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Single-centre evaluation of differential leukocyte ratios as biomarkers of mortality in patients with acute-on-chronic liver failure admitted to the intensive care unit
CCCF Academy. Dong V. 11/12/19; 283401; EP66
Victor Dong
Victor Dong
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ePoster
Topic: Retrospective or Prospective Cohort Study or Case Series

Dong, Victor1; Auzinger, Georg2; Bernal, William2; McPhail, Mark2
1. Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
2. Liver Intensive Therapy Unit, Institute of Liver Studies, King's College Hospital, London, United Kingdom


Introduction:
Acute-on-chronic liver failure (ACLF) is characterized by rapid deterioration of hepatic function along with multiorgan failures following an acute insult in patients with cirrhosis and often necessitates intensive care unit (ICU) admission. ACLF is associated with significant morbidity and mortality. In recent years, differential leukocyte ratios including neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) have been evaluated in different ICU populations as predictors of mortality.

Objectives:
Our aim is to assess NLR and MLR in ACLF patients admitted to the ICU as biomarkers of mortality.
 
Methods:
Retrospective cohort study of 599 cirrhotic patients admitted to the Liver Intensive Therapy Unit at King's College Hospital from 2009 until 2016. Grade of ACLF was determined at the time of ICU admission. Hematological data including neutrophil count, lymphocyte count, and monocyte count was obtained at the time of ICU admission. Primary outcome was in-hospital mortality. NLR and MLR were correlated with the primary outcome. Subgroups of patients including those with alcohol liver disease and sepsis were also evaluated regarding NLR and MLR and in-hospital mortality.
 
Results:
Overall 599 cirrhotic patients were evaluated with 375 (62.6%) being male and median age of 52 years (15-78). 181 (30.2%) patients had ACLF grade 0, 67 (11.2%) had ACLF grade 1, 127 (21.2%) had ACLF grade 2, and 224 (37.4%) had ACLF grade 3. Alcohol was the etiology of chronic liver disease in 296 (49.4%) of patients. Sepsis was present in 277 (46.2%) of patients. In-hospital mortality occurred in 249 (41.6%) patients. Both NLR and MLR were higher in patients with ACLF grades 2 and 3 compared with no ACLF (p<0.0001 for both). Both NLR and MLR were higher in patients with in-hospital mortality (p<0.0001 for both). NLR predicted outcome with an area under the receiver operating characteristic (AUROC) of 0.684 (95%CI 0.641-0.727, p<0.0001) and MLR predicted outcome with AUROC of 0.630 (0.590-0.669, not significant). In the alcohol liver disease group, NLR and MLR both were higher in patients with in-hospital mortality (not significant and p<0.0001 respectively). NLR predicted outcome in this group with AUROC of 0.685 (0.62-0.72, p<0.0001) while MLR predicted outcome with AUROC of 0.635 (0.570-0.700, p<0.0001). In the sepsis group, both NLR and MLR were higher in patients with in-hospital mortality (p<0.01 for both). NLR predicted outcome in this group with AUROC of 0.662(0.598-0.726, p<0.0001) and MLR predicted outcome with AUROC of 0.614(0.546-0.681, p=0.001).
 
Conclusions:
ACLF is associated with high neutrophil and monocyte counts along with low lymphocyte counts. NLR and MLR are associated with higher grades of ACLF and in-hospital mortality. However, NLR and MLR were not highly accurate predictors of in-hospital mortality even in subgroups of alcohol liver disease and patients with sepsis suggesting this is a pan-ACLF phenomenon unrelated to etiology or bacterial infection.


Image Image Image

1. Moreau N, Wittebole X, Fleury Y, Forget P, Laterre PF, Castanares-Zapatero D. Neutrophil-to-Lymphocyte Ratio Predicts Death in Acute-on-Chronic Liver Failure Patients Admitted to the Intensive Care Unit: A Retrospective Cohort Study. Shock 2018;49(4):385–392.

