NLR as mortality indicator for Sepsis and Septic Shock: A Prospective Study

Deepak M U; S Bhoomkar Sanoo; S Bhoomkar Chandan

doi:10.37022/wjcmpr.v8i2.411

Authors

Deepak M U Assistant Professor, Department of General Medicine, Chikkamagaluru Institute of Medical Sciences, Chikkamagaluru, Karnataka, India
Sanoo S Bhoomkar Assistant Professor, Department of Obstetrics and Gynaecology, Chikkamagaluru Institute of Medical Sciences, Chikkamagaluru, Karnataka, India
Chandan S Bhoomkar Assistant Professor, Department of General Surgery, JSS Medical College, JSS Academy of Higher Education & Research, Mysuru, Karnataka, India

Abstract

Background: Sepsis and septic shock are major causes of morbidity and mortality in intensive care units. Early prognostic markers are essential for risk stratification. The neutrophil-lymphocyte ratio (NLR), derived from a routine complete blood count, is a simple and inexpensive marker of systemic inflammation.

Objectives: To assess the relationship between NLR and mortality in patients with sepsis and septic shock and to determine an NLR cut-off associated with unfavourable outcomes.

Methods: A prospective observational study was conducted among 170 patients admitted to the Medical and Respiratory Intensive Care Units at Basaveshwara Medical College and Hospital, Chitradurga, from August 2022 to February 2024. Admission NLR was calculated and patients were categorized into NLR <3 and NLR >3 groups. Clinical, biochemical, and outcome parameters were compared using Chi-square and independent-sample t-tests, with p<0.05 considered significant.

Results: Of 170 patients, 114 (67.1%) had NLR <3 and 56 (32.9%) had NLR >3. Significant differences were observed in ESR (32.8 vs 37.2, p=0.021), bilirubin (4.1 vs 2.5 mg/dL, p<0.001), creatinine (3.5 vs 2.2 mg/dL, p<0.001), mean arterial pressure (106.7 vs 86.7 mmHg, p<0.001), total leucocyte count, and 24-hour NLR (1.66 vs 5.0, p<0.001). Mortality was comparable between groups (12.3% vs 12.5%, p=0.967).

Conclusion: NLR correlated with several markers of organ dysfunction and disease severity but did not discriminate in-hospital mortality in this cohort. Larger multicentric studies with serial NLR measurements are warranted.

Keywords:

Neutrophil-lymphocyte ratio, sepsis, septic shock, mortality, prognosis, intensive care unit

DOI

https://doi.org/10.37022/wjcmpr.v8i2.411

References

1. Fleischmann C, Scherag A, Adhikari NKJ, Hartog CS, Tsaganos T, Schlattmann P, et al. Assessment of global incidence and mortality of hospital-treated sepsis: current estimates and limitations. Am J Respir Crit Care Med. 2016;193(3):259-272. doi:10.1164/rccm.201504-0781OC.

2. Hotchkiss RS, Moldawer LL, Opal SM, Reinhart K, Turnbull IR, Vincent JL. Sepsis and septic shock. Nat Rev Dis Primers. 2016;2:16045. doi:10.1038/nrdp.2016.45.

3. Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. doi:10.1007/s00134-021-06506-y.

4. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.

5. Chatterjee S, Bhattacharya M, Todi SK. Epidemiology of adult-population sepsis in India: a single center 5 year experience. Indian J Crit Care Med. 2017;21(9):573-577. doi:10.4103/ijccm.IJCCM_240_17.

6. Jarczak D, Kluge S, Nierhaus A. Sepsis-pathophysiology and therapeutic concepts. Front Med (Lausanne). 2021;8:628302. doi:10.3389/fmed.2021.628302.

7. Zahorec R. Ratio of neutrophil to lymphocyte counts-rapid and simple parameter of systemic inflammation and stress in critically ill. Bratisl Lek Listy. 2001;102(1):5-14.

8. Ljungström L, Pernestig AK, Jacobsson G, Andersson R, Usener B, Tilevik D. Diagnostic accuracy of procalcitonin, neutrophil-lymphocyte count ratio, C-reactive protein, and lactate in patients with suspected bacterial sepsis. PLoS One. 2017;12(7). doi:10.1371/journal.pone.0181704.

9. Joshi VD, Kalvakolanu DV, Cross AS. Simultaneous activation of apoptosis and inflammation in pathogenesis of septic shock: a hypothesis. FEBS Lett. 2003;555(2):180-184. doi:10.1016/S0014-5793(03)01271-7.

10. de Jager CP, Wever PC, Gemen EF, Kusters R, van Gageldonk-Lafeber AB, van der Poll T, et al. The neutrophil-lymphocyte count ratio in patients with community-acquired pneumonia. PLoS One. 2012;7(10). doi:10.1371/journal.pone.0046561.

11. Qiu X, Wang Q, Zhang Y, Zhao Q, Jiang Z, Zhou L. Prognostic value of neutrophils-to-lymphocytes ratio and platelets-to-lymphocytes ratio in sepsis patients with lymphopenia. Biomark Insights. 2024;19:11772719231223156. doi:10.1177/11772719231223156.

12. Zhang Y, Peng W, Zheng X. The prognostic value of the combined neutrophil-to-lymphocyte ratio (NLR) and neutrophil-to-platelet ratio (NPR) in sepsis. Sci Rep. 2024;14:15075. doi:10.1038/s41598-024-64469-8.

13. Shi Y, Yang C, Chen L, Cheng M, Xie W. Predictive value of neutrophil-to-lymphocyte and platelet ratio in in-hospital mortality in septic patients. Heliyon. 2022;8(11). doi:10.1016/j.heliyon.2022.e11498.

14. Chebl RB, Assaf M, Kattouf N, Haidar S, Khamis M, Abdeldaem K, et al. The association between the neutrophil to lymphocyte ratio and in-hospital mortality among sepsis patients: a prospective study. Medicine (Baltimore). 2022;101(30). doi:10.1097/MD.0000000000029343.

15. Ni J, Wang H, Li Y, Shu Y, Liu Y. Neutrophil to lymphocyte ratio (NLR) as a prognostic marker for in-hospital mortality of patients with sepsis: a secondary analysis based on a single-center, retrospective, cohort study. Medicine (Baltimore). 2019;98(46). doi:10.1097/MD.0000000000018029.

16. Martins EC, Silveira LDF, Viegas K, Beck AD, Fioravantti Júnior G, Cremonese RV, et al. Neutrophil-lymphocyte ratio in the early diagnosis of sepsis in an intensive care unit: a case-control study. Rev Bras Ter Intensiva. 2019;31(1):64-70. doi:10.5935/0103-507X.20190010.

17. Gameiro J, Fonseca JA, Jorge S, Gouveia J, Lopes JA. Neutrophil, lymphocyte and platelet ratio as a predictor of mortality in septic-acute kidney injury patients. Nefrologia (Engl Ed). 2020;40(4):461-468. doi:10.1016/j.nefro.2019.11.006.