Pierre-Louis Willythssa S, Bath Jonathan, Mikkilineni Sesank, Scott Michael C, Harlander-Locke Michael, Rasor Zachary, Smeds Matthew
Division of Vascular Surgery, University of Cincinnati Medical Center, Cincinnati, OH.
Division of Vascular Surgery, University of Missouri Hospitals & Clinics, Columbia, MO.
Ann Vasc Surg. 2019 Jan;54:84-91. doi: 10.1016/j.avsg.2018.10.002. Epub 2018 Oct 17.
The neutrophil-to-lymphocyte ratio (NLR) has become a prognostic marker for proinflammatory states. It is associated with outcomes in many clinical processes including critical limb ischemia. We sought to identify predictors of amputation failure and mortality, in addition to the role of NLR in patients undergoing above-knee amputations (AKAs) or below-knee amputations (BKAs).
All patients undergoing BKA or AKA between 2004 and 2014 at 3 institutions were identified and analyzed (n = 513). Patients were excluded if they did not have a complete blood count with differential within 7 days prior to their operations. Comparison groups were formed between patients requiring unplanned revision and those who did not, and additionally between survivors and nonsurvivors at 30 days postamputation. Patient demographics, intraoperative data, and postoperative courses were compared. A multinomial logistic regression model was created to further compare the groups.
Four hundred and ten patients were included for analysis, of which 142 (35%) required unplanned revision. Nearly 5% of patients (19/410) died within 30 days of the initial amputation. On univariate analysis, those requiring revision were more likely to be current smokers compared to former smokers (P = 0.004 and P = 0.021, respectively), have a lower ankle-brachial index (ABI) (P = 0.019), and have undergone a BKA (P < 0.001). Patients with congestive heart failure (CHF) were less likely to require a revision after an amputation (P = 0.007). Postoperative NLR was higher in patients requiring revision (9.9 vs. 7.0, P < 0.001) and both preoperative and postoperative NLRs were higher in those with 30-day mortality (21.0 vs. 7.0, P < 0.001; 19.4 vs. 7.5, P < 0.001). A multinomial logistic regression model identified CHF (P = 0.004), ABI (P = 0.041), and elevated body mass index (BMI, P = 0.045) as predictors of revision, while coronary artery disease (CAD, P = 0.031), CHF (P = 0.029), and postoperative NLR (P < 0.001) were predictive of 30-day mortality.
Postoperative elevated NLR, CAD, and CHF are predictors of 30-day mortality in patients undergoing major limb amputation, while CHF, elevated ABI, and high BMI are predictors of revision. This study suggests that NLR may have a role as a biomarker for poor outcomes in patients with underlying peripheral vascular disease and warrants further investigation.
中性粒细胞与淋巴细胞比值（NLR）已成为促炎状态的预后标志物。它与包括严重肢体缺血在内的许多临床过程的预后相关。我们试图确定截肢失败和死亡的预测因素，以及NLR在接受膝上截肢（AKA）或膝下截肢（BKA）患者中的作用。
确定并分析了2004年至2014年期间在3家机构接受BKA或AKA的所有患者（n = 513）。如果患者在手术前7天内没有进行完整的血常规及分类检查，则将其排除。在需要计划外翻修的患者与不需要的患者之间，以及截肢后30天的幸存者与非幸存者之间形成比较组。比较患者的人口统计学、术中数据和术后病程。创建了一个多项逻辑回归模型以进一步比较这些组。
纳入410例患者进行分析，其中142例（35%）需要计划外翻修。近5%的患者（19/410）在初次截肢后30天内死亡。单因素分析显示，与既往吸烟者相比，需要翻修的患者当前吸烟的可能性更大（分别为P = 0.004和P = 0.021），踝臂指数（ABI）更低（P = 0.019），且接受的是BKA（P < 0.001）。充血性心力衰竭（CHF）患者截肢后需要翻修的可能性较小（P = 0.007）。需要翻修的患者术后NLR更高（9.9对7.0，P < 0.001），30天死亡率患者的术前和术后NLR均更高（21.0对7.0，P < 0.001；19.4对7.5，P < 0.001）。多项逻辑回归模型确定CHF（P = 0.004）、ABI（P = 0.041）和体重指数升高（BMI，P = 0.045）为翻修的预测因素，而冠状动脉疾病（CAD，P = 0.031）、CHF（P = 0.029）和术后NLR（P < 0.001）是30天死亡率的预测因素。
术后NLR升高、CAD和CHF是接受大肢体截肢患者30天死亡率的预测因素，而CHF、ABI升高和高BMI是翻修的预测因素。本研究表明，NLR可能作为潜在外周血管疾病患者不良预后的生物标志物，值得进一步研究。
