Original article
The early prognostic value of inflammatory markers in patients with acute pancreatitis

https://doi.org/10.1016/j.clinre.2018.11.002Get rights and content

Highlights

  • The prognostic value of inflammation-based markers and a more mature scoring system is compared in a group of acute pancreatitis cases.

  • Neutrophil-lymphocyte ratio and total calcium have the same predictive value as bedside index for severity in acute pancreatitis, and are equally simple and rapid.

Summary

Objectives

The aim of this study was to compare the prognostic value of inflammation-based prognostic markers with the more mature scoring system BISAP in patients with AP and identify the best predictors.

Patients and methods

We retrospectively analysed the data of patients with AP who were treated in our hospital from January 2017 to March 2018 and compared the prognostic value of these inflammation-based prognostic markers with the BISAP score in patients with AP.

Results

Higher BISAP score, NLR, PLR, ACC, and BUN gradually increased (all P < 0.05), and lower LMR and TC (P < 0.001) were associated with severity of AP. Compared with the patients without persistent organ failure, the patients with POF were older (P = 0.049) and had a higher BISAP score (P < 0.001), NLR (P = 0.003), PLR (P < 0.001) and ACC (P = 0.047), BUN (P = 0.011), and creatinine (P = 0.023), RDW (P = 0.021), but lower LMR (P = 0.003) and TC (P < 0.001) at baseline. The BISAP score (OR = 2.117, 95% CI 1.487 to 3.016, P < 0.001), NLR (OR = 1.053, 95% CI: 1.009 to 1.101, P = 0.019) and TC (OR = 0.088, 95% CI: 0.024 to 1.030, P < 0.001) were independent factors for predicting SAP. For predicting the occurrence of POF, TC and PLR had an area under the ROC curve (TC AUC = 0.784, P < 0.001, with a 2.18 cut-off value, PLR AUC = 0.731, P < 0.001, with a 173.13 cut-off value) that was not inferior to the BISAP score (AUC = 0.708), and PLR had the best sensitivity (95.8%), BUN had the best specificity (44.71%), respectively. There is no difference in their predictive value for POF.

Conclusions

NLR and TC are the most powerful markers in this patient series, they have a prognostic value which is not weaker than BISAP, and are equally simple, rapid.

Introduction

Acute pancreatitis (AP) is an acute inflammatory process that starts with local acinar cell injury with variable involvement of other regional tissues or remote organ systems [1]. Although the majority of acute pancreatitis cases are mild, and the prognosis is good, there are still 20–30% of patients who experience serious complications, such as necrosis or organ failure. The overall mortality rate of AP is 5–10% [2]. Therefore, to reduce the risk of early death and to develop early interventions to reduce mortality, clinicians should identify the severity of AP and the presence of complications early.

Currently, most classical methods for assessing the severity of acute pancreatitis have some limitations—namely, most of these methods are not simple, rapid and economical enough. The Ranson [3] and modified Glasgow score [4] require data that were not routinely collected at the time of hospitalization, and both need more time to complete. The APACHE-II was originally developed as an intensive care instrument and requires the collection of several parameters, some of which may not be relevant to AP prognosis [5]. Through these scoring systems, it is currently not possible to judge the severity of AP early, and some patients are not diagnosed within the optimal time frame for early diagnosis and treatment. The BISAP (bedside index for severity in AP) is a simple and accurate method for the early identification of AP patients at increased risk for in-hospital mortality [6]. C-reactive protein, IL-6 also have been used for predicting the severity of pancreatitis [7], [8]. In recent research, in the secondary care hospital, where most patients with AP were initially admitted, compared to the interleukin-6, C-reactive protein, procalcitonin, D-dimer and soluble fms-like tyrosine kinase-1, uPAR measurements had the same value in this prediction [9]. But these simple methods do not make clinicians feel comprehensive and simple. When acute pancreatitis occurs, trypsin is released and the pancreatic exocrine function is activated, which in turn destroys the mechanism of pancreatic self-defense and aggravates the damage and destruction of pancreatic cells [10]. As a result, vascular endothelium is damaged, motor dystonia, vascular permeability are increased, more leukocyte migrate to tissues, and coagulation systems are activated [11]. So a lot of inflammatory markers based on blood cell changes that were inexpensive and easily obtained during the early stage of hospitalization were used to assess the severity of AP, such as the red cell distribution width (RDW) [12], neutrophil–lymphocyte ratio (NLR), lymphocyte–monocyte ratio (LMR) [13], platelet lymphocyte ratio (PLR) [14], total calcium (TC) and albumin-corrected calcium (ACC) [15] and blood urea nitrogen (BUN) [16]. However, there is few literature which has a comprehensive comparison of their predictive functions.

