The relationship between ALT/ALP ratio, PLR and hepatic injury in elderly patients with septic shock

doi:10.11958/20240637

Abstract

Abstract:

Objective To investigate the prognostic value of alanine aminotransferase (ALT)/alkaline phosphatase (ALP) ratio, platelet (PLT) count/lymphocyte (LYM) ratio (PLR) in elderly patients with septic shock complicated with liver injury. Methods The clinical data of 116 patients with septic shock complicated with liver injury were retrospectively analyzed. According to the degree of liver injury, patients were divided into the mild group (39 cases), the moderate group (47 cases) and the severe group (30 cases). According to the survival of patients 28 days after admission, patients were divided into the death group (69 cases) and the survival group (47 cases). Acute physiological score, chronic healthⅡ(APACHE Ⅱ) score and sequential organ failure (SOFA) score were collected. PLT and LYM in peripheral blood were detected, and PLR was calculated. ALT and ALP were measured and ALT/ALP ratio was calculated. White blood cell count, blood lactic acid, C-reactive protein and other laboratory indicators were detected. Multivariate Logistic regression was used to analyze prognostic factors of patients with septic shock complicated with liver injury. The predictive values of ALT/ALP ratio and PLR on the prognosis of patients with septic shock complicated with liver injury were analyzed by receiver operating characteristic (ROC) curve. Results Serum ALT and ALP levels, ALT/ALP ratio, PLT and PLR were increased successively in the mild group, the moderate group and the severe group, while LYM was decreased successively in the three groups (P<0.05). The age, APACHE Ⅱ score, SOFA score, PLR, ALT/ALP ratio and blood lactic acid level were higher in the death group than those in the survival group (P<0.05). There was no significant difference in liver injury degree between the two groups (P<0.05). Multivariate Logistic regression analysis showed that high SOFA score, high PLR, high ALT/ALP ratio and moderate to severe liver injury were risk factors for death in patients with septic shock complicated with liver injury. ROC curve analysis showed that the combined ALT/ALP ratio and PLR prediction efficiency [area under the curve 0.915 (95%CI: 0.849-0.959), sensitivity and specificity 94.20% and 89.36%, respectively] was superior to single prediction (P<0.05). Conclusion Increased ALT/ALP ratio and PLR are associated with aggravation of liver injury and poor prognosis in patients with septic shock. ALT/ALP ratio and PLR can be used as prognostic markers.

Key words: shock, sepsis, elderly, prognosis, alanine aminotransferase, alkaline phosphatase, liver injury, platelet/lymphocyte ratio

CLC Number:

