684–0.824)] and [0.718, 95% CI(0.641–0.787)] respectively.

Conclusions

The inflammatory markers RDW and NLR could be used as independent predictors of 90-day mortality in patients with HBV-ACLF. Compared with MELD score, MELD-Na and CTP, RNTIC had a more powerful predictive value for prognosis of patients with HBV-ACLF.

Neutrophil-Lymphocyte Ratio (NLR) Reflects Myocardial Inhomogeneities in Hemodialyzed Patients

INTRODUCTION

Cardiovascular diseases (CVDs) are a leading cause of death in chronically hemodialyzed (HD) patients. In this group, inflammation exerts significant impact on the prevalence of CVD morbidity and mortality. Spatial QRS-T angle is an independent and strong predictor of CV events, including sudden cardiac death (SCD), both in general population and HD patients. Pathogenesis of widened QRS-T angle is complicated and is not well established.

OBJECTIVES

The study is aimed at evaluating whether inflammation process can contribute to the wide QRS-T angle. Patients and Methods. The retrospective study was performed on 183 HD patients. The control group consisted of 38 patients. Demographic, biochemical, vectorcardiographic, and echocardiographic data were evaluated in all patients. Inflammation process was expressed as neutrophil-lymphocyte ratio (NLR), as well as C-reactive protein (CRP).

RESULTS

Both NLR (3.40 vs. 1.95 (p < 0.0001)) and spatial QRS-T angle (50.76 vs. 93.56 (p < 0.001)) were higher in the examined group, compared to the control group. Similarly, CRP was higher in the examined group than in the control group (8.35 vs. 4.06 (p < 0.001), respectively). The QRS-T angle correlated with NLR, CRP, some structural echocardiographic parameters, parathormone (PTH), and calcium (Ca) concentrations. Multiple regression analysis showed that NLR is an independent QRS-T angle predictor (r = 0.498, p = 0.0027). The ROC curve analysis indicated the cut-off point of NLR equaled 4.59, where the sensitivity and specificity were the highest for predicting myocardial inhomogeneities expressed as widened QRS-T angle.

CONCLUSION

The NLR, as an inflammation marker, may indicate myocardial inhomogeneities in HD patients.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Red cell distribution width-to-lymphocyte ratio: A novel predictor for HBV-related liver cirrhosis

To evaluate the diagnostic power of red cell distribution width-to-lymphocyte ratio (RLR) for HBV-related liver cirrhosis via a retrospective cohort study.Seven hundred fifty healthy controls, 327 chronic hepatitis B (CHB) patients, and 410 patients with HBV-related liver cirrhosis (HBV-LC) were enrolled in this study. RLR, lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio (NLR), red cell distribution width (RDW), AST to platelet ratio index (APRI), and fibrosis index based on the 4 factors (FIB-4) were compared between the 3 groups. The predictive powers of RLR and RDW for HBV-related liver cirrhosis and patient prognosis were evaluated using AUROC.Patients with HBV-related liver cirrhosis had higher RLR, FIB-4, NLR, RDW, APRI, and lower LMR compared with the control and CHB groups. RLR in the HBV-LC group was significantly higher than both CHB and control groups (both P < .05). While RLR in the CHB group was also higher than the control group, the difference was not statistically significant (P > .05). The AUROC of RLR for predicting HBV-related liver cirrhosis was 0.87, and was superior to RDW (0.81), FIB-4 (0.79), and APRI (0.60). With an optimized cut-off value (10.87), RLR had the highest sensitivity (0.88) and specificity (0.72), and was superior to RDW (0.86, 0.64), FIB-4 (0.80, 0.65), and APRI (0.85, 0.48) as a biomarker. For all 3 groups, RLR was negatively correlated (all P < .05) with serum platelet (PLT) and was positively correlated (all P < .05) with FIB-4 and APRI. There was no significant statistical difference in RLR for patients in HBV-LC group who had different prognosis (P > .05).The RLR, a routinely available, inexpensive, and easily calculated measure, can be used as a predictor of HBV-related liver cirrhosis, but not as a predictor of prognosis for patients with liver cirrhosis. Use of RLR may reduce the need for frequent liver biopsies in CHB patients.

