J Knee Surg 2021; 34(02): 171-177
DOI: 10.1055/s-0039-1694043
Original Article

Neutrophil–Lymphocyte Ratio as a Predictor of Venous Thromboembolism after Total Knee Replacement

1   Division of Cardiology, Kangdong Sacred Heart Hospital, Seoul, South Korea
2   Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
3   Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, South Korea
,
Myung-Soo Park
2   Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
4   Division of Cardiology, Dongtan Sacred Heart Hospital, Dongtan, South Korea
,
Sung Eun Kim
1   Division of Cardiology, Kangdong Sacred Heart Hospital, Seoul, South Korea
2   Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
,
Jun-Hee Lee
1   Division of Cardiology, Kangdong Sacred Heart Hospital, Seoul, South Korea
2   Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
,
Dae-Gyun Park
1   Division of Cardiology, Kangdong Sacred Heart Hospital, Seoul, South Korea
2   Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
,
Kyoo-Rok Han
1   Division of Cardiology, Kangdong Sacred Heart Hospital, Seoul, South Korea
2   Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
,
Dong-Jin Oh
1   Division of Cardiology, Kangdong Sacred Heart Hospital, Seoul, South Korea
2   Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
,
3   Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, South Korea
5   Division of Cardiology, Soonchunhyang University Hospital, Seoul, South Korea
› Author Affiliations
Funding None.

Abstract

Venous thromboembolism (VTE) is a potentially serious complication after total knee replacement (TKR), and recent guideline recommends thromboprophylaxis for VTE after TKR. The neutrophil–lymphocyte ratio (NLR) has emerged as a simple and new prognostic biomarker for several cardiovascular diseases. This study was performed to investigate the precise incidence of postoperative VTE and the role of NLR for predicting VTE in patients receiving thromboprophylaxis after TKR. We retrospectively enrolled 264 patients undergoing TKR who underwent routine screening enhanced pulmonary artery and lower extremity venography computed tomography (CT) scan within 7 postoperative days. Biochemical tests were performed within 2 weeks prior to surgery, and the NLR was defined as the absolute neutrophil count in peripheral blood divided by lymphocyte count. All patients received thromboprophylaxis with enoxaparin postoperatively. Of 264 patients, 102 (38.6%) were diagnosed with deep vein thrombosis (DVT) or pulmonary embolism on CT scan. Preoperative NLR was significantly higher in patients with postoperative VTE compared with that in patients without VTE (2.57 ± 1.59 vs. 2.11 ± 1.10, p = 0.011). Receiver operating characteristic curve analysis showed that a preoperative NLR of 1.90 was the best cutoff value for the prediction of postoperative VTE (sensitivity 57.8%, specificity 55.6%, and area under curve 0.589). In the multivariate analysis, a preoperative NLR ≥1.90 was a sole independent predictor of postoperative VTE (odds ratio: 1.95, 95% computed tomography: 1.16–3.31, p = 0.013). The present study shows a higher incidence of VTE (38.6%) after TKR in patients receiving thromboprophylaxis than that reported in previous studies. Furthermore, preoperative NLR was significantly higher in patients with postoperative VTE, and a high preoperative NLR (≥1.90) was an independent predictor of VTE after TKR. NLR measurement may be a simple and useful method for the prediction of VTE in patients undergoing TKR.



Publication History

Received: 31 January 2019

Accepted: 18 June 2019

Article published online:
08 August 2019

© 2019. Thieme. All rights reserved.

