Original ContributionNeutrophil-to-lymphocyte ratio as a prognostic marker in critically-ill septic patients☆
Introduction
Sepsis is a major cause of morbidity and mortality resulting from a devastating host response to infection, and it affects millions of people worldwide each year [1], [2]. Despite recent advances in knowledge about the disease and critical care modalities, the short-term mortality rate in patients with severe sepsis and septic shock remains high, accounting for approximately 30% of all cases [3], [4], [5].
Identifying patients that are at high risk of mortality and accurately anticipating outcomes in the early phase of sepsis is imperative for providing timely and adequate interventions for these patients [6]. However, the complexity and heterogeneity of the disease make this very challenging. In 2001, Zahorec et al. reported a correlation between neutrophilia/lymphocytopenia and the severity of clinical course in oncological intensive care unit (ICU) patients and suggested the neutrophil-to-lymphocyte ratio (NLR) as an indicator of disease severity [7]. Additionally, the NLR is advantageous in regard to simplicity, low cost, and availability compared to many other previously proposed biomarkers, which makes it promising for diagnostic clinicians. Several studies have reported that the NLR is useful in various clinical situations, including cardiovascular disease, malignancies, and infectious diseases [8], [9], [10], [11].
Although the association between the NLR and mortality in patients with sepsis has been investigated, the predictive value of the initial NLR and how it changes during the early resuscitation period are not well understood [12], [13]. In this study, we evaluated the association between the initial NLR and 28-day mortality in patients that presented to the emergency department (ED) with severe sepsis or septic shock. We also investigated the association between change in NLR after ED admission and 28-day mortality.
Section snippets
Study Design
This was a single-center, retrospective cohort study of patients with severe sepsis or septic shock who presented to the ED of Samsung Medical Center, a university-affiliated tertiary teaching hospital located in a metropolitan city. The Samsung Medical Center Institutional Review Board (IRB file number: 2016-01-101) approved this study, and informed consent was waived because the study was conducted retrospectively and no interventions were applied.
Study Population and Definitions
Patients who fulfilled the following
Baseline Characteristics
During the study period, a total of 1728 patients with severe sepsis or septic shock were registered in the sepsis registry. Of these, 333 patients were excluded due to terminal malignancy (n = 160), signed DNR orders, or refusal of invasive procedures (n = 173). A total of 1395 patients were included in the final analysis.
Baseline characteristics of patients across the quintiles are described in Table 1. The median age of the population was 65 years (IQR, 55–73) and 56.4% (n = 787) were male. The
Discussion
The results indicated that the initial NLR measured on ED admission was an independent risk factor for predicting 28-day mortality in patients with severe sepsis or septic shock. In addition, both the persistently low NLR group and the group that had a persistently high NLR during the first two days after ED admission were also associated with increased risk for 28-day mortality.
NLR has been used in critical care medicine and may prove to be a valuable prognostic tool based on the results of
Conclusion
The initial NLR measured at ED admission was independently associated with 28-day mortality in patients with severe sepsis or septic shock in the ED. Persistently low NLR or high NLR values were also significant predictors for 28-day mortality.
Conflict of Interest
The authors have no potential conflicts of interest or funding sources to declare.
References (36)
- et al.
Usefulness of neutrophil-to-lymphocyte ratio in risk stratification of patients with advanced heart failure
Am J Cardiol
(2015) - et al.
Prognostic value of neutrophil to lymphocyte ratio in patients presenting with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention
Am J Cardiol
(2013) - et al.
Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine
Chest
(1992) - et al.
Prognostic importance of neutrophil-lymphocyte ratio in critically ill patients: short- and long-term outcomes
Am J Emerg Med
(2014) - et al.
Procalcitonin as a diagnostic marker for sepsis
Lancet Infect Dis
(2014) - et al.
Assessing available information on the burden of sepsis: global estimates of incidence, prevalence and mortality
J Glob Health
(2012) - et al.
Severe sepsis and septic shock
N Engl J Med
(2013) - et al.
Goal-directed resuscitation for patients with early septic shock
N Engl J Med
(2014) - et al.
A randomized trial of protocol-based care for early septic shock
N Engl J Med
(2014) - et al.
Trial of early, goal-directed resuscitation for septic shock
N Engl J Med
(2015)
Early management of sepsis
Clin Exp Emerg Med
Ratio of neutrophil to lymphocyte counts—rapid and simple parameter of systemic inflammation and stress in critically ill
Bratisl Lek Listy
Prognostic significance of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in oncologic outcomes of esophageal cancer: a systematic review and meta-analysis
Ann Surg Oncol
Lymphocytopenia and neutrophil-lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit
Crit Care
The association between the neutrophil-to-lymphocyte ratio and mortality in critical illness: an observational cohort study
Crit Care
Reversal of neutrophil-to-lymphocyte count ratio in early versus late death from septic shock
Crit Care
2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference
Crit Care Med
Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008
Crit Care Med
Cited by (150)
Inflammatory biomarkers to predict the prognosis of acute bacterial and viral infections
2023, Journal of Critical CareAnti-inflammatory Effect of Low-Intensity Ultrasound in Septic Rats
2023, Ultrasound in Medicine and BiologyAssociation of the neutrophil-lymphocyte ratio with outcome in sick hospitalized neonatal foals
2024, Journal of Veterinary Internal MedicineThe value of neutrophil lymphocyte ratio and systemic immune inflammatory index for diagnosis of coronary artery lesions in patients with Kawasaki disease
2024, Chinese Journal of General Practitioners
- ☆
The authors declare they have no potential conflicts of interest or funding sources.