Amyloid A in Serum and Ascitic Fluid as a Novel Diagnostic Marker of Spontaneous Bacterial Peritonitis

BACKGROUND

Diagnosis of Spontaneous Bacterial Peritonitis (SBP) depends mainly on ascetic fluid culture which may be negative in spite of the clinical suggestion of SBP and high ascetic fluid neutrophilic count.

AIMS

This study aimed to evaluate the biological importance of amyloid A biomarker in both serum and ascetic fluid to diagnose SBP as early as possible and to compare it to other markers (C-reactive protein (CRP), and the neutrophil-to-lymphocyte ratio (NLR)).

METHODS

This study included 37 patients with hepatic ascites; twenty-two of them had SBP, and 15 patients did not have SBP. Serum and ascetic fluid amyloid A, ascetic fluid neutrophil, C-reactive protein, and neutrophil-to-lymphocyte ratio were measured in all subjects before the start of antimicrobial chemotherapy to the infected ones.

RESULTS

Both the serum and ascetic fluid amyloid and also, CRP were significantly higher in patients infected with ascetic fluid than others. The cut-off point of serum amyloid A for early detection of SBP was 9.25ug/ml with the high sensitivity and specificity. For ascetic amyloid A, the sensitivity and specificity were 90.09% and 60% at cut-off point 2.85ug/ml, respectively.

CONCLUSION

Amyloid A in serum and ascitic fluid can be considered as a good biomarker for early diagnosis of SBP.

Predictive utility of the C-reactive protein to albumin ratio in early allograft dysfunction in living donor liver transplantation: A retrospective observational cohort study

BACKGROUND

This study was performed to determine the association between the ratio of C-reactive protein to albumin (CRP/ALB) and the risk of early allograft dysfunction (EAD) in patients undergoing living donor liver transplantation (LDLT).

PATIENTS AND METHODS

A total of 588 adult patients undergoing LDLT were retrospectively investigated, after 22 were excluded because of signs of overt infection or history of ALB infusion. The study population was classified into high and low CRP/ALB ratio groups according to EAD. All laboratory variables, including CRP and ALB, had been collected on the day before surgery. A percentage value for the CRP/ALB ratio (%) was calculated as CRP/ALB × 100.

RESULTS

After LDLT, 83 patients (14.1%) suffered EAD occurrence. A higher CRP/ALB ratio was independently associated with risk of EAD, Model for End-stage Liver Disease score, fresh frozen plasma transfusion, and donor age. Based on a cutoff CRP/ALB ratio (i.e., > 20%), the probability of EAD was significantly (2-fold) higher in the high versus low CRP/ALB group. The predictive utility of CRP/ALB ratio for EAD was greater than those of other inflammatory markers. In addition, patients with a high CRP/ALB ratio had poorer survival than those with a low CRP/ALB ratio during the follow-up period.

CONCLUSIONS

The easily calculated CRP/ALB ratio may allow estimation of the risk of EAD after LDLT and can provide additional information that may facilitate the estimation of a patient's overall condition.

Baseline neutrophil-to-lymphocyte ratio predicts response to corticosteroids and is associated with infection and renal dysfunction in alcoholic hepatitis

BACKGROUND

Treating severe alcoholic hepatitis involves the exposure of patients to corticosteroids for 7 days to assess "response".

AIM

To assess the prognostic and therapeutic implications of baseline neutrophil-to-lymphocyte ratio (NLR) in patients with severe alcoholic hepatitis.

METHODS

Patients recruited to the STOPAH trial and an independent validation group were analysed retrospectively. Area under the receiver operating curve (AUC) analysis was performed. Kaplan-Meier analysis was used to assess survival. Log-rank test and odds ratio (OR) were used for comparative analysis.

