Are Pre and Postoperative Platelet to Lymphocyte Ratio and Neutrophil to Lymphocyte Ratio Associated with Early Postoperative AKI Following CABG?

Parlar, Hakan; Şaşkın, Hüseyin

doi:10.21470/1678-9741-2017-0164

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Brazilian Journal of Cardiovascular Surgery

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ORIGINAL ARTICLES • Braz. J. Cardiovasc. Surg. 33 (3) • May-Jun 2018 • https://doi.org/10.21470/1678-9741-2017-0164 copy

Are Pre and Postoperative Platelet to Lymphocyte Ratio and Neutrophil to Lymphocyte Ratio Associated with Early Postoperative AKI Following CABG?

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

In this study, we investigated the role of two of the recent biomarkers of inflammation on the development of acute kidney injury in the early postoperative period of isolated coronary artery bypass grafting.

Methods:

Three hundred and eleven patients, who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass by the same surgery team in our clinic between May 2010 and October 2014, who had a preoperative serum creatinine level lower than 1.5 mg/dl were included in the study. These patients' records were reviewed retrospectively. The diagnosis of acute kidney injury was performed according to the Kidney Disease Improving Global Outcomes 2012 Acute Kidney Injury Guideline criteria. Patients who developed acute kidney injury in the early postoperative period were classified as Group-1 (n=62) and the patients with normal postoperative renal functions were classified as Group-2 (n=249). The demographic data, body mass index, comorbidities, hematologic/biochemical profiles, preoperative ejection fraction, blood transfusion history, and operative data of the groups were compared. Univariate analyses were performed to determine significant clinical factors, and multiple logistic regression analyses were subsequently done to determine independent predictors of acute kidney injury.

Results:

Sixty-two (19.9%) patients developed acute kidney injury during the first 72 hours postoperatively. Multivariate logistic regression analyses revealed preoperative increased creatinine (P=0.0001), C-reactive protein (P=0.02), neutrophil-lymphocyte ratio (P=0.04) and platelet-lymphocyte ratio (P=0.002); increased postoperative first day leukocyte count (P=0.03), C-reactive protein levels (P=0.02), neutrophil-lymphocyte ratio (P=0.002), platelet-lymphocyte ratio (P=0.01) and increased intubation time (P=0.006) as independent predictors of early postoperative acute kidney injury in patients who underwent isolated coronary artery bypass grafting.

Conclusion:

The preoperative and postoperative increased levels of neutrophil-lymphocyte ratio and platelet-lymphocyte ratio which can be calculated by simple methods from routine blood analysis showed us that these parameters are independent biomarkers directly related to development of acute kidney injury in the early postoperative period.

Keywords:
Coronary Artery Bypass; Acute Kidney Injury; Biomarkers; Inflammation

Abbreviations, acronyms & symbols
ACT	= Activated clotting time	LIMA	= Left internal mammary artery
AKI	= Acute kidney injury	LVEF	= Left ventricular ejection fraction
AUC	= Area under curve	NLR	= Neutrophil to lymphocyte ratio
CABG	= Coronary artery bypass grafting	PCI	= Percutanous coronary intervention
CRP	= C-reactive protein	PLR	= Platelet to lymphocyte ratio
CPB	= Cardiopulmonary bypass	ROC	= Receiver operating curve
ECG	= Electrocardiography	RRT	= Renal replacement therapy
KDIGO	= Kidney Disease Improving Global Outcomes	STEMI	= ST-elevated myocardial infarction
LAD	= Left anterior descending artery	WBC	= White blood cell

Patient's Characteristics	Group I AKI (n=62)	Group II Non-AKI (n=249)	P value
Age (years) (median; min-max)	62 (35-83)	60 (33-82)	0.14^ Mann-Whitney U test
Male (%)	46 (74.2%)	189 (75.9%)	0.78^* * Pearson Chi-Square test or Fisher's Exact test
Female (%)	16 (25.8%)	60 (24.1%)	0.78^* * Pearson Chi-Square test or Fisher's Exact test
BMI (kg/m²) (median; min-max)	28.5 (19.6-37.4)	27.3 (19.0-39.4)	0.11^ Mann-Whitney U test
Hypertension (%)	41 (66.1%)	152 (61.0%)	0.46^* * Pearson Chi-Square test or Fisher's Exact test
Diabetes mellitus (%)	29 (46.8%)	85 (34.1%)	0.07^* * Pearson Chi-Square test or Fisher's Exact test
Smoking (%)	29 (46.8%)	93 (37.3%)	0.17^* * Pearson Chi-Square test or Fisher's Exact test
Hyperlipidaemia (%)	26 (41.9%)	116 (46.6%)	0.51^* * Pearson Chi-Square test or Fisher's Exact test
Ejection fraction (%) (median; min-max)	56.5 (30-68)	58 (30-67)	0.35^ Mann-Whitney U test
History of atrial fibrillation (%)	7 (11.3%)	25 (10.0%)	0.77^* * Pearson Chi-Square test or Fisher's Exact test
History of CVA (%)	2 (3.2%)	6 (2.4%)	0.66^* * Pearson Chi-Square test or Fisher's Exact test
History of MI (%)	14 (22.6%)	51 (20.5%)	0.72^* * Pearson Chi-Square test or Fisher's Exact test

