Neutrophil to Lymphocyte Ratio and Mean Platelet Volume as a Prognostic Predictor Among Patients With Acute on Top of Chronic Liver Cell Failure (ACLF)

Haematological Indices as a Prognostic Predictor Among Patients With Acute on Top of Chronic Liver Cell Failure

Acute on chronic liver failure (ACLF) is a clinical syndrome of sudden hepatic decompensation observed in patients with pre-existing chronic liver disease and associated with one or more extrahepatic organ failures and increased mortality.[1][2][3][4] Regardless of the etiology of chronic liver injury, when a clinician follows the natural history of liver injury, the initial uncomplicated chronic liver disease leads to cirrhosis and, later, the decompensation of liver function with ascites, jaundice, portal hypertension with variceal bleeding, and hepatic encephalopathy. Type-A ACLF is an acute worsening of liver function in a patient with chronic liver disease. Type-B ACLF is when this acute decompensation occurs in patients with cirrhosis, while type-C ACLF is acute worsening of liver function in decompensated cirrhotic.

The etiology of ACLF would be related to a precipitating event in the context of a pre-existing liver condition. Hepatic causes include alcohol-related injury, drug-induced liver injury, viral hepatitis (A, B, C, D, and E), hypoxic injury, or liver surgeries including trans jugular intrahepatic portosystemic shunt (TIPS) placement. Extra-hepatic causes mainly consist of bacterial infections and major surgery. An estimated 40% to 50% of patients are labeled as having an unrecognized precipitating event culminating in ACLF.[5][6][7] The precipitating event has a geographical variation, similar to the etiology of acute liver failure. While acute alcohol injury and bacterial infections are the most common precipitating factor of ACLF in the west; reactivation of chronic hepatitis B, acute hepatitis A, and E infection, along with acute alcohol injury and bacterial infections, are most common in Asia.

• CLF can predict mortality in patient with ACLF and need consideratio for liver transplantation
• Between 24%-40% with cirrhosis develop LCF and admitted into hospital

Grading ACLF helps clinicians assess the prognosis, the usefulness of which has been validated in various studies. ACLF is stratified into 3 grades based on its severity:

Grade-1 ACLF is defined as:

• Single renal failure
• Single liver, coagulation, circulatory, or lung failure that is associated with a serum creatinine level of 1.5 to 1.9 mg/dL and/or hepatic encephalopathy grade 1 or grade 2
• A single brain failure with a serum creatinine level of 1.5 to 1.9 mg/dl Grade-2 ACLF is diagnosed when there are 2 organ failures of any combination. Grade-3 ACLF is diagnosed when there are three or more organ failures of any combination.

The neutrophil-to-lymphocyte ratio (NLR) is an easily accessible biomarker for assessing inflammatory status. It has been shown to be predictive of poor outcome in a variety of diseases, such as cardiovascular disease (8), cancer (9), and postoperative infection (10). In cirrhosis, NLR is a recognized predictor of survival in patients with hepatocarcinoma (11) or hepatitis B virus (HBV) infection, as well as in patients awaiting transplantation (12,13). Moreover, it has been shown that in uncomplicated cirrhosis, higher NLR could predict mortality independently of the model for end-stage liver disease (MELD) and Child-Pugh scores (14).

Aim of the work

• Detecting correlation between lymphocyte/neutrophil ratio and mean platelets volume (MPV)
• Short mortality rate in patients with acute in top of chronic liver cell failure
• Comparison between the predictor different prognostic score and lymphocyte/ neutrophil ratio and mean platelets volume (MPV in patients with acute in top of chronic liver cell failure

Study Overview

• Status: Active, not recruiting
• Conditions: Acute on Top of Chronic Liver Cell Failure

Detailed Description

Aim of the work

• Detecting correlation between lymphocyte/neutrophil ratio and mean platelets volume (MPV)
• Short mortality rate in patients with acute in top of chronic liver cell failure
• Comparison between the predictor different prognostic score and lymphocyte/ neutrophil ratio and mean platelets volume (MPV in patients with acute in top of chronic liver cell failure