2. Zhu S, Waili Y, Qi X, Chen Y, Lou Y. Lymphocyte-monocyte ratio at admission predicts possible outcomes in patients with acute-on-chronic liver failure. Eur J Gastroenterol Hepatol. 2017;29(1):31-35.

ePoster
Topic: Retrospective or Prospective Cohort Study or Case Series

Dong, Victor1; Auzinger, Georg2; Bernal, William2; McPhail, Mark2
1. Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
2. Liver Intensive Therapy Unit, Institute of Liver Studies, King's College Hospital, London, United Kingdom


Introduction:
Acute-on-chronic liver failure (ACLF) is characterized by rapid deterioration of hepatic function along with multiorgan failures following an acute insult in patients with cirrhosis and often necessitates intensive care unit (ICU) admission. ACLF is associated with significant morbidity and mortality. In recent years, differential leukocyte ratios including neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) have been evaluated in different ICU populations as predictors of mortality.

Objectives:
Our aim is to assess NLR and MLR in ACLF patients admitted to the ICU as biomarkers of mortality.
 
Methods:
Retrospective cohort study of 599 cirrhotic patients admitted to the Liver Intensive Therapy Unit at King's College Hospital from 2009 until 2016. Grade of ACLF was determined at the time of ICU admission. Hematological data including neutrophil count, lymphocyte count, and monocyte count was obtained at the time of ICU admission. Primary outcome was in-hospital mortality. NLR and MLR were correlated with the primary outcome. Subgroups of patients including those with alcohol liver disease and sepsis were also evaluated regarding NLR and MLR and in-hospital mortality.
 
Results:
Overall 599 cirrhotic patients were evaluated with 375 (62.6%) being male and median age of 52 years (15-78). 181 (30.2%) patients had ACLF grade 0, 67 (11.2%) had ACLF grade 1, 127 (21.2%) had ACLF grade 2, and 224 (37.4%) had ACLF grade 3. Alcohol was the etiology of chronic liver disease in 296 (49.4%) of patients. Sepsis was present in 277 (46.2%) of patients. In-hospital mortality occurred in 249 (41.6%) patients. Both NLR and MLR were higher in patients with ACLF grades 2 and 3 compared with no ACLF (p<0.0001 for both). Both NLR and MLR were higher in patients with in-hospital mortality (p<0.0001 for both). NLR predicted outcome with an area under the receiver operating characteristic (AUROC) of 0.684 (95%CI 0.641-0.727, p<0.0001) and MLR predicted outcome with AUROC of 0.630 (0.590-0.669, not significant). In the alcohol liver disease group, NLR and MLR both were higher in patients with in-hospital mortality (not significant and p<0.0001 respectively). NLR predicted outcome in this group with AUROC of 0.685 (0.62-0.72, p<0.0001) while MLR predicted outcome with AUROC of 0.635 (0.570-0.700, p<0.0001). In the sepsis group, both NLR and MLR were higher in patients with in-hospital mortality (p<0.01 for both). NLR predicted outcome in this group with AUROC of 0.662(0.598-0.726, p<0.0001) and MLR predicted outcome with AUROC of 0.614(0.546-0.681, p=0.001).
 
Conclusions:
ACLF is associated with high neutrophil and monocyte counts along with low lymphocyte counts. NLR and MLR are associated with higher grades of ACLF and in-hospital mortality. However, NLR and MLR were not highly accurate predictors of in-hospital mortality even in subgroups of alcohol liver disease and patients with sepsis suggesting this is a pan-ACLF phenomenon unrelated to etiology or bacterial infection.


Image Image Image

1. Moreau N, Wittebole X, Fleury Y, Forget P, Laterre PF, Castanares-Zapatero D. Neutrophil-to-Lymphocyte Ratio Predicts Death in Acute-on-Chronic Liver Failure Patients Admitted to the Intensive Care Unit: A Retrospective Cohort Study. Shock 2018;49(4):385–392.

2. Zhu S, Waili Y, Qi X, Chen Y, Lou Y. Lymphocyte-monocyte ratio at admission predicts possible outcomes in patients with acute-on-chronic liver failure. Eur J Gastroenterol Hepatol. 2017;29(1):31-35.

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