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Comparison of APACHE II scores and mortality with CRP/albumin, neutrophil/lymphocyte and thrombocyte/lymphocyte ratios in patients admitted to internal medicine and anesthesia reanimation intensive care unit

  • Ahmet Usta ORCID logo , Emin Gemcioglu ORCID logo EMAIL logo , Salih Baser ORCID logo , Osman Ersoy ORCID logo , Yunus Halil Polat ORCID logo , Abdülsamet Erden ORCID logo and Seval Izdes ORCID logo
Published/Copyright: November 9, 2021
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Journal of Laboratory Medicine
From the journal Journal of Laboratory Medicine Volume 46 Issue 1

Abstract

Objectives

This study aimed to evaluate the relationship between C-reactive protein/albumin (CRP/Alb), neutrophil/lymphocyte (NLR), platelet/lymphocyte (PLR) ratios and the Acute Physiology And Chronic Health Evaluation II (APACHE II) score and 28-day mortality among 400 patients admitted to internal medicine and anesthesia reanimation intensive care unit (ICU).

Methods

This prospective study included a total of 400 patients who were admitted to hospital internal medicine and anesthesia reanimation ICUs.

Results

The most common reasons for ICU admission were pneumonia (29.3%), gastrointestinal bleeding (10.3%), acute exacerbation of chronic kidney disease (CKD) (10.3%), and acute kidney injury (7.5%). The comparison of the laboratory findings with survival outcomes revealed that among the patients with acute exacerbation of CKD, the median NLR (p=0.043) and median CRP/Alb (p=0.021) were significantly higher in patients who died. For all of the patients, the APACHE II score was positively correlated with CRP (p<0.001) and CRP/Alb (p<0.001), negatively correlated with Alb (p<0.001), positively correlated with the NLR (p<0.001), and positively correlated with the PLR.

Conclusions

The APACHE II score was significantly correlated with the CRP/Alb ratio, NLR, and PLR. The NLR and CRP/Alb ratio were statistically associated with mortality in patients hospitalized for acute exacerbation of CKD.

Keywords: APACHE II; CRP/albumin ratio; intensive care; mortality; neutrophil/lymphocyte ratio; thrombocyte/lymphocyte ratio

Introduction

Intensive care scoring systems are widely used to predict recovery, determine the severity of the disease and the degree of organ dysfunction, evaluate treatment effectiveness, standardize patients in clinical trials, and compare the performances of intensive care units (ICUs). The Acute Physiology and Chronic Health Examination (APACHE) II score was originally developed for critically ill patients in intensive care units (ICUs). Patient data obtained from daily measurements are used in scoring, and many clinical scoring systems have been defined as follows: It consists of two main parts: “prognostic” scoring systems that predict mortality and “organ failure” scoring systems that evaluate morbidity. APACHE II. It consists of three parts: acute physiology score, age and chronic health assessment (Table 1). The results from these three sections are summed and patient mortality is determined. The values recorded in APACHE II are the values that deviate the most from normal in the first 24 h of the patient’s intensive care unit. Chronological age was added as a weighted score, since it reflects the decrease in physiological reserve and is an important factor that determines the risk of mortality regardless of disease severity in case of acute illness. The APACHE II scoring system also has its inadequacies: Elderly patients can score higher than necessary, and acute physiology score does not have regulated measures for use of drugs for hemodynamic support therapy, mechanical ventilation [1, 2]. Accordingly, alternative scoring systems are needed for patient assessment in the ICU.

Table 1:

Acute physiology and chronic health evaluation II (APACHE II) score.