RESULTS

Baseline NLR was available for 789 STOPAH patients. The AUC for NLR was modest for 90-day outcome (0.660), but was associated with infection, acute kidney injury (AKI) and severity of alcoholic hepatitis. Ninety-day survival was not affected by prednisolone treatment if NLR < 5 or > 8 but mortality was reduced with prednisolone treatment when the NLR was 5-8 (21.0% cf. 34.5%; P = 0.012). Prednisolone treatment increased the chance of Lille response if the NLR was  ≥ 5 (56.5% cf. 41.1%: P = 0.01; OR 1.86) but increased the risk of day 7 infection (17.3% cf. 7.4%: P = 0.006; OR 2.60) and AKI (20.8% cf. 7.0%: P = 0.008; OR 3.46) if the NLR was > 8. Incorporation of NLR into a modified Glasgow alcoholic hepatitis score (mGAHS) improved the AUC to 0.783 and 0.739 for 28-day and 90-day outcome, respectively.

CONCLUSION

The NLR is associated with AKI and infection in severe alcoholic hepatitis. The NLR identifies those most likely to benefit from corticosteroids at baseline (NLR 5-8). The mGAHS has a good predictive value for 28- and 90-day outcomes.

Neutrophil-to-Lymphocyte Ratio Predicts Death in Acute-on-Chronic Liver Failure Patients Admitted to the Intensive Care Unit: A Retrospective Cohort Study

Supplemental Digital Content is available in the text

The neutrophil-to-lymphocyte ratio (NLR) is an inflammation score recognized as associated with outcome. Although inflammation has been shown to correlate with the development of acute-on-chronic liver failure (ACLF), we sought to investigate the role of NLR in predicting 90-day mortality in cirrhotic patients experiencing ACLF. We performed a retrospective cohort study involving a total of 108 consecutive cirrhotic patients admitted in the intensive care unit (ICU). NLR, clinical and biological data were recorded. Of the total, 75 patients had ACLF. The 90-day mortality rate was 53%. ACLF patients displayed higher NLR values in comparison with cirrhotic patients without ACLF throughout the ICU stay. NLR proved more elevated in nonsurvivors ACLF patients, with mortality correlating with increasing quartiles of NLR. On multivariable Cox regression analysis, NLR was found to be a predictor of mortality along with the Sequential Organ Failure Assessment (SOFA) score and mechanical ventilation requirement. The model for end-stage liver disease (MELD) score was not predictive of 90-days mortality. Performance analysis revealed an area under curve of 0.71 [95% confidence interval: 0.59–0.82] regarding NLR capacity to predict 90-days mortality. When including NLR, SOFA score, and mechanical ventilation requirement into the final model, the area under curve was significantly higher (0.81 [95% confidence interval: 0.72–0.91]).

These findings suggest that NLR is associated with mortality in ACLF patients admitted to the ICU. Combining NLR, SOFA score, and the need for mechanical ventilation could be a useful prognostic tool to identify ACLF patients at a higher risk of mortality.

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cardiac diastolic dysfunction predicts poor prognosis in patients with decompensated liver cirrhosis

BACKGROUND/AIMS

Left ventricular diastolic dysfunction (LVDD) is an early manifestation of cardiac dysfunction in patients with liver cirrhosis (LC). However, the effect of LVDD on survival has not been clarified, especially in decompensated LC.

METHODS

We prospectively enrolled 70 patients with decompensated LC, including ascites or variceal bleeding, at Daejeon St. Mary's Hospital from April 2013 to April 2015. The cardiac function of these patients was evaluated using 2D echocardiography with tissue Doppler imaging. The diagnosis of LVDD was based on the American Society of Echocardiography guidelines. The primary endpoint was overall survival.

RESULTS

Forty-four patients (62.9%) had LVDD. During follow-up (22.3 months), 18 patients died (16 with LVDD and 2 without LVDD). The survival rate was significantly lower in patients with LVDD than in those without LVDD (31.1 months vs. 42.6 months, P=0.01). In a multivariate analysis, the Child-Pugh score and LVDD were independent predictors of survival. Moreover, patients with a ratio of early filling velocity to early diastolic mitral annular velocity (E/e') ≥ 10 (LVDD grade 2) had lower survival than patients with E/e' ratio < 10.

