European Journal of Cardiovascular Medicine

Acute pancreatitis (AP) is an inflammatory condition characterized by localized pancreatic damage that induces systemic inflammation via the activation of cytokine cascades.^[1] Acute pancreatitis is a common cause of emergency hospitalizations in India. The Neutrophil-Lymphocyte Ratio (NLR) and Platelet-Lymphocyte Ratio (PLR), which are calculated from the White Blood Cell Count and its Differential Count, provide a quick assessment of the severity of an inflammatory illness like Acute Pancreatitis.

Acute pancreatitis is a dynamic inflammatory condition that begins with localized acinar cell injury and can affect adjacent tissues or distant organ systems unexpectedly. While the majority of acute pancreatitis cases are minor and self-limited, severe cases may result in necrosis or organ failure in 15-20% of patients. In cases of severe acute pancreatitis (SAP), death rates might reach up to 70%.

A significant drawback of the existing scoring systems for predicting pancreatitis severity is their tendency to transform continuous variables into binary values of equal weight, hence neglecting the synergistic effects arising from the interactions of interdependent systems. The existing clinical prognostic scores seem to have attained their optimal effectiveness, necessitating innovative methods for severity prediction.^[2] The severity of acute pancreatitis is contingent upon systemic organ failure resulting from the patient's systemic inflammatory response, and the unfavorable prognosis of severe acute pancreatitis is believed to arise from uncontrolled systemic inflammatory response syndrome (SIRS) or multiple organ dysfunction syndrome (MODS). CT severity index is an important tool to assess the severity of Pancreatitis.^[3] White blood cell (WBC) counts and C-reactive protein (CRP) levels are contemporary indicators of systemic inflammation that can be assessed using standard hematological assays.^[4]

The WBC count is associated with a poorer outcome according to Ranson’s criteria, Glasgow score, Acute Physiology and Chronic Health Evaluation-II (APACHE II), and Bedside Index of Severity in Acute Pancreatitis (BISAP).^[5,6]  The total WBC count can fluctuate due to different physiological and pathological factors, including hydration status, stress, and pregnancy. Alterations in peripheral blood components are utilised to forecast the prognosis of several disorders, including coronary heart disease, esophageal cancer, colorectal cancer, and hepatocellular carcinoma. The neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are novel biomarkers for this purpose, with several research documented in the literature. Precise indicators of Acute Pancreatitis severity are crucial as they impact clinical decision-making in its management.

Numerous medical conditions have shown that NLR is superior to total white blood cell (WBC) count, which is utilized in the Glasgow-Imrie, APACHE-II, and Ranson scoring systems.^[7] Additionally, some research has indicated that PLR is a better predictive indicator than NLR for some medical diseases.^[8,9,10] Inflammatory diseases have been linked to elevated NLR and PLR ratios, and uncontrolled SIRS and its progression to multi-organ failure syndrome account for poor outcomes in severe AP.

Previous research has demonstrated the association between peripheral lymphocytopenia and the severity of acute pancreatitis. However, the Neutrophil-Lymphocyte Ratio (NLR) and Platelet-Lymphocyte Ratio (PLR) are superior in evaluating the inflammatory response of patients with Acute Pancreatitis. It has now been proven that the PLR-NLR combination can be utilised to predict disease prognosis in Acute Pancreatitis. PLR and NLR more accurately represent the immunological response than total WBC count alone.

AIM AND OBJECTIVES

The aim of this study was to investigate the predictive value of NLR and PLR in male patients with Acute Pancreatitis of Alcoholic Etiology. The objective of this study is to calculate the Neutrophil-Lymphocyte Ratio (NLR) and Platelet-Lymphocyte Ratio (PLR) among acute pancreatitis patients and to investigate if this ratio is helpful as a predictor of severity in acute pancreatitis.

The study included 50 adult male patients with a history of alcoholism who were complaining of pancreatitis-related abdominal pain and were admitted to the emergency room under emergency surgery care at a general tertiary care teaching hospital from January to September 2024 were included. The doctors diagnosed the patients with acute pancreatitis when their serum amylase and/or lipase levels tripled, and their contrast-enhanced computed tomography (CECT) scans revealed acute pancreatitis symptoms.

The exclusion criteria included adult males who were over 80 years of age or younger than 18 years, females of any age, those undergoing treatment for cancer or hematological proliferation disease, those currently on steroids or chemotherapy for any reason, those with acquired immunodeficiency syndrome, those with uremia, those in the late stages of liver cirrhosis, those with active tuberculosis, and those with refractory heart failure.