Preoperative blood results and hematological parameters	Group I AKI (n=62)	Group II Non-AKI (n=249)	P value
Preoperative blood results and hematological parameters	Median (minimum-maximum)	Median (minimum-maximum)	P value
Preoperative hemoglobin (mg/dl)	13.9 (10.6-16.0)	13.5 (10.4-16.5)	0.24^* * Mann-Whitney U test
Preoperative hematocrit (%)	41.8 (30.6-48.9)	40.5 (30.5-48.9)	0.42^* * Mann-Whitney U test
Preoperative creatinine (mg/dl)	1.20 (0.60-1.46)	0.81 (0.60-1.47)	0.0001^* * Mann-Whitney U test
Preoperative urea (mg/dl)	23 (12-47)	18 (10-39)	0.0001^* * Mann-Whitney U test
Preoperative leukocyte count (x10³/µL)	8.4 (5.2-11.4)	8.0 (3.4-11.8)	0.52^* * Mann-Whitney U test
Preoperative platelet count (x10³/µL)	290 (156-444)	278 (145-445)	0.13^* * Mann-Whitney U test
Preoperative CRP (mg/L)	1.12 (0.36-4.58)	0.49 (0.16-4.71)	0.0001^* * Mann-Whitney U test
Preoperative lymphocyte count (x10³/µL)	1.8 (1.0-4.9)	2.2 (0.9-4.9)	0.04^* * Mann-Whitney U test
Preoperative neutrophil count (x10³/µL)	5.9 (2.8-9.6)	5.0 (1.4-9.7)	0.003^* * Mann-Whitney U test
Preoperative NLR	3.3 (1.2-8.9)	2.3 (0.6-8.0)	0.0001^* * Mann-Whitney U test
Preoperative PLR	154.5 (84.7-191.7)	122.9 (80.0-199.3)	0.0001^* * Mann-Whitney U test

Early postoperative period blood results and hematological parameters		Group I AKI (n=62)	Group II Non-AKI (n=249)	P value
		Median (minimum-maximum)	Median (minimum-maximum)	P value
Postoperative hemoglobin (mg/dl)	1 day	8.8 (7.5-11.4)	9.0 (7.4-12.6)	0.50^* * Mann-Whitney U test
Postoperative hematocrit (%)	1 day	28.0 (24.7-36.2)	28.5 (24.3-39.0)	0.52^* * Mann-Whitney U test
Postoperative leukocyte count (x10³/µL)	1 day	15.1 (7.6-21.1)	12.5 (4.7-32.3)	0.0001^* * Mann-Whitney U test
	3 days	13.3 (6.8-26.4)	11.1 (4.6-21.1)	0.0001^* * Mann-Whitney U test
	7 days	10.3 (7.0-23.3)	9.8 (4.3-22.1)	0.30^* * Mann-Whitney U test
Postoperative platelet count (x10³/µL)	1 day	162 (77-331)	177 (71-350)	0.17^* * Mann-Whitney U test
	3 days	165 (65-320)	167 (70-327)	0.50^* * Mann-Whitney U test
	7 days	214 (99-463)	231 (100-408)	0.17^* * Mann-Whitney U test
Postoperative CRP (mg/L)	1 day	32.1 (15.2-44.1)	26.7 (15.2-39.4)	0.0001^* * Mann-Whitney U test
	3 days	43.9 (36.5-63.3)	41.0 (30.5-48.9)	0.0001^* * Mann-Whitney U test
	7 days	9.5 (7.4-19.9)	8.9 (4.8-12.6)	0.0001^* * Mann-Whitney U test
Postoperative lymphocyte count (x10³/µL)	1 day	1.1 (0.4-2.2)	1.5 (0.6-2.6)	0.0001^* * Mann-Whitney U test
	3 days	1.1 (0.4-2.7)	1.3 (0.6-3.3)	0.0001^* * Mann-Whitney U test
	7 days	1.4 (0.6-3.2)	1.9 (0.9-3.7)	0.0001^* * Mann-Whitney U test
Postoperative neutrophil count (x10³/µL)	1 day	8.1 (3.9-11.7)	7.3 (2.8-9.8)	0.009^* * Mann-Whitney U test
	3 days	7.7 (4.0-10.8)	7.4 (3.0-10.8)	0.03^* * Mann-Whitney U test
	7 days	8.1 (3.5-11.0)	6.5 (1.4-10.5)	0.0001^* * Mann-Whitney U test
Postoperative NLR	1 day	7.9 (4.5-10.2)	5.1 (2.1-9.9)	0.0001^* * Mann-Whitney U test
	3 days	7.8 (3.5-10.7)	5.4 (1.4-10.6)	0.0001^* * Mann-Whitney U test
	7 days	5.6 (1.6-10.6)	3.3 (0.5-8.6)	0.0001^* * Mann-Whitney U test
Postoperative PLR	1 day	156.6 (108.2-198.9)	124.7 (72.2-188.6)	0.0001^* * Mann-Whitney U test
	3 days	152.6 (81.5-196.3)	120.9 (69.4-172.5)	0.0001^* * Mann-Whitney U test
	7 days	155.7 (82.5-197.9)	120.0 (68.7-169.2)	0.0001^* * Mann-Whitney U test