Physiologic variable Points
+4 +3 +2 +1 0 +1 +2 +3 +4
1. Temperature, °C ≥41 39–40.9 38.5–38.9 36–38.4 34–35.9 32–33.9 30–31.9 ≤29.9
2. Mean arterial pressure, mmHg ≥160 130–159 110–129 70–109 50–69 ≤49
3. Heart rate,/min ≥180 140–179 110–139 70–109 55–69 40–54 ≤39
4. Respiratory rate,/min ≥50 35–49 25–34 12–24 10–11 6–9 ≤5
5. Oxygenation, mmHg 500 350–499 200–349 <200

>70		 61–70 55–60 <55
6. Acid-base balance a. Arterial, pH

b. Serum HCO3, mEq/L if no arterial blood gas		 ≥7.7≥52 7.6–7.69

41–51.9		 7.5–7.59

32–40.9		 7.33–7.49

22–31.9		 7.25–7.32

18–21.9		 7.15–7.24

15–17.9		 <7.15<15
7. Sodium, mEq/L ≥180 160–179 155–159 150–154 130–149 120–129 111–119 ≤110
8. Potassium, mEq/L ≥7 6–6.9 5.5–5.9 3.5–5.4 3–3.4 2.5–2.9 <2.5
9. Creatinine, mg/dL ≥3.5 2–3.4 1.5–1.9 0.6–1.4 <0.6
10. Hematocrit, % ≥60 50–59.9 46–49.9 30–45.9 20–29.9 <2.5
11. White blood count, ×1,000/mm3 ≥40 20–39.9 15–19.9 3–14.9 1–2.9 <1
12. Glasgow coma score, GCS Score=15 minus actual GCS
A. Total acute physiology score (sum of 12 above points)
B. Age points (years)≤44=0; 45 to 54=2; 55–64=3; 65–74=5; ≥75=6
C. Chronic health pointsa
Total Apache II score (add together the points from A + B + C)

C-reactive protein (CRP) is a positive acute-phase reactant that is synthesized by the liver, and its serum levels increase within hours in response to inflammation and infection [3]. CRP exerts both pro and anti-inflammatory properties. In addition to being an indicator of infection and inflammation, it has a wide range of biological properties and functions [4]. Albumin (Alb) is a negative acute-phase reactant that is synthesized by the liver, and its serum levels decrease during inflammation. Serum Alb acts as an important modulator of plasma oncotic pressure and a carrier of endogenous and exogenous (i.e., drugs) compounds [5]. The CRP/Alb ratio is a novel inflammatory prognostic parameter that is associated with inflammation severity and mortality. It is a more accurate indicator of inflammatory status when compared to CRP or Alb alone. Recent studies have investigated the parameters derived from complete blood count (CBC) results, such as the neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR), as novel indicators of inflammation in the context of many diseases [6]. The physiologic response of leukocytes to stress can result in an increase in neutrophil counts and decline in lymphocyte counts, and the ratio of these neutrophil and lymphocyte counts is used as an indicator of inflammation. Neutrophil activation releases reactive oxygen species, cytokines, proteases, and cationic proteins (such as elastase and lactoferrin), and these neutrophil activation products have been associated with the severity of numerous inflammatory diseases [7]. Platelets also interact with endothelial cells, leukocytes (monocytes, neutrophils, dendritic cells, T-cells) and progenitor cells, and cause the migration of inflammatory cells to lesions, the release of large amounts of inflammatory cytokines, and ultimately, the formation of an inflammatory zone [8].

This study aimed to evaluate the relationship between the CRP/Alb ratio, NLR, and PLR, and the APACHE II score and 28-day mortality among 400 patients admitted to the ICU for various reasons.

Materials and methods

This prospective study included a total of 400 patients admitted to the hospital internal medicine and anesthesia reanimation ICUs between September 2019 and March 2020. The age, gender, reason for ICU admission, comorbidities, sepsis, white blood cell (WBC) count, hemoglobin, thrombocyte, neutrophil, and lymphocyte counts, red cell distribution width (RDW), CRP, Alb, procalcitonin, antibiotic use, 28-day mortality, and APACHE II scores of the patients during hospitalization were recorded. The association between the admission APACHE II scores and 28-day mortality, and biochemistry (CRP and Alb) and CBC parameters (thrombocyte, neutrophil, lymphocyte counts) measured within 24 h after ICU admission were analyzed. Demographic characteristics, clinical and laboratory results, treatment, and outcome were recorded using a standard case report form.

