The effect of AST/ALT (De Ritis) ratio on survival and its relation to tumor histopathological variables in patients with localized renal cell carcinoma

Canat, Lütfi; Ataly, Hasan Anil; Agalarov, Samir; Alkan, İlter; Alturende, Fatih

doi:10.1590/S1677-5538.IBJU.2017.0173

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Original Article • IBJUInt. braz j urol 44 (2) • Mar-Apr 2018 • https://doi.org/10.1590/S1677-5538.IBJU.2017.0173 copy

The effect of AST/ALT (De Ritis) ratio on survival and its relation to tumor histopathological variables in patients with localized renal cell carcinoma

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose

To assess the relationship between De Ritis (aspartate aminotransaminase [AST]/Alanine aminotransaminase [ALT]) ratio and pathological variables and whether it is an independent prognostic factor.

Materials and Methods

We analyzed 298 consecutive patients who underwent radical or partial nephrectomy for non-metastatic renal cell carcinoma (RCC) between 2006 and 2015. The association between De Ritis ratio and pathological variables including tumor size, presence of renal vein invasion, vena cava invasion, renal capsule infiltration, Gerota fascia invasion, renal sinus involvement, renal pelvic invasion, angiolymphatic invasion, adrenal gland involvement, lymph node involvement, tumor necrosis, and Fuhrman's grade was tested. Multivariable Cox analysis was performed to evaluate the impact of this ratio on overall survival and cancer-specific survival.

Results

An increased preoperative De Ritis ratio was significantly associated with renal vein invasion, renal capsule infiltration and renal pelvis involvement (p<0.05) in non-metastatic RCC. On multivariate analysis we found that tumor size, Fuhrman grade and lymph node involvement were independent prognostic factors for cancer-specific survival. AST/ALT ratio had no influence on the risk of overall and cancer-specific survival.

Conclusion

An increased preoperative AST/ALT ratio had a significant association with renal vein invasion, renal capsule infiltration and renal pelvis involvement in patients with non-metastatic RCC. However, it does not appear to be an independent prognostic marker in non-metastatic RCC.

Keywords
Prognosis; Survival; Pathology

Characteristics		Min-Max	Median	Mean±s.d./n-%
Age		22-86	61	61.5±13.2
Sex
	Male			183-61.4%
	Female			115-38.6%
Histological type
	Clear cell			210-70.5%
	Papillary			38-12.7%
Chromophobe				24-8.1%
Collecting duct cell carcinoma				5-1.6%
Undifferentiated				21-7.1%
T Stage
I-II				222-74.50%
III-IV				76-25.50%
Fuhrman Grade
	I			18-6.1%
	II			128-42.9%
	III			78-26.2%
	IV			30-10.1%
	Undefined			44-14.7%
Tumor size (cm)		1.2-17.0	5.0	5.6±2.9
AST		10.0-85.0	19.0	21.8±10.7
ALT		5.0-96.0	17.0	21.5±14.8
AST/ALT		0.5-5.3	1.1	1.2±0.6

	Univariate Model			Multivariate Model
	HR	%95 CI	p	HR	%95CI	p
Age	1.008	0.98 - 1.04	0.640
Sex	5.992	1.40 - 25.73	0.016
Histology type	0.490	0.21 - 1.16	0.106
Fuhrman Grade	3.546	2.03 - 6.20	0.000	2.730	1.56 - 4.79	0.000
Calcium	1.571	0.71 - 3.49	0.268
Hemoglobin	0.761	0.61 - 0.95	0.015
Tumor size	1.308	1.17 - 1.46	0.000	1.230	1.07 - 1.41	0.003
Renal vein invasion	4.966	1.44 - 17.09	0.011
Renal capsule infiltration	3.557	1.38 - 9.18	0.009
Renal sinüs involvement	4.836	2.04 - 11.49	0.000
Adrenal gland involvement	6.332	1.47 - 27.32	0.013
Gerota fascia invasion	35.738	3.99 - 319.8	0.001
Lymph node involvement	13.970	4.62 - 42.22	0.000	6.716	2.16 - 20.9	0.001
Angiolymphatic invasion	10.066	3.99 - 25.42	0.000
Renal pelvis involvement	2.957	1.08 - 8.09	0.035
AST	0.979	0.93 - 1.03	0.409
ALT	0.958	0.91 - 1.00	0.073
AST/ALT	1.306	0.79 - 2.15	0.293