R631

Figures/Tables 5

References 22

[1]	XIAO L, QI L, ZHANG G, et al. Polygonatum sibiricum polysaccharides attenuate lipopoly-saccharide-induced septic liver injury by suppression of pyroptosis via NLRP3/GSDMD signals[J]. Molecules, 2022, 27(18):5999. doi:10.3390/molecules27185999.
[2]	DAI J M, GUO W N, TAN Y Z, et al. Wogonin alleviates liver injury in sepsis through Nrf2-mediated NF-κB signalling suppression[J]. J Cell Mol Med, 2021, 25(12):5782-5798. doi:10.1111/jcmm.16604.
[3]	WANG J, ZHU Q, LI R, et al. YAP1 protects against septic liver injury via ferroptosis resistance[J]. Cell Biosci, 2022, 12(1):163. doi:10.1186/s13578-022-00902-7.
[4]	蒙毅军, 余洪立, 杨石. GLDH、GGT、ALT、ALP联合检测对药物性肝损伤诊断的临床意义[J]. 检验医学与临床, 2019, 16(12):1735-1737.
	MENG Y J, YU H L, YANG S. Clinical significance of GLDH,GGT,ALT and ALP combined detection in the diagnosis of drug-induced liver injury[J]. Laboratory Medicine and Clinic, 2019, 16(12):1735-1737. doi:10.3969/j.issn.1672-9455.2019.12.032.
[5]	黄春洋, 陈杰, 张小丹, 等. 临床诊断的肝细胞型急性药物性肝损伤患者血清ALT/ALP比值变化特点与组织病理学特征分析[J]. 实用肝脏病杂志, 2021, 24(3):379-382.
	HUANG C Y, CHEN J, ZHANG X D, et al. Serum ALT/ALP ratio changes and histopathological features of patients with drug-induced liver injury acute hepatocellular type[J]. Journal of Practical Hepatology, 2021, 24(3):379-382. doi:10.3969/j.issn.1672-5069.2021.03.019.
[6]	WANG G, MIVEFROSHAN A, YAGHOOBPOOR S, et al. Prognostic value of platelet to lymphocyte ratio in sepsis:a systematic review and meta-analysis[J]. Biomed Res Int, 2022,2022:9056363. doi:10.1155/2022/9056363.
[7]	SINGER M, DEUTSCHMAN C S, SEYMOUR C W, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3)[J]. JAMA, 2016, 315(8):801-810. doi:10.1001/jama.2016.0287.
[8]	WOŹNICA E A, INGLOT M, WOŹNICA R K, et al. Liver dysfunction in sepsis[J]. Adv Clin Exp Med, 2018, 27(4):547-551. doi:10.17219/acem/68363.
[9]	KNAUS W A, ZIMMERMAN J E, WAGNER D P, et al. APACHE Ⅱ:a severity of disease classification system[J]. Crit Care Med, 1985, 13(10):818-829.
[10]	FERREIRA F L, BOTA D P, BROSS A, et al. Serial evaluation of the SOFA score to predict outcome in critically ill patients[J]. JAMA, 2001, 286(14):1754-1758. doi:10.1001/jama.286.14.1754.
[11]	YAN J, LI S, LI S. The role of the liver in sepsis[J]. Int Rev Immunol, 2014, 33(6):498-510. doi:10.3109/08830185.2014.889129.
[12]	XIE T, XIN Q, CAO X, et al. Clinical characteristics and construction of a predictive model for patients with sepsis related liver injury[J]. Clin Chim Acta, 2022, 537:80-86. doi:10.1016/j.cca.2022.10.004.
[13]	KNUDSEN A R, ANDERSEN K J, HAMILTON-DUTOIT S, et al. Correlation between liver cell necrosis and circulating alanine aminotransferase after ischaemia/reperfusion injuries in the rat liver[J]. Int J Exp Pathol, 2016, 97(2):133-138. doi:10.1111/iep.12188.
[14]	WU H, WANG Y, YAO Q, et al. Alkaline phosphatase attenuates LPS-induced liver injury by regulating the miR-146a-related inflammatory pathway[J]. Int Immunopharmacol, 2021, 101(Pt A):108149. doi:10.1016/j.intimp.2021.108149
[15]	LI Z, LIU T, FENG Y, et al. PPARγ alleviates sepsis-induced liver injury by inhibiting hepatocyte pyroptosis via inhibition of the ROS/TXNIP/NLRP3 signaling pathway[J]. Oxid Med Cell Longev, 2022,2022:1269747. doi:10.1155/2022/1269747.
[16]	JIANG Z, BO L, MENG Y, et al. Overexpression of homeodomain-interacting protein kinase 2 (HIPK2) attenuates sepsis-mediated liver injury by restoring autophagy[J]. Cell Death Dis, 2018, 9(9):847. doi:10.1038/s41419-018-0838-9.
[17]	THORUP C V, CHRISTENSEN S, HVAS A M. Immature platelets as a predictor of disease severity and mortality in sepsis and septic shock:a systematic review[J]. Semin Thromb Hemost, 2020, 46(3):320-327. doi:10.1055/s-0039-3400256.
[18]	DREWRY A M, SAMRA N, SKRUPKY L P, et al. Persistent lymphopenia after diagnosis of sepsis predicts mortality[J]. Shock, 2014, 42(5):383-391. doi:10.1097/SHK.00000000000000234.
[19]	KOSEKLI M A. Mean platelet volume and platelet to lymphocyte count ratio are associated with hepatitis B-related liver fibrosis[J]. Eur J Gastroenterol Hepatol, 2022, 34(3):324-327. doi:10.1097/MEG.00000000000002219.
[20]	廖国豪, 程斌, 余红雨, 等. 中性粒细胞与淋巴细胞比值和血小板计数与淋巴细胞比值与胆源性急性胰腺炎严重程度及并发肝损伤的相关性研究[J]. 中国全科医学, 2022, 25(12):1449-1454.
	LIAO G H, CHENG B, YU H Y, et al. Correlation between neutrophil to lymphocyte ratio,platelet to lymphocyte ratio and severity of biliary acute pancreatitis and concurrent liver injury[J]. Chinese General Practice, 2022, 25(12):1449-1454. doi:10.12114/j.issn.1007-9572.2021.02.141.
[21]	胡琼英, 罗建蓉, 艾承锦, 等. 血小板/淋巴细胞比值对肝细胞癌的预后价值评价[J]. 实用医院临床杂志, 2018, 15(6):78-80.
	HU Q Y, LUO J R, AI C J, et al. Prognostic value of platelet-to-lymphocyte ratio for hepatocellular carcinoma[J]. Practical Journal of Clinical Medicine, 2018, 15(6):78-80. doi:10.3969/j.issn.1672-6170.2018.06.024.
[22]	MORRIS S M, CHAUHAN A. The role of platelet mediated thromboinflammation in acute liver injury[J]. Front Immunol, 2022,13:1037645. doi:10.3389/fimmu.2022.1037645.