The inclusion criteria were being ≥18 years of age and being admitted to the internal medicine and anesthesia reanimation ICUs, while the exclusion criteria were trauma, malignancies, chronic hepatitis and cirrhosis of the liver, and malnutrition due to potentially altering CRP and Alb levels. Also excluded were patients receiving exogenous Alb therapy.

For this study, the CRP was measured using a commercial kit in a Siemens BN II System autoanalyzer (Munich, Germany) based on nephelometry. Alb was measured with the bromocresol green colorimetric method using a commercial kit on a Roche Cobas 8000 automated platform (Mannheim, Germany).

Three inflammatory markers were used to determine the association between APACHE II and mortality among ICU patients, comprising the CRP/Alb ratio, neutrophil to lymphocyte ratio (NLR), and platelet to lymphocyte ratio (PLR).

CBC was performed using blood samples collected into K2EDTA tubes in an Sysmex XE-2100 automated CBC device (Mundelein, IL, USA). This study was approved by the local Ethics Committee (approval number 26379996/106, date 18/09/2019).

Statistical analysis

Data were analyzed using IBM SPSS Statistics for Windows 20.0 (IBM Corp., Armonk, NY, USA). Normality of data distribution was evaluated using the Kolmogorov-Smirnov test. Normally distributed data were expressed as the mean ± standard deviation, and non-normally distributed data were expressed as the median (minimum-maximum). Categorical variables were expressed as numbers and percentages. Pairwise comparison was performed using the student t-test and Mann–Whitney U test for normally and non-normally distributed numerical variables, respectively. The chi-square and Fisher exact tests were used for the comparison of categorical variables. Correlations between numerical variables were evaluated using the Spearman correlation analysis. A p-value<0.05 was accepted as statistically significant.

Results

The study included a total of 400 patients, comprising 203 females (50.8%) and 197 males (49.2%). The mean age of the patients was 73.2 ± 16.1 years (range 18–103).

Of the patients, 95.5% (n=382) had at least one comorbidity, the most common being hypertension (50.5%, n=202), diabetes mellitus (34.8%, n=139), chronic kidney disease (CKD) (283%, n=139), coronary artery disease (24.5%, n=98), and chronic heart failure (24%, n=96) (Figure 1). The most common reasons for ICU admission were pneumonia (29.3%), gastrointestinal (GI) bleeding (10.3%), acute exacerbation of CKD (10.3%), acute kidney injury (7.5%), urosepsis (5.5%), decompensated heart failure (4.3%), hypernatremia (4.3%), and diabetic ketoacidosis (3.3%). Of the patients admitted to the ICU, 37.3% (n=149) had sepsis. The 28-day mortality rate was 35.5% (n=142) (Table 2). The distribution of laboratory results according to survival among these patients is presented in Table 3.

Figure 1: Most common comorbidities. HT, hypertension; DM, diabetes mellitus; CKD, chronic kidney disease; CAD, coronary artery disease; CHF, chronic heart failure; COPD, chronic obstructive pulmoner disease; AF, atrial fibrillation.
Figure 1:

Most common comorbidities. HT, hypertension; DM, diabetes mellitus; CKD, chronic kidney disease; CAD, coronary artery disease; CHF, chronic heart failure; COPD, chronic obstructive pulmoner disease; AF, atrial fibrillation.

Table 2:

Reasons for ICU admission and ICU sepsis incidence and survival outcomes.

Reason for ICU admission Total n=400 n (%)
Pneumonia 117 (29.3)
Gastrointestinal bleeding 41 (10.3)
Acute exacerbation of CKD 41 (10.3)
Acute kidney disease 30 (7.5)
Urosepsis 22 (5.5)
Decompensated heart failure 17 (4.3)
Hypernatremia 17 (4.3)
Diabetic ketoacidosis 13 (3.3)
Events and survival Total n=400 n (%)
Sepsis 149 (37.3)
28-day survival
Survived 258 (64.5)
Died 142 (35.5)
Table 3:

Distribution of the clinical and laboratory findings according to survival outcome and the four most common reasons for ICU admission.

