Prognostic value of rise in neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) in predicting the mortality in paediatric intensive care

Siby Mathews, Aswathy Rajan, Santosh T. Soans


Background: When the body is stressed in diverse pathological conditions, it responds by mounting an inflammatory response. Predictive biomarkers reflecting the response may serve as guide to management. Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio has been frequently used in adult patients as an indicator for mortality. However, no study has looked into their use within pediatric population. The objective of the study is to assess the prognostic value of rise in NLR and PLR in pediatric intensive care as markers of mortality.

Methods: A retrospective study based on 3 year data from HIMS and G-HEALTH data systems of AJ Institute of Medical Science, of all patients admitted to PICU after excluding those in whom all the study parameters were not retrievable, were postoperative patients and/or stay was less than 5 days. NLR and PLR ratios were determined and compared to PELOD 2 using SPSS version 17.0.

Results: The demographic data was matched. PELOD 2 (>20) predicted mortality in 72.2% of the patients, while NLR increase predicted in 61.1% and PLR increase in 77.8%. A decreasing trend in NLR and PLR were both closely related to better survival. Among the 3, Rise in PLR had higher sensitivity, specificity, PPV, NPV, and overall accuracy of 72.73% (p <0.001) to predict mortality.

Conclusions: The study gives an insight into the fact that simple and inexpensive markers such as rise in NLR and PLR helps in predicting the mortality in the pediatric intensive care which is comparable to PELOD 2 score.


Mortality indicator, NLR, NLR rise, Pediatric intensive care, PLR, PLR rise, Prognostic indicator

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Leteurtre S, Duhamel A, Salleron J, Grandbastien B, Lacroix J, Leclerc F. PELOD-2. Critical Care Medicine. 2013;41(7):1761-73.

Proctor M, Morrison D, Talwar D, Balmer S, Fletcher C, O’Reilly, et al. A comparison of inflammation-based prognostic scores in patients with cancer. A Glasgow Inflammation Outcome Study. Europ J Cancer. 2011;47(17):2633-41.

Mantovani A, Pierotti MA. Cancer and inflammation: A complex relationship. Cancer Lett. 2008;267:180-1.

Yoldas H, Karagoz I, Ogun M, Velioglu Y, Yildiz I, Bilgi M, et al. Novel mortality markers for critically ill patients. J Intens Care Med. 2018;088506661775338.

Demirkol S, Balta S, Unlu M, Arslan Z, Cakar M, Kucuk U, et al. Neutrophils/lymphocytes ratio in patients with cardiac syndrome X and its association with carotid intima-media thickness. Clin Appl Thrombosis/Hemostasis. 2012;20(3):250-5.

Torun S, Tunca B, Suvaka B, Yildiz H, Tas A, Sayilir A, et al. Assessment of neutrophil-lymphocyte ratio in ulcerative colitis: A promising marker in predicting disease severity. Clin Res Hepatol Gastroenterol. 2012;36(5):491-7.

Walsh SR, Cook EJ, Goulder F, Justin TA, Keeling NJ. Neutrophil lymphocyte ratio as a prognostic factor in colorectal cancer. J Surg Oncol. 2005;91:181-4.

Keizman D, Ish-Shalom M, Huang P, Eisenberger M, Pili R, Hammers H, et al. The association of pre-treatment neutrophil to lymphocyte ratio with response rate, progression free survival and overall survival of patients treated with sunitinib for metastatic renal cell carcinoma. Europ J Cancer. 2012;48(2):202-8.

Buyukkaya E, Karakaş M, Karakaş E, Akçay A, Tanboga I, Kurt M, et al. Correlation of neutrophil to lymphocyte ratio with the presence and severity of metabolic syndrome. Clin Appl Thrombosis/Hemostasis. 2012;20(2):159-63.

Smith R, Bosonnet L, Raraty M, Sutton R, Neoptolemos J, Campbell F, et al. Preoperative platelet-lymphocyte ratio is an independent significant prognostic marker in resected pancreatic ductal adenocarcinoma. Am J Surg. 2009;197(4):466-72.

