’Letters to the Editor Directions of odds ratios might be inappropriate in the paper by Tafarel et al.
Neutrophil-to-lymphocyte ratio as a predictor of fibrosis in inactive hepatitis B carriers
Han Denga, Xingshun Qia, Yongji Wangb,c and Xiaozhong Guoa, aLiver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, bMedical Department, 309th Hospital of Chinese People’s Liberation Army, Beijing and cDepartment of Health Statistics, Fourth Military Medical University, Xi’an, China
Cemal N. Ercina, Teoman Dogrua and Erdim Sertoglub, aDepartment of Gastroenterology, Gulhane School of Medicine and bBiochemistry Laboratory, Ankara Mevki Military Hospital, Anittepe Dispensary, Ankara, Turkey
Correspondence to Xiaozhong Guo, MD, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang 110840, China Tel: + 86 24 28897603; fax: + 86 24 28851113; e-mail: [email protected] Received 7 January 2015 Accepted 8 January 2015
Recently, we have read with great interest the paper by Tafarel et al. [1] evaluating the role of noninvasive markers in predicting the presence of esophageal varices in cirrhotic patients. In the multivariate analyses, the variables that were associated significantly with the absence of esophageal varices (without vs. with esophageal varices in Table 2) included the model for the end-stage liver disease (MELD) score [odds ratio (OR) = 0.70; 95% confidence interval (CI) = 0.50–1, P = 0.02], aspartate aminotransferase to platelets index (APRI) (OR = 0.80; 95% CI = 0.70–1, P = 0.01), aspartate aminotransferase (AST) level (OR = 1.40; 95% CI = 1–2, P = 0.01), total bilirubin (TB) level (OR = 3.20; 95% CI = 1.40–7.20, P = 0.04), and platelets count (OR = 0.80; 95% CI = 0.80–0.90, P < 0.01). As we all know, OR is used to observe the relationship between exposed factors and the risk of disease. If OR is greater than 1, the presence of exposed factors increases the risk of disease; otherwise, it decreases the risk of disease. On the basis of the above-mentioned findings, it can be concluded that an increased MELD score, APRI, and platelets count should be associated significantly with a lower proportion of patients without esophageal varices; by contrast, an increased AST and TB level should be associated significantly with a higher proportion of patients without esophageal varices. If so, their conclusions might be misleading. The directions of ORs for the MELD score and APRI were right, but those for AST, TB, and platelets were inconsistent with our clinical practices. Therefore, we enquire about whether the directions of ORs for AST, TB, and platelets count were appropriate in their multivariate analyses. Acknowledgements Conflict of interests
There are no conflicts of interest. Reference 1
Tafarel JR, Tolentino LH, Correa LM, Bonilha DR, Piauilino P, Martins FP, et al. Prediction of esophageal varices in hepatic cirrhosis by noninvasive markers. Eur J Gastroenterol Hepatol 2011; 23:754–758. DOI: 10.1097/MEG.0000000000000301
European Journal of Gastroenterology & Hepatology 2015, 27:475–477
Correspondence to Erdim Sertoglu, MD, Biochemistry Laboratory, Ankara, Mevki Military Hospital, Anittepe Dispensary, Ankara, 06580, Turkey Tel: + 90 507 140 3616; fax: + 90 312 304 3300; e-mail: [email protected] Received 12 January 2015 Accepted 14 January 2015
We read with great interest the article by Yilmaz et al. [1] reporting the neutrophil–lymphocyte ratio (NLR) as a noninvasive tool for the prediction of fibrosis in inactive hepatitis B carriers. We believe that some points should be discussed. First, some patients had hyperglycemia that is consistent with the diagnosis of type 2 diabetes. Although BMI was similar in both groups, there was no information on BMI values, and systolic and diastolic blood pressure levels. Moreover, there were no data on the prevalence of metabolic syndrome in the study population. However, it is well known that NLR can easily be affected by this metabolic abnormality [2–5]. Second, the European Association for the Study of the Liver (EASL) guideline recommends that liver biopsy should be performed in patients with either increased alanine transaminase and hepatitis B virus (HBV) DNA levels more than 2000 IU/ml (or both) to determine the degree of necroinflammation and fibrosis [6]. In this study, although some patients had minimally elevated aspartate aminotransferase and alanine transaminase levels, HBV DNA levels of all patients were lower than 2000 IU/ml. Consequently, the indication of the liver biopsy in the study is not clear and questionable. Third, study participants were divided into two groups according to the fibrosis score: 0–1 as inactive carriers and above 2 as patients with chronic active HBV. However, there are no data on this classification in the literature. Finally, the authors concluded that histologic activity index and NLR were found to be correlated negatively. However, there is no information on inflammatory activity, defined as histology activity indexes, and other histologic findings of the study population. Therefore, we would like to ask the authors whether they can present some data on the issues mentioned above. This may provide the readers with clearer information on the relationship between NLR and liver injury in this clinically relevant condition.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