• Study Type: Observational
• Enrollment (Actual): 170

Contacts and Locations

Study Locations

• Egypt
  • Assiut, Egypt, 71715
    • Faculty of Medicine - Assiut University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

• Sampling Method: Probability Sample

Study Population

above 18 years below 85 years

Description

Inclusion Criteria:

• Laboratory Confirmation

  • Availability of complete blood count (CBC) with differentials (for NLR calculation: neutrophils/lymphocytes).
  • MPV measured at baseline (preferably before interventions like transfusions or antibiotics).

• Clinical Data Availability

  • Sufficient clinical and biochemical data for prognostic scoring (e.g., MELD, Child-Pugh, CLIF-SOFA).
  • Follow-up data for assessing outcomes (e.g., 30-day mortality, transplant-free survival).

• Age & Consent

  • Adults (typically ≥18 years).
  • Informed consent obtained (if prospective study).

Exclusion Criteria:

• Confounding Hematologic Conditions

  • Active hematologic malignancies (leukemia, lymphoma).
  • Recent blood transfusions (within 48-72 hours, as they may alter NLR/MPV).
  • Known myeloproliferative disorders or bone marrow suppression.

• Recent Infections or Inflammatory Conditions

  • Active non-hepatic infections (e.g., sepsis, pneumonia, HIV) unless ACLF is infection-triggered.
  • Autoimmune diseases (e.g., rheumatoid arthritis, SLE) that may affect NLR.

• Medications Affecting NLR/MPV

  • Recent steroid/immunosuppressant use (modifies WBC counts).
  • Chemotherapy or recent surgery (alters inflammatory markers).

Study Plan

How is the study designed?

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
neutrophil / lymphocyte ratio	Detecting correlation between neutrophil / lymphocyte ratio and mean platelets volume (MPV); 30 days and 90 days mortality; Liver Transplant free survival	12 Moths from 1/10/2024 - 1/10/2026

Collaborators and Investigators

• Sponsor: Assiut University

Publications and helpful links

General Publications

• Patil V, Jain M, Venkataraman J. Paracentesis-induced acute kidney injury in decompensated cirrhosis - prevalence and predictors. Clin Exp Hepatol. 2019 Mar;5(1):55-59. doi: 10.5114/ceh.2019.83157. Epub 2019 Feb 20.
• Praktiknjo M, Clees C, Pigliacelli A, Fischer S, Jansen C, Lehmann J, Pohlmann A, Lattanzi B, Krabbe VK, Strassburg CP, Arroyo V, Merli M, Meyer C, Trebicka J. Sarcopenia Is Associated With Development of Acute-on-Chronic Liver Failure in Decompensated Liver Cirrhosis Receiving Transjugular Intrahepatic Portosystemic Shunt. Clin Transl Gastroenterol. 2019 Apr;10(4):e00025. doi: 10.14309/ctg.0000000000000025.
• Cai JJ, Wang K, Jiang HQ, Han T. Characteristics, Risk Factors, and Adverse Outcomes of Hyperkalemia in Acute-on-Chronic Liver Failure Patients. Biomed Res Int. 2019 Feb 27;2019:6025726. doi: 10.1155/2019/6025726. eCollection 2019.

Study record dates

Study Major Dates

• Study Start (Actual): October 1, 2024
• Primary Completion (Estimated): October 1, 2026
• Study Completion (Estimated): October 1, 2027

Study Registration Dates

• First Submitted: February 27, 2025
• First Submitted That Met QC Criteria: February 27, 2025
• First Posted (Actual): March 4, 2025

Study Record Updates

• Last Update Posted (Actual): April 22, 2025
• Last Update Submitted That Met QC Criteria: April 17, 2025
• Last Verified: April 1, 2025

More Information

Terms related to this study

• Other Study ID Numbers: liver cell failure; assiut university (Other Identifier: assiut university)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: The study is intended to be inside Assiut University and there is no other facility participate into the study

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No