		AST/ALT			P^* * Mann-Whitney u test, AST = aspartate transaminase; ALT = alanine transaminase
		Min-Mak	Medyan	Ort.±s.s.
Renal vein invasion	(-)	0.45 - 5.31	1.06	1.20 ± 0.58	0.013
Renal vein invasion	(+)	1.10 - 2.33	1.44	1.58 ± 0.41	0.013
Renal capsule infiltration	(-)	0.47 - 5.31	1.06	1.20 ± 0.58	0.049
Renal capsule infiltration	(+)	0.45 - 2.60	1.40	1.41 ± 0.54	0.049
Renal sinüs involvement	(-)	0.45 - 5.31	1.00	1.19 ± 0.59	0.079
Renal sinüs involvement	(+)	0.47 - 2.60	1.22	1.34 ± 0.53	0.079
Adrenal gland involvement	(-)	0.45 - 5.31	1.08	1.22 ± 0.58	0.749
Adrenal gland involvement	(+)	1.00 - 1.40	1.10	1.17 ± 0.21	0.749
Gerota fascia invasion	(-)	0.45 - 5.31	1.08	1.22 ± 0.58	0.505
Gerota fascia invasion	(+)	1.40 - 1.40	1.40	1.40 ±.	0.505
Lymph node involvement	(-)	0.45 - 5.31	1.07	1.22 ± 0.58	0.467
Lymph node involvement	(+)	0.79 - 2.00	1.33	1.36 ± 0.53	0.467
Angiolymphatic invasion	(-)	0.45 - 5.31	1.07	1.21 ± 0.59	0.355
Angiolymphatic invasion	(+)	0.76 - 2.38	1.16	1.31 ± 0.52	0.355
Renal pelvis involvement	(-)	0.45 - 2.71	1.06	1.16 ± 0.46	0.004
Renal pelvis involvement	(+)	0.81 - 5.31	1.56	1.74 ± 1.08	0.004
Tumor necrosis	(-)	0.47 - 5.31	1.07	1.22 ± 0.60	0.726
Tumor necrosis	(+)	0.45 - 2.29	1.20	1.24 ± 0.50	0.726

		AST/ALT≥1.5 n=80		AST/ALT<1.5 n=218		P
		n	%	n	%	P
Renal vein invasion		8	10	10	4.58	0.025
Renal capsule infiltration		16	20	18	8.25	0.015
Renal sinüs involvement		18	22.5	42	19.26	0.325
Adrenal gland involvement		2	2.5	6	2.75	0.438
Gerota fascia invasion		2	2.5	4	1.83	0.168
Lymph node involvement		4	5	8	3.66	0.315
Angiolymphatic invasion		10	12.5	26	11.92	0.521
Renal pelvis involvement		18	22.5	12	5.5	0.001
Tumor necrosis		14	17.5	32	14.67	0.425
Pathological stage						0.735
	I-II	56	70	166	76.2
	III-IV	24	30	52	23.8
Fuhrman grade						0.065
	I	4	5	14	6.4
	II	34	42.5	94	43.11
	III	24	30	54	24.7
	IV	12	10	18	8.25
Histological type						0.455
	Clear-cell	58	72.5	152	69.7
	Papillary	9	11.2	29	13.3
Chromophobe		6	7.5	18	8.2
Collecting duct cell carcinoma		2	2.5	3	1.3
Undifferentiated		5	6.2	16	7.3

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[1] Correspondence address: Lütfi Canat, MD, Department of Urology, Okmeydani Training and Research Hospital, Istanbul, Turkey, Şişli, Istanbul, 34371, Turkey. Fax: + 90 212 221-7776 E-mail: drhlcanat@gmail.com