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Observational Study
. 2025 Aug;20(5):1371-1380.
doi: 10.1007/s11739-025-03955-x. Epub 2025 May 20.

Neutrophil-lymphocyte ratio is associated with worse outcomes in patients with cirrhosis: insights from the PRO-LIVER Registry

Tania D'Amico #  1 , Marzia Miglionico #  1 , Roberto Cangemi  2 , Giulio Francesco Romiti  1 , Benedetta De Fabrizio  1 , Salvatore Fasano  1 , Fabrizio Recchia  1 , Lucia Stefanini  1 , Valeria Raparelli  1   3   4   5 , Francesco Violi  6 , Stefania Basili  1 ; P. R. O.-LIVER Collaborators
Collaborators, Affiliations
Observational Study

Neutrophil-lymphocyte ratio is associated with worse outcomes in patients with cirrhosis: insights from the PRO-LIVER Registry

Tania D'Amico et al. Intern Emerg Med. 2025 Aug.

Abstract

Background: Liver cirrhosis (LC) is a leading global cause of morbidity and mortality, with inflammation playing a key role in disease progression and clinical complications of LC. The Neutrophil/Lymphocyte Ratio (NLR), a readily available marker of systemic inflammation, has been linked to short-term adverse outcomes in LC, but data on long-term follow-up are limited. This study aimed to investigate the relationship between NLR and long-term all-cause mortality in an unselected cohort of LC patients.

Methods: Data were gathered from the Italian multicenter observational study "PRO-LIVER". Patients with available data to calculate NLR at baseline were included. Baseline clinical determinants of NLR and the association of NRL with all-cause mortality at 2-year follow-up were evaluated.

Results: From the overall cohort (n = 753), 506 patients with LC (31% female, mean age 64.8 ± 11.9 years) were included in the analysis. Median value of NLR was 2.42 (Interquartile Range [IQR]: 1.61-3.52). At baseline, patients with NLR ≥ 2.42 were more likely to have Child-Pugh B or C, hepatocellular carcinoma (HCC), or portal vein thrombosis (PVT). After a median follow-up of 21 months, 129 patients died: 44 (17%) with NLR < 2.42 and 85 (34%) with NLR ≥ 2.42 (p < 0.001). At multiple-adjusted Cox regression analysis, NLR ≥ 2.42 was independently associated with all-cause mortality (HR: 1.65; 95% CI: 1.12-2.44; p = 0.012), along with age, Child-Pugh C class, HCC and PVT.

Conclusions: NLR is associated with long-term all-cause mortality in LC. NLR may serve as a potentially easily available tool to aid risk refinement in LC.

Trial registration number: ClinicalTrials.gov Identifier: NCT01470547.

Keywords: Cirrhosis; Inflammation; Mortality; Neutrophil–lymphocyte ratio.

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Conflict of interest statement

Declarations. Conflict of interest: The authors declare that they have no conflict of interest. Human and animal rights: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent: Informed consent was obtained from all individual participants included in the study.

Figures

Fig. 1
Fig. 1
Flowchart of the study
Fig. 2
Fig. 2
Kaplan–Meier estimates of time to mortality according to baseline NLR levels during the long-term follow-up
See this image and copyright information in PMC

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