CONCLUSION

The presence of LVDD is associated with poor survival in patients with decompensated LC. Therefore, it may be important to monitor and closely follow LVDD patients.

Hematological Indices in Portal Hypertension: Cirrhosis versus Noncirrhotic Portal Hypertension

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

Possible Synergistic Effects of Glutathione and C-Reactive Protein in the Progression of Liver Cirrhosis

Liver cirrhosis is often associated with increased inflammatory responses and changes of glutathione (GSH) status. The possible interactions between these two factors in mediating damages of liver function remain unclear. Here, we measured the inflammatory responses and GSH status in liver cirrhotic patients and compared them with healthy subjects. In addition, we assessed the relationship of the GSH status and levels of inflammatory markers with the severity of the disease. This was a cross-sectional study. In total, we recruited 63 liver cirrhotic patients with Child⁻Turcotte⁻Pugh class A scores, and 12 patients with class B⁻C scores, together with 110 healthy subjects. Patients with class B⁻C scores showed the highest level of high-sensitivity C-reactive protein (hs-CRP) when compared with class A patients or healthy subjects. Patients in class A group had significantly higher GSH levels when compared with class B⁻C group or healthy subjects. After adjusting for potential confounders and each other, serum hs-CRP levels showed positive association with the Child⁻Turcotte⁻Pugh scores, while GSH levels showed negative association with Child⁻Turcotte⁻Pugh scores. Interactions were found between levels of plasma GSH and serum hs-CRP (β = 0.004, p = 0.016). CRP and GSH levels, which had showed interactions, were associated with the severity of liver cirrhosis.

Increased Level of Interleukin 6 Associates With Increased 90-Day and 1-Year Mortality in Patients With End-Stage Liver Disease

BACKGROUND & AIMS

Organ allocation for liver transplantation is based on prognosis, using the model for end-stage liver disease (MELD) or MELD including serum sodium (MELD-Na) score. These scores do not consider systemic inflammation and septic complications. Blood level of C-reactive protein (CRP), in addition to the MELD score, associates with mortality in patients with end-stage liver disease, whereas levels of interleukin 6 (IL6) have not been systematically studied.

METHODS

We performed a retrospective observational cohort study of 474 patients with end-stage liver disease (63.5% male; median age, 56.9 years), evaluated for liver transplantation in Germany, with at least 1 year of follow up. Data were collected on blood levels of CRP, IL6, and white blood cell count (WBC). Findings were analyzed in relation to mortality and compared with patients' MELD scores and MELD-Na scores. For survival analysis, the cohort was divided into quartiles of IL6, CRP, and WBC levels, as well as MELD scores. Log-rank test and the Cox proportional hazards regression model were used to compare the groups, and area under the receiver operating characteristic (AUROC) values were calculated.

RESULTS

Blood levels of IL6 and MELD scores associated with mortality: none of the patients with levels of IL6 below the first quartile (below 5.3 pg/mL) died within 1 year. In contrast, 67.7% of the patients in the highest quartile of IL6 level (37.0 pg/mL or more) died within 1 year. MELD score also correlated with mortality: among patients with MELD scores below 8.7, 0.9% died within 1 year, whereas in patients with MELD scores of 18.0 or more, 67.4% died within 1 year. The predictive value of level of IL6 (AUROC, 0.940) was higher than level of CRP (AUROC, 0.866) (P = .009) or WBC (AUROC, 0.773) (P < .001) for 90-day mortality. MELD scores associated with 90-day mortality (AUROC, 0.933) (P = .756) as did MELD-Na score (AUROC, 0.946) (P = .771). Level of IL6 associated with 1-year mortality (AUROC, 0.916) to a greater extent than liver synthesis or detoxification markers international normalized ratio (AUROC, 0.839) (P = .007) or bilirubin (AUROC 0.846) (P = .007). Level of IL6 was an independent, significant risk factor for mortality after adjustment for MELD score, MELD-Na score, level of CRP, or WBC.

