The Prognostic Value And Mechanism Of Nomogram Incorporating NLR In Patients With Decompensated Liver Cirrhosis

Aims:Liver cirrhosis has a high prevalence around the world.Moreover,HBV infection is one of the most common etiologies in China.After a prolonged course of stable liver cirrhosis,patients often develop into decompensated liver cirrhosis with gastroesophageal varices with bleeding,ascites,hepatic encephalopathy,hypersplenism and infections even hepatoma,which reduce the quality of life and cause poor outcomes eventually.Traditional prognostic measurements of Model for endstage of liver disease(MELD)and Child-Pugh classification have some drawbacks.MELD has a lower sensitivity and specificity of prognostic prediction with a score lower than 20.While with subjective factors(hepatic encephalopathy and ascites degree)involved in Child-Pugh classification,it is difficult to establish standard for clinical doctors to evaluate.Moreover,it has a narrow range for detailed evaluation.Both of them did not take inflammatory marker into consideration,which has been proven deeply involved in patients with decompensated liver cirrhosis.Neutrophil to lymphocyte ratio(NLR)as a serum inflammatory marker is a novel indicator in peripheral blood which has been widely used to evaluate the prognosis of malignancy and cirrhosis.Elevation of NLR demonstrated the poor prognosis of patients.Combination of NLR and other indicators may improve the accuracy of prognosis prediction in cirrhotics.Evaluate the performance of NLR in all kinds of decompensated liver cirrhosis.Furthermore,use the independent risk factors of 30 days mortality in these patients developing a nomogram model for visually evaluation.Then,evaluate whether NLR can improve the prediction accuracy of MELD in patients with low MELD score(≤ 20 scores).Investigate the association between NLR and cirrhosis associated immune dysfunction.Method: Three hundred and sixty consecutive patients with the decompensated liver cirrhosis were admitted at Department of Gastroenterology and Hepatology,Tianjin Medical University General Hospital from Feb 2014 to Feb 2017.They were divided by admission time into two groups as derivation group(N=235)and validation group(N=125).We collected the history and laboratory blood test within 24 hours after their admission and then followed them for 30 days.Patients died within 30 dayswere in the death group(N=17),others were in the survival group(N=218).We collected 5ml blood samples from 49 patients and 12 healthy adults,and test the difference of cytokines between decompensated liver cirrhosis and healthy adults.Furthermore,we compared the relationship between NLR and cytokines.Results: There are higher NLR levels in the death group rather than the survival group and NLR is an independent risk factor for 30 days mortality adjusted to MELD and albumin.NLR has a higher area under ROC(0.864)than MELD(0.816).Moreover,it may improve the prediction ability in patients with MELD lower than 20.Nomogram incorporating MELD,albumin and NLR can be used in patients with decompensated liver cirrhosis for 30 days mortality.Conclusion: Elevation of NLR correlated with short-term mortality(30 days)with decompensated liver cirrhosis.NLR may improve the prediction ability in patients with MELD lower than 20.Moreover,NLR is a marker of systemic inflammation response which is positive correlated with pro-inflammatory cytokines(IL-6,IL-8).Adding systemic inflammation biomarker into MELD as a form of Nomogram can be used in patients with decompensated liver cirrhosis for 30 days mortality.