Variables Pneumonia p-Value GI bleeding p-Value AKI p-Value Acute exacerbation of CKD p-Value
Survived n=66 Died n=51 Survived n=30 Died n=11 Survived n=16 Died n=14 Survived n=24 Died n=17
APACHE II 21.5 (5–41) 19 (1–43) 0.207 25.5 (5–46) 24 (6–36) 0.942 20.5 (5–41) 13.5 (3–34) 0.085 17.5 (7–35) 16 (8–35) 0.0895
WBC 11,255 9,640 0.43 10,085 9,060 0.851 11,075 14,080 0.355 10,940 11,460 0.412
(3,300–35,640) (3,450–32,740) (4,500–26,760) (3,080–49,520) (5,010–34,220) (6,240–18,530) (1,670–23,530) (2,100–48,950)
Hemoglobin 10.6 ± 2.4 11.2 ± 2.2 0.152 10.6 ± 2.1 10 ± 1.5 0.365 11.4 ± 2.4 11.5 ± 1.9 0.934 10.6 ± 2.3 10.7 ± 2.2 0.853
Platelet 232,500 249,000 0.562 171,000 275,000 0.174 263,500 206,000 0.110 239,500 188,000 0.302
(12,000–670,000) (17,000–468,000) (46,000–480,000) (83,000–867,000) (60,000–723,000) (94,000–705,000) (36,000–483,000) (19,000–730,000)
Neutrophil 9,625 8,300 0.335 7,965 6,460 0.851 8,870 11,495 0.448 8,695 10,050 0.354
(1710–33,720) (1710–27,600) (1900–20,770) (2,800–46,140) (3,790–30,630) (5,180–16,360) (1,180–19,150) (1980–47,100)
Lymphocyte 1,015 (240–13,020) 1,140 (140–3,740) 0.771 820 (260–3,830) 1,340 (200–3,550) 0.942 875 (250–5,740) 1,560 (330–3,710) 0.179 1,335 (350–3,720) 1,080 (250–4,440) 0.315
RDW 17.2 ± 3.4 16.6 ± 3.1 0.364 18 ± 3.4 18.2 ± 3.5 0.844 16.6 ± 2.7 15.3 ± 2.6 0.166 16.6 ± 3.1 16.9 ± 2.4 0.803
CRP 97 (9–312) 68 (4–417) 0.238 84.5 (13–270) 148 (3–185) 0.653 96.5 (8–303) 65 (3–195) 0.193 75 (4–228) 82 (7–258) 0.905
Alb 3.2 ± 0.8 3.3 ± 0.9 0.459 2.9 ± 0.8 3.1 ± 0.9 0.583 3.2 ± 0.7 3.4 ± 0.8 0.447 3.4 ± 0.8 3 ± 0.6 0.089
Procalcitonin 0.7 (0–75) 0.5 (0–75) 0.217 1.1 (0.1–19.8) 1.7 (0.2–55) 0.329 0.5 (0.1–50) 0.2 (0–5.1) 0.294 0.6 (0–26) 0.9 (0.1–75) 0.843
Creatinine 1.7 (0.4–12) 1.7 (0.4–14.1) 0.405 1.5 (0.3–5.3) 1.8 (0.6–6.5) 0.851 1.5 (0.6–3.3) 1 (0.3–3.2) 0.294 1.3 (0.5–10) 2 (0.8–5.3) 0.153
NLR 7.8 (0.9–63.7) 8.7 (0.8–60.6) 0.800 8.8 (1.2–54.3) 10 (3–50.2) 0.896 10.3 (0.8–36.2) 6.5 (3.3–43.3) 0.154 5.9 (1.7–19) 8.4 (3–66.3) 0.050a
PLR 190.6 (20.2–1,466.7) 203.8 (35.8–1964.3) 0.413 196.9 (58.2–634.6) 298.9 (51.9–1,360) 0.287 292.9 (43.2–924) 158.1 (25.3–687.9) 0.064 162.3 (52–826.8) 171.8 (63.3–632) 0.711
CRP/Alb 26.3 (2.4–141.1) 16.4 (1.1–131.9) 0.327 27.8 (3.6–122.7) 50.3 (0.8–87.5) 0.965 21.1 (1.9–137.7) 16.5 (0.7–72.2) 0.400 15.6 (1–83.3) 23 (2.2–143.3) 0.032a