We obtained informed consent from the patients to accept their participation in the study. We calculated the Neutrophil-Lymphocyte Ratio (NLR) and PLR from the differential counts of their WBC counts in blood samples taken at the time of admission. The Neutrophil-Lymphocyte Ratio (NLR) can be defined as the ratio (NLR=ANC/ALC) between the measured Absolute Neutrophil Count (ANC) and the Absolute Lymphocyte Count (ALC). ANC = [(%Neutrophils) x WBC]/100 and ALC = [(%Lymphocytes) x WBC]/100. TheAPC stands for Absolute Platelet Count, and ALC for [(%Lymphocytes) x WBC]/100. The Platelet-Lymphocyte Ratio (PLR) is the ratio (PLR=APC/ALC) between the Absolute Platelet Count (APC) and the Absolute Lymphocyte Count (ALC). To see how bad the acute pancreatitis was (mild, moderate, or severe), we plotted these NLR and PLR values against the MCSI scores from the contrast-enhanced computed tomography (CECT) scans that were done on these patients.

ANOVA (Analysis Of Variance) interpreted the continuous variables obtained from the study subjects' data. The categorical variables were described and interpreted by the chi-squared (χ²) test. We conducted correlation analysis on specific parameters to determine the correlation coefficient. We performed the above statistical procedures using the statistical package IBM SPSS Statistics 29. The study limitation is that it is a single-institution, non-blinded study with a short study duration and a small sample size.

Out of 50 sample size, patients were classified based on the Modified Computed Tomography Severity Index (MCTSI), with 24 (48%) as having Mild Acute Pancreatitis, 18 (36%) patients as having Moderate Acute Pancreatitis and 8 (16%) patients as Severe Acute Pancreatitis.

Comparing the age group, the mean age group for mild, moderate and severe pancreatitis were 41.8±9.9 years, 41.2 ±10.9 years and 43.1± 11.6 years respectively.

Table No. 1 Correlation between Serum Amylase & Lipase and NLR & PLR

• Correlation Co-efficient between Serum Amylase & NLR was 0.758381938
• Correlation Co-efficient between Serum Lipase & NLR was 0.740160993
• Correlation Co-efficient between Serum Amylase & PLR was 0.355924047
• Correlation Co-efficient between Serum Lipase & PLR was 0.233246524

                      Fig. No. 1 Correlation between Serum Amylase & Lipase and NLR & PLR

Table No. 2 Sensitivity & Specificity of NLR & PLR for Mild, Moderate & Severe Acute Pancreatitis

The Sensitivity and Specificity of the NLR & PLR values were also arrived at. The The Sensitivity of NLR (@ 5 Cut-off value) in Mild AP was 83.33%, while the Sensitivity of PLR (@150 Cut-off value) in Mild AP was comparable at 82.54%. The Sensitivity of NLR (@7.5 Cut-off value) for Moderate AP, was better at 76.00%, whereas the Sensitivity of PLR (@225 Cut-off) for Moderate AP was comparatively less at 65.88%. The Sensitivity of NLR (@10 Cut-off value) in Severe AP, was 72.00%, wherein, the Sensitivity of PLR (@300 Cut-off value) in Severe AP was 68.72%.

The Specificity of NLR (@ 5 Cut-off value) in Mild AP was 50.00%, while the Specificity of PLR (@150 Cut-off value) in Mild AP was comparable at 55.78%. The Specificity of NLR (@7.5 Cut-off value) for Moderate AP, was comparable at 64.00%, whereas the Specificity for PLR (@225 Cut-off) in Moderate AP was at 62.12%. The Specificity of NLR (@10 Cut-off value) in Severe AP, was better at 75.66%, wherein, the Specificity of PLR (@300 Cut-off value) in Severe AP was 64.76%.

Fig. No. 2 Sensitivity & Specificity of NLR & PLR for Mild, Moderate & Severe Acute Pancreatitis

Table No. 3 Neutrophil-Lymphocyte Ratio in Mild, Moderate & Severe Acute Pancreatitis

The Neutrophil-Lymphocyte Ratio for Mild Acute Pancreatitis had a Mean of 5.5 with a Standard Deviation of 1.0, for Moderate Acute Pancreatitis had a Mean of 7.9 with a Standard Deviation of 1.3, and for Severe Acute Pancreatitis had a Mean of 11.2 with a Standard Deviation of 1.5. On statistical analysis, this gives a F value of 77.824 with P value at 0.0000000000000012212453270876722.

Fig. No. 3 Neutrophil-Lymphocyte Ratio in Mild, Moderate & Severe Acute Pancreatitis

Table No. 4 Platelet-Lymphocyte Ratio in Mild, Moderate & Severe Acute Pancreatitis

The Platelet-Lymphocyte Ratio for Mild Acute Pancreatitis had a Mean of 165.3 with a Standard Deviation of 37.1, for Moderate Acute Pancreatitis had a Mean of 202.1 with a Standard Deviation of 34.4, and for Severe Acute Pancreatitis had a Mean of 313.1 with a Standard Deviation of 34.8. On statistical analysis, this gives a F value of 53.069 with P value at 0.0000000000008807399254351367.

