The role of Neutrophil-Lymphocyte-Ratio (NLR) and Platelet-Lymphocyte-Ratio (PLR) as a biomarker for distinguishing between complicated and uncomplicated appendicitis

Abstract

Introduction Acute appendicitis (AA) is one of the most common acute general surgical presentations affecting 7% of the population at some point in their lifetime. The ability to assess the risk of complicated appendicitis (CA) from uncomplicated appendicitis (UA) in acute appendicitis (AA) could reduce the associated morbidity and mortality. The value of platelet lymphocyte ratio (PLR) as an inflammatory marker increases when its fluctuations are interpreted along with other complementary hematologic indices, such as neutrophil-to-lymphocyte ratio (NLR), which provides additional information about the disease activity. Hence, we postulated that NLR and/or PLR could serve as a potential surrogate marker in assessing the severity of AA. Aim This study aims to investigate the use of PLR and/or NLR as a surrogate biomarker in differentiating uncomplicated from complicated appendicitis. Material and methods This retrospective study was conducted at Russells Hall Hospital from January 1, 2017, to December 31, 2020. Data of all patients over age 16 years that had histologically confirmed appendicitis were retrieved. NLR and PLR were calculated from the admission hemogram, and the ratios were compared between uncomplicated (UA) or complicated appendicitis (CA). Cut-off values were calculated using the summarized ROC curve; in addition, the sensitivity and specificity with 95% confidence intervals were determined using SPSS 25.0 (IBM Corp., Armonk, NY). Results A total of 799 patients were analyzed, of which 469 (58.7%) were female. The median age was 31.2 years. The difference between NLR and PLR within the two appendicitis groups was significant (P=0.05; Kruskal-Wallis). Cohen's kappa (degree of inter-rater agreement) between NLR and PLR showed a moderate agreement of 0.589 (P<0.001). We equally demonstrated an exponential relationship between PLR and NLR (R2 =0.510, P<0.05). For UA, the area under the curve (AUC) and the cut-off for NLR and PLR were 0.715, 4.75 with a confidence interval (CI) of 0.678-0.653 and 0.632, 155 with a CI of 0.591-0.672, respectively. For CA, using NLR and PLR, the AUC and cut-off were 0.727, 6.96 with a CI of 0.687-0.768 and 0.653, 180.5 with a CI of 0.602-0.703, respectively; all were significant with a P of <0.001. Conclusion NLR and PLR are a reliable, less cumbersome surrogate biomarker for assessing the severity of acute appendicitis.