  1. Normally distributed data are expressed as the mean ± standard deviation. Non-normally distributed data are expressed as the median (minimum-maximum). aStatistically significant.

Accordingly, among the patients with acute exacerbation of CKD, the neutrophil count (median 16,630 vs. 10,780, p=0.030), WBC (median 14,000 vs. 8,820, p=0.025), NLR (median 11.8 vs. 5.7, p=0.043), and CRP/Alb (median 38 vs. 11.1, p=0.021) were significantly higher in patients who died when compared to those who survived (Figure 2).

Figure 2: CRP/Alb distribution according to survival among patients admitted to the ICU for the four most common reasons.
Figure 2:

CRP/Alb distribution according to survival among patients admitted to the ICU for the four most common reasons.

For all of the patients, the APACHE II scores were strongly positively correlated with the RDW (r=0.712, p<0.001), CRP (r=0.840, p<0.001), and CRP/Alb (r=0.852, p<0.001), strongly negatively correlated with Alb (r=−0.756, p<0.001) and moderately positively correlated with procalcitonin (r=0.541, p<0.001) and the NLR (r=0.559, p<0.001) (Table 4) (Figure 3). Moreover, the APACHE II scores were significantly weakly positively correlated with the WBC, neutrophil, AST, creatinine, urea, potassium, and PLR, and significantly weakly negatively correlated with hemoglobin, lymphocyte count, and calcium. Similar correlations were observed when the variables were analyzed in terms of 28-day survival (Table 4).

Table 4:

Laboratory findings according to the APACHE II score.

Laboratory results APACHE II score
Overall Survived Died
r p-Value r p-Value r p-Value
WBC 0.242 <0.001a 0.216 <0.001a 0.299 <0.001a
Hemoglobin −0.207 <0.001a −0.177 0.004a −0.243 0.004a
Platelet −0.039 0.437 −0.065 0.297 0.009 0.917
Neutrophil 0.308 <0.001a 0.280 <0.001a 0.367 <0.001a
Lymphocyte −0.447 <0.001a −0.396 <0.001a −0.532 <0.001a
RDW 0.712 <0.001a 0.724 <0.001a 0.685 <0.001a
CRP 0.840 <0.001a 0.835 <0.001a 0.850 <0.001a
Alb −0.756 <0.001a −0.790 <0.001a −0.701 <0.001a
Procalcitonin 0.541 <0.001a 0.528 <0.001a 0.571 <0.001a
ALT 0.065 0.192 0.104 0.096 −0.002 0.978
AST 0.171 0.001a 0.185 0.003a 0.126 0.134
Creatinine 0.333 <0.001a 0.332 <0.001a 0.347 <0.001a
Urea 0.402 <0.001a 0.374 <0.001a 0.453 <0.001a
Sodium 0.074 0.141 0.035 0.576 0.144 0.087
Potassium 0.117 0.019a 0.142 0.022a 0.090 0.285
Calcium −0.152 0.002a −0.148 0.018a −0.163 0.050a
NLR 0.559 <0.001a 0.498 <0.001a 0.652 <0.001a
PLR 0.333 <0.001a 0.269 <0.001a 0.438 <0.001a
CRP/Alb 0.852 <0.001a 0.842 <0.001a 0.867 <0.001a

  1. aStatistically significant.