CONCLUSIONS

In a retrospective analysis, we found high blood levels of IL6 to associate with 90-day and 1-year mortality in patients with end-stage liver disease; its predictive value was comparable to that of MELD or MELD-Na score, and was higher than that of level of CRP or WBC. Further studies should be performed to confirm the results in different cohorts.

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

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

Platelets-to-lymphocyte ratio is a good predictor of liver fibrosis and insulin resistance in hepatitis C virus-related liver disease

BACKGROUND

Hepatitis C virus (HCV) is a global health problem that is complicated by liver fibrosis and insulin resistance (IR).

AIM

The aim of this study was to validate neutrophils-to-lymphocytes ratio (NLR) and platelets-to-lymphocytes ratio (PLR) as indirect biomarkers of liver fibrosis and IR in HCV patients.

PATIENTS AND METHODS

One hundred and fifty patients were enrolled. Physical examination, BMI, liver function tests, serum creatinine, complete blood count, serum HCV RNA count by PCR, and abdominal ultrasonography were performed. Transient elastography measurement using FibroScan was performed. Patients were classified into those with mild fibrosis (F1-F3) and significant fibrosis (F4). IR was defined as homeostasis model assessment of IR more than 2. NLR and PLR were calculated.

RESULTS

The average age of the patients was 47.21±10.51 years, mainly men (n=119; 79.3%), and 87.3% (n=131) had IR and 44.7% (n=67) had significant fibrosis. PLR was lower in patients with IR (74.95±37.90 vs. 94.71±31.45; P=0.032) unlike the NLR, which was comparable (P>0.05). Patients with significant fibrosis had lower PLR (66.43±39.38 vs. 86.35±33.85; P=0.001) unlike NLR (P>0.05). PLR (cutoff≥77.47) had 78.9% sensitivity, 60.3% specificity, 22.4% positive predictive value, and 95.2% negative predictive value for non-IR (P=0.008). At a cutoff of at least 63.71, PLR had 73.5% sensitivity, 61.2% specificity, 70.1% positive predictive value, and 65.1% negative predictive value for nonsignificant fibrosis (P=0.001). Age and PLR (odds ratio=0.99; 95% confidence interval=0.976-0.999) were predictors of IR, whereas age, total bilirubin, serum albumin, liver stiffness, and PLR (odds ratio=0.98; 95% confidence interval=0.974-0.994) were predictors of significant fibrosis.

CONCLUSION

PLR is useful in distinguishing the patients with significant fibrosis or IR unlike NLR.

Clinical characteristics and prognostic factors of liver cirrhosis patients with systemic inflammatory response syndrome

AIM

Our objective is to study the clinical characteristics of cirrhosis patients with SIRS and investigate its prognostic factors.

METHODS

We analyzed 285 consecutive patients and their data were evaluated retrospectively. Data were compared in patients with/without SIRS during hospitalization. Univariate and multivariate Cox regression analyses were undertaken separately for cirrhotic patients with SIRS to assess predictive factors for 90-day mortality.

RESULTS

The mortality was 38.24% (52/136) in patients with SIRS and 6.04% (9/149) in patients without SIRS for 90-day follow-up (P < 0.001). The univariate analysis showed gastrointestinal hemorrhage (P < 0.001), hepatic encephalopathy (P < 0.001), albumin <30 g/L (P < 0.037), creatinine (Cr) >175 µmol/L (P < 0.001), cholinesterase(ChE) activity <3000 U/L (P = 0.019), white blood cell count ≥10 000 (109/L) (P = 0.018), neutrophils ≥80% (P = 0.018), C-reactive protein (CRP) ≥25 mg/L (P < 0.001), procalcitonin ≥1.0 ng/mL (P = 0.007), Child-Pugh class C (P < 0.001), septicemia (P < 0.001), pulmonary infection (P < 0.001),multi-site infection (P = 0.001), acute-on-chronic liver failure (ACLF) (P < 0.001), and advanced hepatocellular carcinoma (HCC) (P < 0.001). In multivariate analysis, only Cr ≥175 µmol/L (hazard ratio [HR] = 2.768; confidence interval [CI], 1.53-5.04; P = 0.001), C-reactive protein ≥25 mg/L (HR = 3.179; CI, 1.772-7.03; P = 0.004), multi-site infection (HR = 19.427; CI, 7.484-50.431; P < 0.001), ACLF (HR = 7.308; CI, 3.048-17.521; P < 0.001), advanced HCC (HR = 2.523; CI, 1.019-6.248; P = 0.045) were independent predictors of 90-day mortality in cirrhotic patients with SIRS.

