Advertisement

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

  • Yin-Chou Hsu
    Affiliations
    Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan

    School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung, Taiwan
    Search for articles by this author
  • Yong-Ye Yang
    Affiliations
    Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
    Search for articles by this author
  • I-Ting Tsai
    Correspondence
    Corresponding author at: Department of Emergency Medicine, E-Da Hospital, No.1, Yida Road, Jiao-su Village, Kaohsiung City, Yan-chao District 82445, Taiwan.
    Affiliations
    Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan

    School of Medicine for International Student, I-Shou University, Kaohsiung, Taiwan
    Search for articles by this author
Published:December 03, 2020DOI:https://doi.org/10.1016/j.ajem.2020.11.071

      Abstract

      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.

      Keywords

      Abbreviations:

      qSOFA (quick Sequential Organ Failure Assessment), SIRS (Systemic Inflammatory Response Syndrome), MELD (Model for End-stage Liver Disease), ED (emergent department), ACLF (acute-on-chronic liver failure), LMR (lymphocyte-to-monocyte ratio), NLR (neutrophil-to-lymphocyte ratio), ROC (receiver operating characteristic), AUC (area under curve), INR (international normalized ratio), aHR (adjusted hazard ratio)
      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Tsochatzis E.A.
        • Bosch J.
        • Burroughs A.K.
        Liver cirrhosis.
        Lancet. 2014; 383: 1749-1761
        • Bunchorntavakul C.
        • Chamroonkul N.
        • Chavalitdhamrong D.
        Bacterial infections in cirrhosis: a critical review and practical guidance.
        World J Hepatol. 2016; 8: 307
        • Jalan R.
        • Yurdaydin C.
        • Bajaj J.S.
        • Acharya S.K.
        • Arroyo V.
        • Lin H.-C.
        • et al.
        Toward an improved definition of acute-on-chronic liver failure.
        Gastroenterology. 2014; 147: 4-10
        • Vincent J.-L.
        • Jones G.
        • David S.
        • Olariu E.
        • Cadwell K.K.
        Frequency and mortality of septic shock in Europe and North America: a systematic review and meta-analysis.
        Crit Care. 2019; 23: 1-11
        • Moreau R.
        • Hadengue A.
        • Soupison T.
        • Kirstetter P.
        • Mamzer M.-F.
        • Vanjak D.
        • et al.
        Septic shock in patients with cirrhosis: hemodynamic and metabolic characteristics and intensive care unit outcome.
        Crit Care Med. 1992; 20: 746-750
        • Gustot T.
        • Durand F.
        • Lebrec D.
        • Vincent J.L.
        • Moreau R.
        Severe sepsis in cirrhosis.
        Hepatology. 2009; 50: 2022-2033
        • Piano S.
        • Bartoletti M.
        • Tonon M.
        • Baldassarre M.
        • Chies G.
        • Romano A.
        • et al.
        Assessment of Sepsis-3 criteria and quick SOFA in patients with cirrhosis and bacterial infections.
        Gut. 2018; 67: 1892-1899
        • Patidar K.R.
        • Shaw J.
        • Acharya C.
        • Thacker L.R.
        • White M.B.
        • Ganapathy D.
        • et al.
        No association between quick sequential organ failure assessment and outcomes of patients with cirrhosis and infections.
        Clin Gastroenterol Hepatol. 2017; 15: 1803-1804
        • Son J.
        • Choi S.
        • Huh J.W.
        • Lim C.-M.
        • Koh Y.
        • Kim K.M.
        • et al.
        The quick sepsis-related organ failure score has limited value for predicting adverse outcomes in sepsis patients with liver cirrhosis.
        Korean J Intern Med. 2020; 35: 861
        • Lim L.-G.
        • Tan X.-X.E.
        • Woo S.-J.
        • Dan Y.-Y.
        • Lee Y.-M.
        • Lai V.
        • et al.
        Risk factors for mortality in cirrhotic patients with sepsis.
        Hepatol Int. 2011; 5: 800-807
        • Kwon J.H.
        • Jang J.W.
        • Kim Y.W.
        • Lee S.W.
        • Nam S.W.
        • Jaegal D.
        • et al.
        The usefulness of C-reactive protein and neutrophil-to-lymphocyte ratio for predicting the outcome in hospitalized patients with liver cirrhosis.
        BMC Gastroenterol. 2015; 15: 1-7
        • Jamil Z.
        • Durrani A.A.
        Assessing the outcome of patients with liver cirrhosis during hospital stay: a comparison of lymphocyte/monocyte ratio with MELD and child-Pugh scores.
        Turk J Gastroenterol. 2018; 29: 308
        • Biyik M.
        • Ucar R.
        • Solak Y.
        • Gungor G.
        • Polat I.
        • Gaipov A.
        • et al.
        Blood neutrophil-to-lymphocyte ratio independently predicts survival in patients with liver cirrhosis.
        Eur J Gastroenterol Hepatol. 2013; 25: 435-441
        • Rice J.
        • Dodge J.L.
        • Bambha K.M.
        • Bajaj J.S.
        • Reddy K.R.
        • Gralla J.
        • et al.
        Neutrophil-to-Lymphocyte ratio associates independently with mortality in hospitalized patients with cirrhosis.
        Clin Gastroenterol Hepatol. 2018; 16 (e1): 1786-1791