Kishi Y, Kopetz S, Chun Y, Palavecino M, Abdalla E, Vauthey J. Blood neutrophil-to-lymphocyte ratio predicts survival in patients with colorectal liver metastases treated with systemic chemotherapy. Ann Surg Oncol. 2009;16(3):614-22.

Iskandar H, Mulyo D, Agnes P, Suryatin Y. Comparioson of pediatric logistic organ dysfunction (PELOD) score and pediatric risk of mortality (PRISM) III as a mortality predictor in patients with dengue shock syndrome. Pediatr. 2008;121(Supplement 2):S129.1-S129.

El-Nawawy A, Mohsen A, Abdel-Malik M, Taman S. Performance of the pediatric logistic organ dysfunction (PELOD) and (PELOD-2) scores in a pediatric intensive care unit of a developing country. Europ J Pediatr. 2017;176(7):849-55.

Zhang L, Huang H, Cheng Y, Qin Z. Predictive value of four pediatric scores of critical illness and mortality on evaluating mortality risk in pediatric critical patients. China Crit Care Med. 2018;30(1):51-6.

Gonçalves J, Severo M, Rocha C, Jardim J, Mota T, Ribeiro A. Performance of PRISM III and PELOD-2 scores in a pediatric intensive care unit. Europ J Pediatr. 2015;174(10):1305-10.

George J, Namboodiripad A. Evaluation of modified paediatric logistic organ dysfunction scoring system in predicting the outcome in critically ill children. Int J Contemp Pediatr. 2018;5(3):879.

Schlapbach L, Straney L, Bellomo R, MacLaren G, Pilcher D. Prognostic accuracy of age-adapted SOFA, SIRS, PELOD-2, and qSOFA for in-hospital mortality among children with suspected infection admitted to the intensive care unit. Intensive Care Medicine. 2017;44(2):179-88.

Mısırlıoğlu M, Bekdaş M, Kabakuş N. Platelet-lymphocyte ratio in predicting mortality of patients in pediatric intensive care unit. J Clin Analytical Med. 2018;9(6):488-92.

Khilnani P, Sarma D, Singh R, Uttam R, Rajdev S, Makkar A, et al. Dermographic profile and outcome analysis of a tertiary level pediatric intensive care unit. Indian J Pediatr. 2004;71:587-91.

Nipshagen MD, Polderman KH, DeVictor D, Gemke RJ. Pediatric intensive care: result of a European survey. Intensive Care Medicine. 2002;28(12):1797-803.

Randolph AG, Gonzales CA, Cortellini L, Yeh TS. Growth of pediatric intensive care units in the United States from 1995 to 2001. J Pediatr. 2004;144(6):792-8.

Earle M, Martinez Natera O, Zaslavsky A, Quinones E, Carrillo H, Gonzalez EG, et al. Outcome of pediatric intensive care at six centers in Mexico and Ecuador. Critical Care Med. 1997;25(9):1462-7.

Dursun A, Özsoylu S, Akyıldız B. Neutrophil-to-lymphocyte ratio and mean platelet volume can be useful markers to predict sepsis in children. Pak J Med Sci. 2018;34(4).

Dahn M, Whitcomb M, Lange M, Jacobs L. Altered T-lymphocyte subsets in severe sepsis. Am Surg. 1988;54(7):450-5.

Le Tulzo Y, Pangault C, Gacouin A, Guilloux V, Tribut O, Amiot L, et al. Early circulating lymphocyte apoptosis in human septic shock is associated with poor outcome. Shock. 2002;18(6):487-94.

Zahorec R. Ratio of neutrophil to lymphocyte counts-rapid and simple parameter of systemic inflammation and stress in critically ill. Bratisl Lek Listy. 2001;102(1):5-14.

Imtiaz F, Shafique K, Mirza S, Ayoob Z, Vart P, Rao S. Neutrophil lymphocyte ratio as a measure of systemic inflammation in prevalent chronic diseases in Asian population. Int Arch Med. 2012;5(1):2.

Jilma B, Blann A, Pernerstorfer T, Stohlawetz P, Eichler H, Vondrovec B, et al. Regulation of adhesion molecules during human endotoxemia. Am J Resp Crit Care Med. 1999;159(3):857-63.