CONCLUSION

Cr ≥ 175 µmol/L, CRP ≥ 25 mg/L, multi-site infection, ACLF, and advanced HCC independently predicted a higher rate of 90-day mortality in liver cirrhosis with SIRS.

Does neutrophil-to-lymphocyte ratio predict 1-year mortality in patients with primary biliary cholangitis? Results from a retrospective study with validation cohort

OBJECTIVES

Neutrophil-to-lymphocyte ratio (NLR) has been used to predict prognosis in various liver diseases, but its role in primary biliary cholangitis (PBC) is not clarified. We aimed to investigate the prognostic usefulness of NLR for 1-year mortality in PBC.

METHODS

The study recruited a retrospective cohort with 88 patients with PBC and a prospective validation cohort with 63 participants who were followed-up for 1 year. NLR and other laboratory measurements were analysed by multivariate regression model for identifying independent factors for early mortality. The cut-off threshold of NLR was determined by calculating the area under the receiver operating characteristics curve (AUROC) and used in a subsequent Kaplan-Meier survival analysis.

RESULTS

Univariate and multivariate analyses showed that Mayo Risk Score (MRS), serum creatinine and NLR were independent indicators for mortality. NLR yielded significantly higher AUROC (0.86) than those of platelet-to-lymphocyte ratio (0.58, p=0.03), but comparable with MRS (0.87, p=0.88). Spearman's correlation analysis represented a positive correlation between escalating NLR and aggravating Child-Pugh grade (r=0.44, p<0.001). Patients with NLR <2.18 exhibited higher survival (with 100% sensitivity and 67.1% specificity) within 1 year follow-up duration, and NLR ≥2.18 was indicative of higher mortality (log-rank test, p<0.001). In addition, these results were internally confirmed by a validation cohort.

CONCLUSION

NLR is closely related to short-term mortality in patients with PBC.

Neutrophil-lymphocyte ratio predicts hospital-acquired bacterial infections in decompensated cirrhosis

BACKGROUND

Bacterial infection is a frequent complication and severe burden in cirrhotic patients. We determined the utility of neutrophil-to-lymphocyte ratio (NLR) to predict the hospital-acquired (HA) bacterial infections episode in patients with decompensated cirrhosis.

METHODS

We retrospectively included 2066 consecutive decompensated cirrhotic patients from two separate tertiary hospitals, divided into training (n=1377) and validation (n=689) set. All data were collected on admission and all overt bacterial infections occurring after >48h of hospital stay were registered.

RESULTS

The incidence of HA bacterial infections in training and validation cohort was 35.87% and 31.05% respectively. Multivariate analysis showed that total bilirubin (TBil), albumin, white blood cell count (WBC) and NLR were independent predictors of HA bacterial infections. We established a Model_NTWA using these four variables and a Model_TWA which did not include NLR. Areas under the curves (AUC) of Model_NTWA (0.859) and NLR (0.824) were higher than which of Model_TWA (0.713), WBC (0.675), TBil (0.593) and Albumin (0.583). Consistent with training cohort, validation cohort showed similar results. Patients with NLR of at least 4.33 had a significantly lower survival (P<0.001).

CONCLUSIONS

NLR can be used as a novel noninvasive marker to predict the occurrence of HA bacterial infections in decompensated cirrhotic patients.