组别	n	ALT/（U/L）	ALP/（U/L）	ALT/ALP比值	PLT/（×10⁹/L）	LYM/（×10⁹/L）	PLR
轻度组	39	62.78±7.47	135.20±.89	0.46±0.02	368.27±20.92	2.36±0.10	161.67±20.31
中度组	47	75.05±11.30^a	142.25±6.95^a	0.54±0.06^a	451.07±37.74^a	1.96±0.29^a	231.27±28.72^a
重度组	30	90.06±9.54^ab	147.67±4.08^ab	0.62±0.01^ab	490.80±17.23^ab	1.62±0.09^ab	301.32±8.73^ab
F		67.119^＊	50.598^＊	144.472^＊	173.663^＊	114.590^＊	336.943^＊

组别	n	ALT/（U/L）	ALP/（U/L）	ALT/ALP比值	PLT/（×10⁹/L）	LYM/（×10⁹/L）	PLR
轻度组	39	62.78±7.47	135.20±.89	0.46±0.02	368.27±20.92	2.36±0.10	161.67±20.31
中度组	47	75.05±11.30^a	142.25±6.95^a	0.54±0.06^a	451.07±37.74^a	1.96±0.29^a	231.27±28.72^a
重度组	30	90.06±9.54^ab	147.67±4.08^ab	0.62±0.01^ab	490.80±17.23^ab	1.62±0.09^ab	301.32±8.73^ab
F		67.119^＊	50.598^＊	144.472^＊	173.663^＊	114.590^＊	336.943^＊

组别		n			年龄/岁		性别（男/女）				吸烟史（有/无）	饮酒史（有/无）			体质量指数/ （kg/m²）				高血压（有/无）			高脂血症（有/无）			糖尿病（有/无）			感染部位（肺/腹腔/皮肤及软组织/泌尿系统）
死亡组		69			67.96±2.17		42/27				31/38	29/40			23.01±2.71				30/39			27/42			21/48			28/16/9/16
存活组		47			64.07±2.64		25/22				24/23	18/29			23.52±2.47				24/23			22/25			18/29			15/13/6/13
t或χ²					8.252^＊		0.676				0.422	0.161			1.041				0.647			0.676			0.775			1.015
组别	肝损伤程度（轻度/中度/重度）					APACHEⅡ评分/分			SOFA 评分/分				D-二聚体/（mg/L）				凝血酶原时间/s			INR			WBC/ （×10⁹/L）			PLT/ （×10⁹/L）				LYM/ （×10⁹/L）
死亡组	28/21/20					18.32±2.32			10.10±2.05				0.53±0.11				15.31±1.95			1.58±0.33			9.87±3.01			444.06±97.64				1.88±0.44
存活组	11/26/10					16.01±1.92			6.37±1.39				0.51±0.09				14.48±1.78			1.57±0.28			8.91±2.82			435.94±85.49				1.94±0.38
t或χ²	7.368^＊					5.642^＊			10.886^＊				1.124				1.309			0.041			1.730			0.462				0.753
组别			PLR					尿酸/（μmol/L）						血肌酐/（μmol/L）				尿素氮/（mmol/L）						ALT/（U/L）					ALP/（U/L）
死亡组			232.67±8.01					353.38±62.46						96.00±20.76				6.74±2.22						73.71±20.92					144.06±11.05
存活组			210.70±10.34					352.49±46.73						93.51±20.16				6.31±2.16						71.87±19.60					142.49±10.66
t或χ²			12.882^＊					0.083						0.641				1.026						0.478					0.762
组别				ALT/ALP比值						TBIL/（μmol/L）						CRP/（mg/L）					PCT/（μg/L）						血乳酸/（mmol/L）
死亡组				0.53±0.05						45.93±11.80						20.11±4.39					0.94±0.20						1.95±0.21
存活组				0.51±0.02						41.95±12.50						19.80±4.46					0.96±0.19						1.72±0.18
t或χ²				2.711^＊						1.738						0.375					0.099						5.558^＊