Fig. No. 4 Platelet-Lymphocyte Ratio in Mild, Moderate & Severe Acute Pancreatitis

In our study on 50 patients, 24 (48%) had mild acute pancreatitis, 18 (36%) had moderate acute pancreatitis, and 8 (16%) patients had severe acute pancreatitis.

In our study, most of the patients who presented with acute pancreatitis belonged to the 30-to-50-year-old age group. Comparing the age group, the mean age group for mild, moderate, and severe pancreatitis were 41.8 ± 9.9 years, 41.2 ± 10.9 years, and 43.1 ± 11.6 years, respectively.

We compared the serum amylase and lipase values to NLR and PLR and found a positive correlation.The correlation coefficient between serum amylase and NLR ,the correlation coefficient between serum lipase and NLR ,the correlation coefficient between serum amylase and PLR ,the correlation coefficient between serum lipase and PLR, were statistically significant with the p value < 0.0001, which indicated a strong correlation between the increase in serum amylase and the increase in NLR in acute pancreatitis.^[11,12]

We also arrived at the Sensitivity and Specificity of the NLR & PLR values, finding that the Sensitivity of NLR (@7.5 Cut-off value) for Moderate AP was better at 76.00%, while the Sensitivity of PLR (@225 Cut-off) for Moderate AP was comparatively less at 65.88%. The Specificity of NLR (@10 Cut-off value) in Severe AP was better at 75.66%, while the Specificity of PLR (@300 Cut-off value) in Severe AP was 64.76%.

We found a highly significant relationship between the NLR & PLR values and the severity grading (mild/moderate/severe) of acute pancreatitis in MCTSI. (p<0.01).^[13,14]

The Neutrophil-Lymphocyte Ratio for Mild Acute Pancreatitis had a mean of 5.5. The mean for moderate acute pancreatitis was 7.9, with a standard deviation of 1.0. The standard deviation was 1.3, and the mean for Severe Acute Pancreatitis was 11.2. Standard Deviation: 1.5. Statistical analysis yields an F value of 77.824 and a P value of < 0.0001, which is highly significant (p < 0.01).^[15,16]

The mean Platelet-Lymphocyte Ratio for Mild Acute Pancreatitis was 165.3. The mean for moderate acute pancreatitis was 202.1, with a standard deviation of 37.1. The standard deviation was 34.4, and the mean for Severe Acute Pancreatitis was 313.1. Standard Deviation: 34.8. Statistical analysis yields a F value of 53.069 with a P value of < 0.0001, which is highly significant (p < 0.01).

The study's primary finding is that patients presenting with acute pancreatitis had elevated Neutrophil Lymphocyte Ratio (NLR) and Platelet-Lymphocyte Ratio (PLR). A rise in neutrophil count corresponds with the  development of SIRS and MODS, which are the hallmarks of acute pancreatitis. Lymphocyte number increases  following the initial stress and mediates the subsequent inflammatory response.^[17,18]

Our study offers the advantage of calculating NLR & PLR using only a total WBC and a differential count. In comparison to other severity scoring systems, where there are multiple parameters required to calculate the prognosis, NLR analysis just needs a single blood test.

In our study, NLR can be done at the time of admission, which can act as a guide to identify patients who may progress to severe pancreatitis. Early identification and intensive management of patients progressing to severe pancreatitis can reduce mortality and morbidity. You can calculate NLR & PLR at any level of care in a hospital, whether it's secondary care or tertiary care. The calculated NLR & PLR can serve as a guide for referring patients with poor prognoses to a higher center for intensive care and management.

Elevation of NLR & PLR is significantly associated with increasing severity of Pancreatitis and both are independent negative prognostic indicators in Acute Pancreatitis. Continuous monitoring on each day will provide a dynamic reflection of the immunity and inflammatory response of the body to pancreatitis and hence predict the prognosis earlier. Together, NLR & PLR, give more accurate prediction regarding the severity of Pancreatitis. NLR & PLR being derived from a basic blood investigation like WBC Count, add no additional cost to the patient, and is far more superior in predicting the severity in Acute Pancreatitis than WBC count alone. NLR & PLR assessment trespasses the limitation of Ranson’s scoring system that, it can be used at the time of admission itself. It also covers the limitation of APACHE II scoring system in a way that it avoids multiple parameters needed for assessment.

Ethical Approval

Ethical Approval was obtained from the Institutional Ethical Committee of Kanyakumari Government Medical College, Nagercoil, Kanyakumari District, Tamil Nadu, India.

Conflicts of Interest

The authors have no conflicts of interest to declare.

Financial Assistance

The authors declare that no funding was received for this study.

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