Figure 3: Indices associated with APACHE II.
Figure 3:

Indices associated with APACHE II.

Discussion

Here in, the most common reasons for ICU admission were pneumonia, GI bleeding, acute exacerbation of CKD, and AKI. Survival was not found to be significantly correlated with the CRP/Alb ratio, median NLR, or PLR among the patients with pneumonia, GI bleeding, or AKI; however, survival was significantly associated with the median neutrophil count, median WBC, median NLR, and median CRP/Alb among the patients with an acute exacerbation of CKD. When selecting a predictive scoring system, one must consider the feasibility, ease of use, applicability, and performance of the system in the relevant population. The ratios that were included in the current study were easy to use. Therefore, these ratios were compared with mortality and the APACHE II score, the reliability of which has been confirmed by previous studies [9]. The prospective nature of this study allowed for the use the APACHE II scores obtained at the time of ICU admission.

The prospective nature and large sample size also made it possible to perform subgroup analyses. Although there are studies that have investigated CRP/Alb ratio, NLR, and PLR, some of which were among ICU patients, to the best of our knowledge, no studies to date have performed detailed subgroup analyses. In the current study, CKD was more prevalent among patients who died when compared to those who survived (38% vs. 22.9%, p=0.001). Renal insufficiency is prominent in ICU patients and usually results in poor outcomes, is commonly diagnosed late despite advances in diagnostics, and is still not adequately managed. Advances in novel diagnostic methods may improve treatment outcomes. Therefore, further studies are needed to determine the reasons behind poor prognosis and determine how to reduce acute and long-term risk among high-risk patients.

A growing number of recent studies have focused on the relationship between the NLR and PLR, and tumor characteristics. High PLR was associated with increased lymph node metastasis in colorectal and cervical cancer [10]. Xue et al. reported that increased PLR predicted a poor survival outcome among hepatocellular carcinoma patients receiving transarterial chemoembolization [11]. In their study on hepatocellular carcinoma (HCC), Zheng et al. demonstrated that the NLR and PLR were independent predictors of HCC recurrence and survival, and proposed that routine NLR and PLR measurements were easy-to-use and accessible parameters that should be considered as biomarkers in the clinical management of HCC [12]. In their studies on acute pulmonary embolism mortality, Soylu et al. found that an increased NLR was associated with mortality in patients with acute pulmonary embolism [13]. The reason for the superiority of NLR and PLR can be explained as follows: from an inverse perspective, the elevated ratios in the present patient group were primarily ascribed to lymphopenia. Currently, the NLR is accepted as a parameter that reflects the negative effects of high neutrophil (indicating acute inflammation) and low lymphocyte numbers (indicating physiological stress) together [14, 15].

The current study diverged from the literature in that survival was not found to be significantly correlated with the NLR or PLR among the patients with pneumonia, GI bleeding, or AKI; however, survival was significantly associated with the median NLR (11.8 vs. 5.7, p=0.043) among the patients with an acute exacerbation of CKD. This study also included a subgroup analysis. For all of the patients, the APACHE II scores were moderately positively correlated with the NLR (r=0.559, p<0.001). Velissaris et al. similarly found that the APACHE II scores were positively correlated with the NLR among 50 patients hospitalized for sepsis (r=0.384, p=0.006) [16]. There are no other studies in the literature examining the relationship between the APACHE II scores and the NLR in this large a sample.