组别		n			年龄/岁		性别（男/女）				吸烟史（有/无）	饮酒史（有/无）			体质量指数/ （kg/m²）				高血压（有/无）			高脂血症（有/无）			糖尿病（有/无）			感染部位（肺/腹腔/皮肤及软组织/泌尿系统）
死亡组		69			67.96±2.17		42/27				31/38	29/40			23.01±2.71				30/39			27/42			21/48			28/16/9/16
存活组		47			64.07±2.64		25/22				24/23	18/29			23.52±2.47				24/23			22/25			18/29			15/13/6/13
t或χ²					8.252^＊		0.676				0.422	0.161			1.041				0.647			0.676			0.775			1.015
组别	肝损伤程度（轻度/中度/重度）					APACHEⅡ评分/分			SOFA 评分/分				D-二聚体/（mg/L）				凝血酶原时间/s			INR			WBC/ （×10⁹/L）			PLT/ （×10⁹/L）				LYM/ （×10⁹/L）
死亡组	28/21/20					18.32±2.32			10.10±2.05				0.53±0.11				15.31±1.95			1.58±0.33			9.87±3.01			444.06±97.64				1.88±0.44
存活组	11/26/10					16.01±1.92			6.37±1.39				0.51±0.09				14.48±1.78			1.57±0.28			8.91±2.82			435.94±85.49				1.94±0.38
t或χ²	7.368^＊					5.642^＊			10.886^＊				1.124				1.309			0.041			1.730			0.462				0.753
组别			PLR					尿酸/（μmol/L）						血肌酐/（μmol/L）				尿素氮/（mmol/L）						ALT/（U/L）					ALP/（U/L）
死亡组			232.67±8.01					353.38±62.46						96.00±20.76				6.74±2.22						73.71±20.92					144.06±11.05
存活组			210.70±10.34					352.49±46.73						93.51±20.16				6.31±2.16						71.87±19.60					142.49±10.66
t或χ²			12.882^＊					0.083						0.641				1.026						0.478					0.762
组别				ALT/ALP比值						TBIL/（μmol/L）						CRP/（mg/L）					PCT/（μg/L）						血乳酸/（mmol/L）
死亡组				0.53±0.05						45.93±11.80						20.11±4.39					0.94±0.20						1.95±0.21
存活组				0.51±0.02						41.95±12.50						19.80±4.46					0.96±0.19						1.72±0.18
t或χ²				2.711^＊						1.738						0.375					0.099						5.558^＊

因素	β	SE	Wald χ²	P	OR（95%CI）
PLR	0.682	0.287	5.647	0.003	1.978（1.127~3.471）
ALT/ALP比值	0.715	0.301	5.643	0.004	2.044（1.133~3.688）
SOFA评分	0.815	0.325	6.289	0.002	2.259（1.195~4.272）
肝损伤程度	0.915	0.357	6.569	<0.001	2.497（1.240~5.026）
常数项	15.325	4.192	13.365	<0.001	4 524 420.23