In this study, we retrospectively analysed the data of patients with AP who were treated in our hospital from January 2017 to March 2018 and compared the prognostic value of these inflammation-based prognostic markers with the relatively mature scoring system BISAP in patients with AP to identify the best predictors.

Section snippets

Participants

This retrospective cohort analysis consecutively enrolled a series of patients with AP who were admitted to the Department of Pancreatic Surgery at our hospital between 1 March 2017 and 1 April 2018. A diagnosis of AP required two of three features:

  • prolonged abdominal pain characteristic of AP;

  • threefold elevation of serum amylase and/or lipase levels above the normal range;

  • characteristic findings of AP on abdominal MRI and/or CT scan.

Patients with the following features were excluded from this

Ethics statement

Each patient was treated in accordance with the ethical principles outlined in the Declaration of Helsinki. Demographic information, including age, sex, aetiology and complications, and laboratory analysis was collected from medical records.

Statistical analysis

Variables are expressed as the mean ± SD or median (range) and categorical data as percentages, as appropriate. Differences between the groups were assessed using an independent sample t-test, Mann–Whitney U test or Chi2 test, as appropriate. Multiple comparisons were performed by one-way analysis of variance or Kruskal–Wallis H tests, as appropriate. Multivariate logistic regression analyses were used to assess whether the inflammatory markers were independent factors for predicting SAP in

Patient characteristics

A total of 279 patients with AP (130 MAP, 131 MSAP and 18 SAP) were enrolled in the study. Forty-one patients were excluded from the analysis. Twenty-seven patients received treatment before admission, eight patients had tumours, five patients suffered from postpartum pancreatitis, and one patient had immune disease. Table 1, Table 2 show the baseline characteristics of the patients. There were no significant differences in age (P = 0.193), sex (P = 0.850), accompanying liver failure or

Discussion

In the present study, we compared the prognostic value of general inflammation-based prognostic markers with the more mature scoring system BISAP in the same patients. We found that same as the BISAP, NLR, PLR, LMR, TC, ACC, BUN, creatinine and RDW have correlation with severity of AP. The BISAP score, NLR and TC can be used as independent predictors of the severity of pancreatitis. The ROC curve results indicated that most of the inflammation-based markers could predict whether the organ

Conclusion

In conclusion, we find that compared with BISAP score, NLR and TC could also be used as independent factors to predict the severity of pancreatitis. The NLR, LMR, PLR, TC, ACC, BUN, creatinine and RDW have the same prognostic value as BISAP for POF. NLR and TC are the most powerful marker in this patient series, they have the same predictive power as BISAP, and are equally simple, rapid. When applying these markers, all possible influences from therapy should be considered.

Limitations

This study has several limitations. First, the number of patients enrolled in this study was small. Second, we did not compare inflammatory markers with other biochemical markers and the Grading standards, such as Ranson and modified Glasgow score and APACHE-II, so the results have some limitations. Third, we did not describe the changes in these inflammatory markers during treatment, which could help better predict the prognosis of AP. Despite these limitations, this study also has some

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosure of interest

The authors declare that they have no competing interest.

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