C-Reactive Protein/Albumin Ratio vs. Prognostic Nutritional Index as the Best Predictor of Early Mortality in Hospitalized Older Patients, Regardless of Admitting Diagnosis

Abstract

Background: Malnutrition and systemic inflammation are major determinants of poor outcomes in hospitalized older adults, such as length of hospital stay (LOS), mortality, and readmission risk. The C-reactive protein to albumin ratio (CRP/Alb) and the Prognostic Nutritional Index (PNI) are simple biomarkers reflecting inflammation and nutritional status. Additionally, the PNI offers a straightforward method to assess both the nutritional state and mortality risk in older patients. Objective: The objective of this study was to compare the predictive accuracy of the CRP/Alb ratio and PNI for early in-hospital mortality at 7 and 30 days after admission in older patients, independent of admitting diagnosis. Methods: We retrospectively analyzed 2776 patients aged 65 years and older, admitted to the Internal Medicine and Aging Unit of the "Policlinico Riuniti" University Hospital in Foggia, Italy, between 2019 and 2025. Laboratory data at admission included CRP, albumin, and total lymphocyte count (TLC). The CRP/Alb ratio and PNI were calculated. Prognostic performance for 7- and 30-day mortality for both the CRP/Alb ratio and PNI was assessed using ROC curves, Cox regression, Kaplan-Meier survival analyses, and positive predictive value (PPV) comparisons, stratified by rehospitalization status and length of stay (LOS). The likelihood-ratio test was also performed to compare the 7- and 30-day mortality PPVs of the CRP/Alb ratio and the PNI, both for all patients and for re-hospitalized patients. Results: In-hospital mortality occurred in 444 patients (16%). Deceased patients showed significantly higher CRP/Alb ratios and lower PNI values than survivors (p < 0.001). Both the CRP/Alb ratio and PNI independently predicted 7- and 30-day mortality. A CRP/Alb ratio > 8 strongly predicted very early mortality (HR 10.46 for 7-day death), whereas a PNI < 38 predicted both 7- and 30-day mortality (HR 8.84 and HR 3.54, respectively). Among non-rehospitalized patients, the PNI demonstrated superior predictive performance regardless of LOS (p < 0.001). Among rehospitalized patients, the PNI was a more accurate predictor for short LOS (<7 days), while the CRP/Alb ratio performed better for longer LOS (≥7 days). Conclusions: Both the CRP/Alb ratio and PNI are inexpensive, readily available biomarkers for early risk stratification in hospitalized older adults. The CRP/Alb ratio is particularly effective in detecting very early mortality risk, while the PNI offers refined prognostic value across selected subgroups. Integrating these markers at admission may support personalized geriatric care and timely interventions.

Keywords: CRP/albumin ratio; Prognostic Nutritional Index; in-hospital mortality; inflammation; malnutrition; older adults.

Figure 1

Flowchart steps from the starting population to the final cohort included in the analysis.

Figure 2

Analysis of ROC curves of PNI (a), CRP/Alb ratio (b), CRP/Alb ratio among LOS < 7 or ≥7 days (c), and CRP/Alb ratio among LOS < 7 or ≥7 days (d) as predictors of mortality, compared with the reference line (red line).

Figure 3

(a) Kaplan–Meier survival estimates stratified by CRP/Alb ratio < 8 vs. CRP/Alb ratio ≥ 8 after 30 days of hospitalization (chi-square 82.26; p < 0.001). (b) Kaplan–Meier survival estimates stratified by CRP/Alb ratio < 8 vs. CRP/Alb ratio ≥ 8 within 7 days of hospitalization (chi-square 140.29; p < 0.001).

Figure 3

(a) Kaplan–Meier survival estimates stratified by CRP/Alb ratio < 8 vs. CRP/Alb ratio ≥ 8 after 30 days of hospitalization (chi-square 82.26; p < 0.001). (b) Kaplan–Meier survival estimates stratified by CRP/Alb ratio < 8 vs. CRP/Alb ratio ≥ 8 within 7 days of hospitalization (chi-square 140.29; p < 0.001).

Figure 4

(a) Kaplan–Meier survival estimates stratified by PNI < 38 vs. PNI ≥ 38 after 30 days of hospitalization (chi-square 108.82; p < 0.001). (b) Kaplan–Meier survival estimates stratified by PNI < 38 vs. PNI ≥ 38 within 7 days of hospitalization (chi-square 138.31; p < 0.001).

Figure 4

(a) Kaplan–Meier survival estimates stratified by PNI < 38 vs. PNI ≥ 38 after 30 days of hospitalization (chi-square 108.82; p < 0.001). (b) Kaplan–Meier survival estimates stratified by PNI < 38 vs. PNI ≥ 38 within 7 days of hospitalization (chi-square 138.31; p < 0.001).