        • 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: 31-35
        • Singer M.
        • Deutschman C.S.
        • Seymour C.W.
        • Shankar-Hari M.
        • Annane D.
        • Bauer M.
        • et al.
        The third international consensus definitions for sepsis and septic shock (Sepsis-3).
        JAMA. 2016; 315: 801-810
        • Drolz A.
        • Horvatits T.
        • Rutter K.
        • Landahl F.
        • Roedl K.
        • Meersseman P.
        • et al.
        Lactate improves prediction of short-term mortality in critically ill patients with cirrhosis: a multinational study.
        Hepatology. 2019; 69: 258-269
        • Von Elm E.
        • Altman D.G.
        • Egger M.
        • Pocock S.J.
        • Gøtzsche P.C.
        • Vandenbroucke J.P.
        The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies.
        Ann Intern Med. 2007; 147: 573-577
        • Peng Y.
        • Qi X.
        • Guo X.
        Child–Pugh versus MELD score for the assessment of prognosis in liver cirrhosis: a systematic review and meta-analysis of observational studies.
        Medicine. 2016; 95: e2877
        • Moreau R.
        • Jalan R.
        • Gines P.
        • Pavesi M.
        • Angeli P.
        • Cordoba J.
        • et al.
        Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis.
        Gastroenterology. 2013; 144 (e9): 1426-1437
        • Dellinger R.P.
        • Levy M.M.
        • Rhodes A.
        • Annane D.
        • Gerlach H.
        • Opal S.M.
        • et al.
        Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock, 2012.
        Intensive Care Med. 2013; 39: 165-228
        • Jiang J.
        • Yang J.
        • Mei J.
        • Jin Y.
        • Lu Y.
        Head-to-head comparison of qSOFA and SIRS criteria in predicting the mortality of infected patients in the emergency department: a meta-analysis.
        Scand J Trauma Resus Emer Med. 2018; 26: 56
        • Jalan R.
        • Fernandez J.
        • Wiest R.
        • Schnabl B.
        • Moreau R.
        • Angeli P.
        • et al.
        Bacterial infections in cirrhosis: a position statement based on the EASL special conference 2013.
        J Hepatol. 2014; 60: 1310-1324
        • DeLong E.R.
        • DeLong D.M.
        • Clarke-Pearson D.L.
        Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.
        Biometrics. 1988; : 837-845
        • Fernández J.
        • Gustot T.
        Management of bacterial infections in cirrhosis.
        J Hepatol. 2012; 56: S1-S12
        • Müller M.
        • Schefold J.C.
        • Leichtle A.B.
        • Srivastava D.
        • Lindner G.
        • Exadaktylos A.
        • et al.
        qSOFA score not predictive of in-hospital mortality in emergency patients with decompensated liver cirrhosis.
        Medizinische Klinik-Intensivmedizin und Notfallmedizin. 2019; 114: 724-732
        • Trotter J.F.
        • Brimhall B.
        • Arjal R.
        • Phillips C.
        Specific laboratory methodologies achieve higher model for endstage liver disease (MELD) scores for patients listed for liver transplantation.
        Liver Transpl. 2004; 10: 995-1000
        • Cholongitas E.
        • Marelli L.
        • Kerry A.
        • Senzolo M.
        • Goodier D.W.
        • Nair D.
        • et al.
        Different methods of creatinine measurement significantly affect MELD scores.
        Liver Transpl. 2007; 13: 523-529
        • Zhang J.
        • Feng G.
        • Zhao Y.
        • Zhang J.
        • Feng L.
        • Yang J.
        Association between lymphocyte-to-monocyte ratio (LMR) and the mortality of HBV-related liver cirrhosis: a retrospective cohort study.
        BMJ Open. 2015; 5
        • Lin Z.-X.
        • Ruan D.-Y.
        • Li Y.
        • Wu D.-H.
        • Ma X.-K.
        • Chen J.
        • et al.
        Lymphocyte-to-monocyte ratio predicts survival of patients with hepatocellular carcinoma after curative resection.
        World J Gastroenterol: WJG. 2015; 21: 10898
        • Yang Y.-T.
        • Jiang J.-H.
        • Yang H.-J.
        • Wu Z.-j.
        • Xiao Z.-M.
        • Xiang B.-D.
        The lymphocyte-to-monocyte ratio is a superior predictor of overall survival compared to established biomarkers in HCC patients undergoing liver resection.
        Sci Rep. 2018; 8: 1-7
        • Piotrowski D.
        • Sączewska-Piotrowska A.
        • Jaroszewicz J.
        • Boroń-Kaczmarska A.
        Lymphocyte-to-monocyte ratio as the best simple predictor of bacterial infection in patients with liver cirrhosis.
        Int J Environ Res Public Health. 2020; 17: 1727
        • Levy M.M.
        • Evans L.E.
        • Rhodes A.
        The surviving sepsis campaign bundle: 2018 update.
        Intensive Care Med. 2018; 44: 925-928
        • Kraut J.A.
        • Madias N.E.
        Lactic acidosis.
        N Engl J Med. 2014; 371: 2309-2319
        • Sun D.-Q.
        • Zheng C.-F.
        • Lu F.-B.
        • Van Poucke S.
        • Chen X.-M.
        • Chen Y.-P.
        • et al.
        Serum lactate level accurately predicts mortality in critically ill patients with cirrhosis with acute kidney injury.
        Eur J Gastroenterol Hepatol. 2018; 30: 1361-1367