Prognostic Significance of Preoperative Neutrophil-Lymphocyte Ratio in Vascular Surgery: Systematic Review and Meta-Analysis

Abstract

Objective: The global burden of surgical vascular disease is increasing and with it, the need for cost-effective, accessible prognostic biomarkers to aid optimization of peri-operative outcomes. The neutrophil-lymphocyte ratio (NLR) is emerging as a potential candidate biomarker for perioperative risk stratification. We therefore performed this systematic review and meta-analysis on the prognostic value of elevated preoperative NLR in vascular surgery. Methods: We searched Embase (Ovid), Medline (Ovid), and the Cochrane Library database from inception to June 2019. Screening was performed, and included all peer-reviewed original research studies reporting preoperative NLR in adult emergent and elective vascular surgical patients. Studies were assessed for bias and quality of evidence using a standardized tool. Meta-analysis was performed by general linear (mixed-effects) modelling where possible, and otherwise a narrative review was conducted. Between-study heterogeneity was estimated using the Chi-squared statistic and explored qualitatively. Results: Fourteen studies involving 5,652 patients were included. The overall methodological quality was good. Elevated preoperative NLR was associated with increased risk of long-term mortality (HR 1.40 [95%CI: 1.13-1.74], Chi-squared 60.3%, 7 studies, 3,637 people) and short-term mortality (OR: 3.08; 95%CI: 1.91-4.95), Chi-squared 66.59%, 4 studies, 945 people). Outcome measures used by fewer studies such as graft patency and amputation free survival were assessed via narrative review. Conclusions: NLR is a promising, readily obtainable, prognostic biomarker for mortality outcomes following vascular surgery. Heterogeneity in patient factors, severity of vascular disease, and type of vascular surgery performed renders direct comparison of outcomes from the current literature challenging. This systematic review supports further investigation for NLR measurement in pre-vascular surgical risk stratification. In particular, the establishment of a universally accepted NLR cut-off value is of importance in real-world implementation of this biomarker.

The association of neutrophil–lymphocyte ratio and platelet–lymphocyte ratio with retinal vein occlusion: a systematic review and meta‐analysis

“…As the ratio of neutrophils to lymphocytes, NLR has also been found to be elevated in atherosclerosis (Balta et al 2016) and cardiovascular disease (Afari & Bhat 2016). More importantly, elevations in NLR have, in recent years, been also found to be of predictive value (both diagnostic and prognostic) in a range of cardiovascular (Kalay et al 2012;Borg Caruana et al 2020;Jackson et al 2020;Liu et al 2020) and ophthalmic conditions such as diabetic retinopathy and age-related macular degeneration (Ulu et al 2013;Ilhan et al 2015). The PLR is a similar emerging inflammatory biomarker that elevates in thrombocytosis and lymphopenia.…”

“…2020; Jackson et al. 2020; Liu et al. 2020) and ophthalmic conditions such as diabetic retinopathy and age‐related macular degeneration (Ulu et al.…”

The Prognostic Significance of Neutrophil to Lymphocyte Ratio (NLR), Monocyte to Lymphocyte Ratio (MLR) and Platelet to Lymphocyte Ratio (PLR) on Long-Term Survival in Off-Pump Coronary Artery Bypass Grafting (OPCAB) Procedures

“…The relation between immune and non-immune agents are underlined including reperfusion injury, coronary endothelial dysfunction, and inflammation [ 66 ]. The meta-analysis performed by Jackson et al on patients referred for vascular procedures link the preoperative NLR to all-cause mortality and indicate the relation between immune and non-immune individual predisposition to over reactivity of the inflammatory system [ 67 ]. The results from our study, presenting increased postoperative NLR (above 3.5) as a significant mortality factor in multivariable analysis, is a compromise with previous reports.…”

Neutrophil-to-Lymphocyte Ratio Could Predict Outcome in Patients Presenting with Acute Limb Ischemia

“…In accordance with previous published papers on oncological and vascular diseases, our experience has confirmed the role of the baseline NLR value as an excellent marker for inflammatory processes and a promising risk stratification tool [ 15 , 16 , 17 , 18 , 19 , 20 ]. Previous published studies evaluated the prognostic role of preoperative NLR values in vascular disease, and the importance of establishing a unique cut-off [ 20 , 21 ]. Kordzazdeh et al reported that a preoperative NLR > 5 could be considered as an independent predictor of 30-day mortality in patients treated for abdominal aortic aneurysms (AAA), irrespective of age, gender, comorbidities, AAA size, blood loss, and length of hospital stay [ 22 ].…”