Classification of Severity of Neutrophil-to-Lymphocyte Ratio (NLR) in Liver Disease
There is no established standardized classification system for NLR severity specifically in liver disease, but research evidence suggests that NLR values above 3.0 are generally considered elevated and associated with worse outcomes in various liver conditions, while normal NLR ranges between 1-2. 1
General NLR Reference Ranges
- Normal NLR ranges between 1-2 in healthy adults, with values higher than 3.0 considered pathological 1
- NLR values in the "grey zone" between 2.3-3.0 may serve as an early warning of pathological processes including inflammation, infection, or chronic disease 1
- Values below 0.7 in adults are also considered pathological and may indicate immune dysfunction 1
NLR in Specific Liver Disease Contexts
Acute-on-Chronic Liver Failure (AoCLF)
- Elevated NLR at admission independently predicts 3-month mortality in patients with acute-on-chronic liver failure 2
- Patients with AoCLF have significantly higher NLRs compared to healthy controls and patients with chronic hepatitis B 2
- Higher NLR values correlate with increased severity of liver disease and mortality rates in AoCLF 2
Non-Alcoholic Fatty Liver Disease (NAFLD)
- The evidence regarding NLR classification in NAFLD is contradictory and conflicting 3, 4
- One study found that lower NLR values were inversely associated with advanced inflammatory activity and significant fibrosis in NAFLD patients, suggesting a paradoxical relationship 3
- However, another larger study (226 patients) found no association between NLR and severity of hepatic inflammation or fibrosis in NAFLD, concluding that NLR cannot be recommended as a surrogate marker of liver injury in this population 4
Primary Liver Cancer
- NLR >3.0 (with interquartile range 2.5-5.0) is the most commonly used cut-off value for predicting poor prognosis in primary liver cancer 1, 5
- High NLR predicts poor overall survival (HR 2.102) and disease-free survival (HR 2.474) in primary liver cancer patients 5
- Elevated NLR is associated with tumor vascular invasion and elevated alpha-fetoprotein levels 5
Critical Illness and Severe Liver Disease
- NLR values above 11-17, or even higher than 30, indicate severe critical illness, high stress levels, and serious systemic inflammation 1
- Improving clinical course and lower mortality risk are associated with decline of NLR values below 7 1
- Dynamic changes in NLR should be monitored daily in acute disease or critical illness, as changes precede clinical deterioration by several hours 1
Important Clinical Caveats
- NLR is not liver-specific and is influenced by many conditions including age, medications, chronic diseases (coronary heart disease, stroke, diabetes, obesity), psychiatric diagnoses, anemia, and stress 1
- NLR has high sensitivity but low specificity for inflammation and stress, making it useful for screening but requiring correlation with other clinical parameters 1
- The lack of standardized cut-off values across different liver diseases limits its utility as a standalone diagnostic or prognostic marker 3, 4
- Serial monitoring of NLR trends is more valuable than single measurements for assessing disease progression or response to treatment 1