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  • References

  • 1 Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ. ; American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (2, Suppl): 7S-47S
  • 2 Januel J-M, Chen G, Ruffieux C. et al; IMECCHI Group. Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review. JAMA 2012; 307 (03) 294-303
  • 3 Falck-Ytter Y, Francis CW, Johanson NA. et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (2, Suppl): e278S-e325S
  • 4 White RH, Zhou H, Romano PS. Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures. Thromb Haemost 2003; 90 (03) 446-455
  • 5 Jaffer AK, Barsoum WK, Krebs V, Hurbanek JG, Morra N, Brotman DJ. Duration of anesthesia and venous thromboembolism after hip and knee arthroplasty. Mayo Clin Proc 2005; 80 (06) 732-738
  • 6 Agnelli G, Bolis G, Capussotti L. et al. A clinical outcome-based prospective study on venous thromboembolism after cancer surgery: the @RISTOS project. Ann Surg 2006; 243 (01) 89-95
  • 7 Kaya H, Ertaş F, İslamoğlu Y. et al. Association between neutrophil to lymphocyte ratio and severity of coronary artery disease. Clin Appl Thromb Hemost 2014; 20 (01) 50-54
  • 8 Lattanzi S, Cagnetti C, Rinaldi C, Angelocola S, Provinciali L, Silvestrini M. Neutrophil-to-lymphocyte ratio improves outcome prediction of acute intracerebral hemorrhage. J Neurol Sci 2018; 387: 98-102
  • 9 Yu S, Arima H, Bertmar C, Clarke S, Herkes G, Krause M. Neutrophil to lymphocyte ratio and early clinical outcomes in patients with acute ischemic stroke. J Neurol Sci 2018; 387: 115-118
  • 10 Templeton AJ, McNamara MG, Šeruga B. et al. Prognostic role of neutrophil-to-lymphocyte ratio in solid tumors: a systematic review and meta-analysis. J Natl Cancer Inst 2014; 106 (06) dju124
  • 11 de Jager CP, van Wijk PT, Mathoera RB, de Jongh-Leuvenink J, van der Poll T, Wever PC. Lymphocytopenia and neutrophil-lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit. Crit Care 2010; 14 (05) R192
  • 12 Tamhane UU, Aneja S, Montgomery D, Rogers E-K, Eagle KA, Gurm HS. Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome. Am J Cardiol 2008; 102 (06) 653-657
  • 13 Núñez J, Núñez E, Bodí V. et al. Usefulness of the neutrophil to lymphocyte ratio in predicting long-term mortality in ST segment elevation myocardial infarction. Am J Cardiol 2008; 101 (06) 747-752
  • 14 Gibson PH, Croal BL, Cuthbertson BH. et al. Preoperative neutrophil-lymphocyte ratio and outcome from coronary artery bypass grafting. Am Heart J 2007; 154 (05) 995-1002
  • 15 Ertem AG, Ozcelik F, Kasapkara HA. et al. Neutrophil lymphocyte ratio as a predictor of left ventricular apical Thrombus in patients with myocardial infarction. Korean Circ J 2016; 46 (06) 768-773
  • 16 Galasko CS, Edwards DH, Fearn CB, Barber HM. The value of low dosage heparin for the prophylaxis of thromboembolism in patients with transcervical and intertrochanteric femoral fractures. Acta Orthop Scand 1976; 47 (03) 276-282
  • 17 Eskeland G, Solheim K, Skjörten F. Anticoagulant prophylaxis, thromboembolism and mortality in elderly patients with hip fractures. A controlled clinical trial. Acta Chir Scand 1966; 131 (01) 16-29
  • 18 Jørgensen PS, Knudsen JB, Broeng L. et al. The thromboprophylactic effect of a low-molecular-weight heparin (Fragmin) in hip fracture surgery. A placebo-controlled study. Clin Orthop Relat Res 1992; (278) 95-100
  • 19 Hill J, Treasure T. National Clinical Guideline Centre for Acute and Chronic Conditions. Reducing the risk of venous thromboembolism in patients admitted to hospital: summary of NICE guidance. BMJ 2010; 340: c95
  • 20 Habscheid W, Höhmann M, Wilhelm T, Epping J. Real-time ultrasound in the diagnosis of acute deep venous thrombosis of the lower extremity. Angiology 1990; 41 (08) 599-608
  • 21 Rose SC, Zwiebel WJ, Murdock LE. et al. Insensitivity of color Doppler flow imaging for detection of acute calf deep venous thrombosis in asymptomatic postoperative patients. J Vasc Interv Radiol 1993; 4 (01) 111-117
  • 22 Dietch ZC, Edwards BL, Thames M, Shah PM, Williams MD, Sawyer RG. Rate of lower-extremity ultrasonography in trauma patients is associated with rate of deep venous thrombosis but not pulmonary embolism. Surgery 2015; 158 (02) 379-385
  • 23 Saghazadeh A, Rezaei N. Inflammation as a cause of venous thromboembolism. Crit Rev Oncol Hematol 2016; 99: 272-285
  • 24 van Aken BE, den Heijer M, Bos GM, van Deventer SJ, Reitsma PH. Recurrent venous thrombosis and markers of inflammation. Thromb Haemost 2000; 83 (04) 536-539
  • 25 Matos MF, Lourenço DM, Orikaza CM, Bajerl JA, Noguti MA, Morelli VM. The role of IL-6, IL-8 and MCP-1 and their promoter polymorphisms IL-6 -174GC, IL-8 -251AT and MCP-1 -2518AG in the risk of venous thromboembolism: a case-control study. Thromb Res 2011; 128 (03) 216-220
  • 26 Baetta R, Corsini A. Role of polymorphonuclear neutrophils in atherosclerosis: current state and future perspectives. Atherosclerosis 2010; 210 (01) 1-13
  • 27 Stewart GJ. Neutrophils and deep venous thrombosis. Haemostasis 1993; 23 (Suppl. 01) 127-140
  • 28 Nakos G, Kitsiouli EI, Lekka ME. Bronchoalveolar lavage alterations in pulmonary embolism. Am J Respir Crit Care Med 1998; 158 (5 Pt 1): 1504-1510
  • 29 Orde MM, Puranik R, Morrow PL, Duflou J. Myocardial pathology in pulmonary thromboembolism. Heart 2011; 97 (20) 1695-1699
  • 30 Bakirci EM, Topcu S, Kalkan K. et al. The role of the nonspecific inflammatory markers in determining the anatomic extent of venous thromboembolism. Clin Appl Thromb Hemost 2015; 21 (02) 181-185
  • 31 Lowe G, Rumley A, Woodward M, Vessey M. C-reactive protein, idiopathic venous thromboembolism and hormone replacement therapy. Thromb Haemost 2000; 84 (04) 730-731
  • 32 Kamphuisen PW, Eikenboom JC, Vos HL. et al. Increased levels of factor VIII and fibrinogen in patients with venous thrombosis are not caused by acute phase reactions. Thromb Haemost 1999; 81 (05) 680-683
  • 33 Tsai AW, Cushman M, Rosamond WD. et al. Coagulation factors, inflammation markers, and venous thromboembolism: the longitudinal investigation of thromboembolism etiology (LITE). Am J Med 2002; 113 (08) 636-642
  • 34 Quist-Paulsen P, Naess IA, Cannegieter SC. et al. Arterial cardiovascular risk factors and venous thrombosis: results from a population-based, prospective study (the HUNT 2). Haematologica 2010; 95 (01) 119-125