0954-691X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
475
Neutrophil-to-lymphocyte ratio as a predictor of fibrosis in inactive hepatitis B carriers
Han Denga, Xingshun Qia, Yongji Wangb,c and Xiaozhong Guoa, aLiver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, bMedical Department, 309th Hospital of Chinese People’s Liberation Army, Beijing and cDepartment of Health Statistics, Fourth Military Medical University, Xi’an, China
Cemal N. Ercina, Teoman Dogrua and Erdim Sertoglub, aDepartment of Gastroenterology, Gulhane School of Medicine and bBiochemistry Laboratory, Ankara Mevki Military Hospital, Anittepe Dispensary, Ankara, Turkey
Correspondence to Xiaozhong Guo, MD, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang 110840, China Tel: + 86 24 28897603; fax: + 86 24 28851113; e-mail: [email protected] Received 7 January 2015 Accepted 8 January 2015
Recently, we have read with great interest the paper by Tafarel et al. [1] evaluating the role of noninvasive markers in predicting the presence of esophageal varices in cirrhotic patients. In the multivariate analyses, the variables that were associated significantly with the absence of esophageal varices (without vs. with esophageal varices in Table 2) included the model for the end-stage liver disease (MELD) score [odds ratio (OR) = 0.70; 95% confidence interval (CI) = 0.50–1, P = 0.02], aspartate aminotransferase to platelets index (APRI) (OR = 0.80; 95% CI = 0.70–1, P = 0.01), aspartate aminotransferase (AST) level (OR = 1.40; 95% CI = 1–2, P = 0.01), total bilirubin (TB) level (OR = 3.20; 95% CI = 1.40–7.20, P = 0.04), and platelets count (OR = 0.80; 95% CI = 0.80–0.90, P < 0.01). As we all know, OR is used to observe the relationship between exposed factors and the risk of disease. If OR is greater than 1, the presence of exposed factors increases the risk of disease; otherwise, it decreases the risk of disease. On the basis of the above-mentioned findings, it can be concluded that an increased MELD score, APRI, and platelets count should be associated significantly with a lower proportion of patients without esophageal varices; by contrast, an increased AST and TB level should be associated significantly with a higher proportion of patients without esophageal varices. If so, their conclusions might be misleading. The directions of ORs for the MELD score and APRI were right, but those for AST, TB, and platelets were inconsistent with our clinical practices. Therefore, we enquire about whether the directions of ORs for AST, TB, and platelets count were appropriate in their multivariate analyses. Acknowledgements Conflict of interests
There are no conflicts of interest. Reference 1
Tafarel JR, Tolentino LH, Correa LM, Bonilha DR, Piauilino P, Martins FP, et al. Prediction of esophageal varices in hepatic cirrhosis by noninvasive markers. Eur J Gastroenterol Hepatol 2011; 23:754–758. DOI: 10.1097/MEG.0000000000000301
European Journal of Gastroenterology & Hepatology 2015, 27:475–477
Correspondence to Erdim Sertoglu, MD, Biochemistry Laboratory, Ankara, Mevki Military Hospital, Anittepe Dispensary, Ankara, 06580, Turkey Tel: + 90 507 140 3616; fax: + 90 312 304 3300; e-mail: [email protected] Received 12 January 2015 Accepted 14 January 2015
We read with great interest the article by Yilmaz et al. [1] reporting the neutrophil–lymphocyte ratio (NLR) as a noninvasive tool for the prediction of fibrosis in inactive hepatitis B carriers. We believe that some points should be discussed. First, some patients had hyperglycemia that is consistent with the diagnosis of type 2 diabetes. Although BMI was similar in both groups, there was no information on BMI values, and systolic and diastolic blood pressure levels. Moreover, there were no data on the prevalence of metabolic syndrome in the study population. However, it is well known that NLR can easily be affected by this metabolic abnormality [2–5]. Second, the European Association for the Study of the Liver (EASL) guideline recommends that liver biopsy should be performed in patients with either increased alanine transaminase and hepatitis B virus (HBV) DNA levels more than 2000 IU/ml (or both) to determine the degree of necroinflammation and fibrosis [6]. In this study, although some patients had minimally elevated aspartate aminotransferase and alanine transaminase levels, HBV DNA levels of all patients were lower than 2000 IU/ml. Consequently, the indication of the liver biopsy in the study is not clear and questionable. Third, study participants were divided into two groups according to the fibrosis score: 0–1 as inactive carriers and above 2 as patients with chronic active HBV. However, there are no data on this classification in the literature. Finally, the authors concluded that histologic activity index and NLR were found to be correlated negatively. However, there is no information on inflammatory activity, defined as histology activity indexes, and other histologic findings of the study population. Therefore, we would like to ask the authors whether they can present some data on the issues mentioned above. This may provide the readers with clearer information on the relationship between NLR and liver injury in this clinically relevant condition.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
0954-691X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
475