Recently, it has been demonstrated that the CRP/Alb ratio can be used as a biomarker for monitoring disease activity in patients with rheumatoid arthritis [17] and inflammation severity in Crohn’s disease [18]. A study by Kinoshita et al. demonstrated that the CRP/Alb ratio is a more useful prognostic factor in patients with hepatocellular carcinoma when compared to the modified Glasgow Prognostic Score [19]. The findings of the current study were different from the literature in that survival was not found to be significantly correlated with the CRP/Alb ratio among the patients with pneumonia, GI bleeding, or AKI; however, survival was significantly associated with the CRP/Alb ratio (38 vs. 11.1, p=0.021) among the patients with an acute exacerbation of CKD. For all of the patients, the APACHE II scores were strongly positively correlated with CRP (r=0.840, p<0.001) and CRP/Alb (r=0.852, p<0.001). The main purpose of the current study was to investigate the relationship between the APACHE II scores and CRP/Alb ratio, NLR, and PLR parameters. Accordingly, the APACHE II scores were found to be strongly positively correlated with the CRP/Alb ratio, moderately positively correlated with the NLR, and weakly positively correlated with the PLR.

A retrospective study of 117 emergency ICU patients by Wang et al. reported that the RDW was an independent predictor of in-hospital mortality among elderly sepsis patients, and a high RDW was associated with poor prognosis [20]. This finding suggested that the RDW may serve as a prognostic biomarker. Sunil et al. analyzed the correlation between the RDW and other prognostic models, and 30-day mortality among adult ICU patients with AKI requiring dialysis. They found the RDW to be strongly and significantly correlated with the APACHE II scores and concluded that the RDW was a better predictor of mortality among ICU patients with AKI requiring dialysis when compared to the other disease severity scoring systems [21]. In contrast, RDW was not found to be significantly associated with survival herein, but a strong positive correlation between the RDW and the APACHE II scores was found (r=0.712, p<0.001). Similarly, Zhang et al. reported a significant positive correlation between the APACHE II scores and RDW among 42 severely acute pancreatitis patients in the ICU [22]. However, there are no other studies investigating the relationship between the RDW and APACHE II scores among this many subjects.

Önal et al. investigated Alb levels and prognosis in 113 patients aged over 65 years who were admitted to the anesthesia ICU and found that Alb was significantly lower in patients who died than in those who survived (p<0.001), and Alb was associated with the APACHE II scores and mortality [23]. A strong negative correlation was found in the current study between the APACHE II scores and Alb (r=−0.756, p<0.001), but not between Alb and mortality (p=0.843). This discrepancy can be ascribed to the differences in the populations of the study, where all patients ≥18 years of age we included in the current study, while Önal et al. included only patients >65 years of age. Moreover, patients receiving exogenous Alb therapy were also excluded in the current study. Mei Yin et al. evaluated serum Alb levels and sepsis prognosis among 116 ICU patients and reported the overall 28-day mortality to be 26.7%, and the most common infection source to be the lower respiratory tract. Patients who died had lower serum Alb levels and higher APACHE II scores when compared to the patients who survived. Multivariate Cox regression analysis revealed the serum Alb level (<29.2 g/L) and APACHE II score to be independent risk factors for mortality [24].

The limitations of the current study included its single-center design and only having evaluated the APACHE II for ICU scoring. The strengths of the study were its prospective design, large sample size, and having compared the APACHE II scores and mortality with both the biochemical and hematological parameters.

Conclusions

The APACHE II score was significantly correlated with the CRP/Alb ratio, NLR, and PLR. The NLR and CRP/Alb were statistically associated with mortality in patients hospitalized for an acute exacerbation of CKD.

Corresponding author: Emin Gemcioglu, MD, Department of Internal Medicine, Ankara City Hospital, Ankara 06100, Turkey, Phone: +90 505 9369141, Fax: +90 312 3100194, E-mail:

  1. Research funding: None declared.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Informed consent was obtained from all individuals included in this study.

  5. Ethical approval: Research involving human subjects complied with all relevant national regulations, institutional policies and is in accordance with the tenets of the Helsinki Declaration (as revised in 2013), and has been approved by the authors’ institutional review board (Yildirim Beyazit University, Faculty of Medicine, Ethics Committee) or equivalent committee (Approval Number 26379996/106, Date 18/09/2019).