Duffy B, Gurm H, Rajagopal V, Gupta R, Ellis S, Bhatt D. Usefulness of an elevated neutrophil to lymphocyte ratio in predicting long-term mortality after percutaneous coronary intervention. Am J Cardiol. 2006;97(7):993-6.

Gauchan E, Adhikari S. C-reactive protein versus neutrophil/lymphocyte ratio in differentiating bacterial and non-bacterial pneumonia in children. J Nepal Health Res Council. 2016;14(34):154-8.

Yigit Y, Yilmaz S, Akdogan A, Halhalli H, Ozbek AE, Gencer EG. The role of neutrophil–lymphocyte ratio and red blood cell distribution width in the classification of febrile seizures. Eur Rev Med Pharmacol Sci. 2017;21(3):554-9.

Yilmaz B, Ayhan ACAR Y. Investigation of the diagnostic value of neutrophil to lymphocyte ratio in pediatric appendicitis cases. Iranian J Pediatr. 2017;27(3):e9593.

NI A. Reference values of neutrophil-lymphocyte ratio, platelet-lymphocyte ratio and mean platelet volume in healthy adults in north central Nigeria. J Blood Lymph. 2016;6(1).

Forget P, Khalifa C, Defour J, Latinne D, Van Pel M, De Kock M. What is the normal value of the neutrophil-to-lymphocyte ratio? BMC Research Notes. 2017;10(1).

Lee J, Kim N, Na S, Youn Y, Shin C. Reference values of neutrophil-lymphocyte ratio, lymphocyte-monocyte ratio, platelet-lymphocyte ratio, and mean platelet volume in healthy adults in South Korea. Medicine. 2018;97(26):e11138.

Yao C, Liu X, Tang Z. Prognostic role of neutrophil-lymphocyte ratio and platelet-lymphocyte ratio for hospital mortality in patients with AECOPD. Int J Chronic Obstructive Pulmonary Dis. 2017;12:2285-90.

Durmus E, Kivrak T, Gerin F, Sunbul M, Sari I, Erdogan O. Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio are predictors of heart failure. Arquivos Brasileiros de Cardiologia. 2015;105(6):606-13.

Shimoyama Y, Umegaki O, Agui T, Kadono N, Minami T. Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio are superior to other inflammation-based prognostic scores in predicting the mortality of patients with gastrointestinal perforation. JA Clinical Reports. 2017;3(1).

Azab B, Shah N, Akerman M, McGinn J. Value of platelet/lymphocyte ratio as a predictor of all-cause mortality after non-ST-elevation myocardial infarction. J Thrombosis Thrombolysis. 2012;34(3):326-34.

Nishimori M, Tsunemine H, Maruoka H, Itoh K, Kodaka T, Matsuoka H, et al. Marked thrombocytosis in chronic eosinophilic pneumonia and analysis of cytokine mechanism. J Clin Exp Hematopathol. 2015;55(2):97-102.

Yohannan M, Higgy K, Al-Mashhadani S, Santhosh-Kumar C. Thrombocytosis. Clin Pediatr. 1994;33(6):340-3.

Feng JF, Huang Y, Chen QX. Preoperative platelet lymphocyte ratio (PLR) is superior to neutrophil lymphocyte ratio (NLR) as a predictive factor in patients with esophageal squamous cell carcinoma. World J Surg Oncol. 2014;12:58.

Furuncuoglu Y, Tulgar S, Dogan AN, Cakar S, Tulgar YK, Cakiroglu B. How obesity affects the neutrophil/lymphocyte and platelet/lymphocyte ratio, systemic immune-inflammatory index and platelet indices: a retrospective study. Europ Rev Med Pharmacol Sci. 2016;20(7):1300-6.

Pedrazzani C, Mantovani G, Fernandes E, Bagante F, Luca Salvagno G, Surci N, et al. Assessment of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and platelet count as predictors of long-term outcome after R0 resection for colorectal cancer. Sci Reports. 2017;7(1).

Seo Y, Jeong J, Choi J, Moon I. Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio: novel markers for diagnosis and prognosis in patients with idiopathic sudden sensorineural hearing loss. Dis Markers. 2014;2014:1-6.