Characteristics	Group I AKI (n=62)	Group II Non-AKI (n=249)	P value
Characteristics	Median (minimum-maximum)	Median (minimum-maximum)	P value
Aortic cross clamp time (minutes)	51 (23-84)	51 (21-76)	0.73^ Mann-Whitney U test
Cardiopulmonary bypass time (minutes)	84.5 (47-114)	84 (42-110)	0.50^ Mann-Whitney U test
Number of distal anastomoses	3 (1-5)	3 (1-5)	0.68^ Mann-Whitney U test
Amount of drainage (ml)	300 (200-1350)	300 (150-1250)	0.08^* * Pearson Chi-Square test or Fisher's Exact test
Intubation time (hours)	8 (3-16)	5 (3-21)	0.0001^ Mann-Whitney U test
Stay in the intensive care unit (hours)	37.5 (21-87)	21 (17-66)	0.0001^ Mann-Whitney U test
Total duration of hospital stay (days)	8 (5-14)	5 (5-10)	0.0001^ Mann-Whitney U test
Use of inotropic support (%)	16 (25.8%)	33 (13.3%)	0.02^* * Pearson Chi-Square test or Fisher's Exact test
Use of blood products (%)	31 (50.0%)	117 (47.0%)	0.67^* * Pearson Chi-Square test or Fisher's Exact test

Variables	Postoperative AKI
Variables	Unadjusted OR (95% CI)	P	Adjusted OR (95% CI)	P
Gender	0.91 (0.48-1.73)	0.87	__	__
Age	1.02 (0.99-1.05)	0.16	__	__
Ejection fraction (%)	0.98 (0.95-1.01)	0.15	__	__
Diabetes mellitus	1.70 (0.97-2.98)	0.17	__	__
Hypertension	1.25 (0.70-2.24)	0.46	__	__
Hyperlipidaemia	0.83 (0.47-1.45)	0.51	__	__
Smoking	1.47 (0.84-2.58)	0.18	__	__
BMI	1.05 (0.98-1.12)	0.20	__	__
Preoperative creatinine (mg/dl)	2464.06 (383.62-15827.07)	0.0001	4097.94 (52.93-317299.77)	0.0001
Preoperative urea (mg/dl)	1.12 (1.07-1.17)	0.0001	1.05 (0.94-1.18)	0.37
Preoperative platelet (x10³/µL)	1.00 (0.99-1.01)	0.12	__	__
Preoperative CRP (mg/l)	3.17 (2.12-4.75)	0.0001	2.71 (1.16-6.35)	0.02
Preoperative hemoglobin (mg/dl)	1.13 (0.92-1.37)	0.24	__	__
Preoperative leukocyte (x10³/µL)	0.99 (0.98-1.00)	0.44	__	__
Preoperative NLR	1.76 (1.38-2.23)	0.0001	0.45 (0.22-0.95)	0.04
Preoperative PLR	1.05 (1.03-1.07)	0.0001	1.06 (1.02-1.10)	0.002
Postoperative first day platelet (x10³/µL)	1.32 (1.08-1.62)	0.007	1.00 (0.99-1.01)	0.20
Postoperative first day hemoglobin (mg/l)	0.90 (0.70-1.16)	0.42	__	__
Postoperative first day leukocyte (x10³/µL)	0.97 (0.92-1.02)	0.0001	1.01(0.99-1.03)	0.03
Postoperative first day CRP (mg/l)	1.25 (1.17-1.33)	0.0001	1.19 (1.02-1.36)	0.02
Postoperative first day NLR	2.46 (1.97-3.07)	0.0001	3.04 (1.51-6.10)	0.002
Postoperative first day PLR	1.09 (1.07-1.12)	0.0001	1.06 (1.01-1.10)	0.01
Aortic cross clamp time	1.01 (0.99-1.03)	0.48	__	__
Number of distal anastomoses	1.11 (0.82-1.49)	0.50	__	__
CPB time	1.01 (0.99-1.03)	0.37	__	__
Intubation time	1.44 (1.27-1.63)	0.0001	1.64 (1.15-2.33)	0.006
Use of blood products	1.13 (0.65-1.97)	0.67	__	__
Use of inotropic support	2.28 (1.16-4.48)	0.02	0.31(0.08-2.29)	0.17
Amount of drainage	1.00 (0.99-1.01)	0.18	__	__

Authors' roles & responsibilities
HP	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final approval of the version to be published
HŞ	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final approval of the version to be published

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[1] Correspondence Address: Hakan Parlar, SBU Derince Training and Research Hospital, Department of Cardiovascular Surgery - Kocaeli, Turkey - Zip code: 41900. E-mail: hakanparlarcvs@gmail.com