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Supplementary Material

The online version of this article offers supplementary material (https://doi.org/10.1515/labmed-2021-0061).

Received: 2021-05-22
Accepted: 2021-09-24
Published Online: 2021-11-09
Published in Print: 2022-02-23

© 2021 Ahmet Usta et al., published by De Gruyter, Berlin/Boston

This work is licensed under the Creative Commons Attribution 4.0 International License.

Articles in the same Issue

  1. Frontmatter
  2. Obituary
  3. In Memoriam of Beniam Ghebremedhin
  4. Review
  5. New and emerging technologies for the diagnosis of urinary tract infections
  6. Original Articles
  7. Blood indices and circulating tumor cells for predicting metastasis of hepatocellular carcinoma after liver transplantation
  8. Comparison of APACHE II scores and mortality with CRP/albumin, neutrophil/lymphocyte and thrombocyte/lymphocyte ratios in patients admitted to internal medicine and anesthesia reanimation intensive care unit
  9. The correlation between the prevalence of gestational diabetes mellitus and maternal age in Southern China
  10. The investigation of serum protein profiles in anal fistula for potential biomarkers
  11. Evaluation of antioxidant and antiinflammatory activity of ethanolic extracts of Polygonum senticosum in lipopolysaccharide-induced RAW 264.7 macrophages
  12. Prevalence of SARS-CoV-2 antibodies in hospital employees, Central Germany
  13. Fast forward evolution in real time: the rapid spread of SARS-CoV-2 variant of concern lineage B.1.1.7 in Saxony-Anhalt over a period of 5 months
  14. Letters to the Editor
  15. It did not stop there: rapid substitution of circulating SARS-CoV-2 variant of concern B.1.1.7 (Alpha) by variant of concern B.1.617.2 (Delta) and further evolution of different Delta sublineages in Southern Saxony-Anhalt in late summer 2021
  16. In reply to a review article “Review of potentials and limitations of indirect approaches for estimating reference limits/intervals of quantitative procedures in laboratory medicine”
  17. Reply to the letter of Katayev and Fleming
https://doi.org/10.1515/labmed-2021-0061
Keywords for this article
APACHE II; CRP/albumin ratio; intensive care; mortality; neutrophil/lymphocyte ratio; thrombocyte/lymphocyte ratio
Creative Commons
BY 4.0

Articles in the same Issue

  1. Frontmatter
  2. Obituary
  3. In Memoriam of Beniam Ghebremedhin
  4. Review
  5. New and emerging technologies for the diagnosis of urinary tract infections
  6. Original Articles
  7. Blood indices and circulating tumor cells for predicting metastasis of hepatocellular carcinoma after liver transplantation
  8. Comparison of APACHE II scores and mortality with CRP/albumin, neutrophil/lymphocyte and thrombocyte/lymphocyte ratios in patients admitted to internal medicine and anesthesia reanimation intensive care unit
  9. The correlation between the prevalence of gestational diabetes mellitus and maternal age in Southern China
  10. The investigation of serum protein profiles in anal fistula for potential biomarkers
  11. Evaluation of antioxidant and antiinflammatory activity of ethanolic extracts of Polygonum senticosum in lipopolysaccharide-induced RAW 264.7 macrophages
  12. Prevalence of SARS-CoV-2 antibodies in hospital employees, Central Germany
  13. Fast forward evolution in real time: the rapid spread of SARS-CoV-2 variant of concern lineage B.1.1.7 in Saxony-Anhalt over a period of 5 months
  14. Letters to the Editor
  15. It did not stop there: rapid substitution of circulating SARS-CoV-2 variant of concern B.1.1.7 (Alpha) by variant of concern B.1.617.2 (Delta) and further evolution of different Delta sublineages in Southern Saxony-Anhalt in late summer 2021
  16. In reply to a review article “Review of potentials and limitations of indirect approaches for estimating reference limits/intervals of quantitative procedures in laboratory medicine”
  17. Reply to the letter of Katayev and Fleming
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