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 Table of Contents 
Year : 2020  |  Volume : 9  |  Issue : 12  |  Page : 5944-5947  

Diagnostic accuracy of the postoperative C - reactive protein to albumin ratio in prediction of complications after major abdominal surgery

Department of General Surgery, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

Date of Submission31-Jul-2020
Date of Decision29-Sep-2020
Date of Acceptance24-Nov-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Prof. Manish Swarnkar
M4/10, Meghdoot Apartment, JNMC Campus, Wardha - 442 001, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jfmpc.jfmpc_1565_20

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Introduction: postoperative complications are common after surgery for both benign and malignant disease, and results in infections, extended hospital stay, delayed return to normal status, increased financial burden and long-term morbidity hence early recognition of surgical complications and management is of utmost importance. Aim: To assess the predictive value of C-reactive protein to albumin ratio (CAR) and C-reactive protein (CRP) in determining the post-operative complications following major abdominal surgeries. Methods: this two-year prospective observational study was carried out at acharya vinoba bhave hospital and risk factors for post-operative complications in 100 eligible patients who were undergone major abdominal surgeries were identified using uni and multivariate analysis. Cut Coff values, PPV, sensitivity and specificity of CAR and CRP was analysed by ROC curve. Results: in our study 62% patient developed post-operative complications and CAR on post-op. day three found to be independent risk factor for prediction of post-op. complication and has higher PPV than CRP. CAR cut-off value of 2.16 is associated with more post op complications. Conclusion: From our study it can be hypothesized that patients having CAR value of more than 2.16 on post op day 3 should be monitored carefully for development of complications. So that early intervention could reduce the unwanted sequelae associated with it.

Keywords: Clavien-Dindo classification, C - reactive protein, infections, major abdominal surgery postoperative complications

How to cite this article:
Swarnkar M, Pendkar R. Diagnostic accuracy of the postoperative C - reactive protein to albumin ratio in prediction of complications after major abdominal surgery. J Family Med Prim Care 2020;9:5944-7

How to cite this URL:
Swarnkar M, Pendkar R. Diagnostic accuracy of the postoperative C - reactive protein to albumin ratio in prediction of complications after major abdominal surgery. J Family Med Prim Care [serial online] 2020 [cited 2021 May 14];9:5944-7. Available from: https://www.jfmpc.com/text.asp?2020/9/12/5944/305603

  Introduction Top

Postoperative complications after major abdominal surgery are reported in up to 40% of patients and pose a major clinical problem due to their association with increased morbidity and mortality.[1],[2] Apart from increased morbidity and mortality rates it results in longer in-hospital stay, higher costs and even increased cancer recurrence rates.[1] Early diagnosis and treatment are paramount to improve these outcomes.

Stress response to surgical intervention because of augmented immune, neuroendocrine and metabolic response leads to increased postoperative complications.[3] Surgical intervention leads to activation of inflammatory response and release of Pro-inflammatory cytokines like IL-1, IL-6 and TNF- α upon which liver responses with increase or decrease of acute phase protein like CRP, albumin, fibrinogen and complement component of C3 and C4.[3] CRP has been widely studied to predict postoperative complications and also as a guide for safe discharge following colorectal surgery.[4] But major drawback associated with using CRP alone as a marker for post-operative complications is its slow kinetics peaking values on 2nd or 3rd day which could be too late for intervention, whereas albumin shows immediate response to surgical stress and also a reliable predictor of deranged protein metabolism which occurs in response to surgical stress.[3],[4]

Thus, ratio of CRP to albumin will precisely reflect the inflammatory and nutritional status and could serve as marker of negative outcome. Recently, Ishizuka and colleagues[5] found a significant correlation between negative oncological outcomes in colorectal cancer patients and an elevated CRP to albumin ratio. Therefore, we theorize that CAR could be used as a simple and reliable predictor to identify patient at risk for postoperative complications. In the present study, we have evaluated the correlation between CAR and postoperative complications and compared the diagnostic accuracy between postoperative CAR and CRP in these patients.

  Materials and Methods Top

The present study was conducted in department of general surgery at Acharya Vinoba Bhave rural hospital. After approval from institutional ethical committee data of the all the eligible patient undergoing elective major abdominal surgeries between August 2017 to September 2019 was collected. Those Patients who were reoperated prior to third postoperative day, albumin infusion prior to operation or during two postoperative days, ileostomy or colostomy closure, multivisceral resection, inflammatory bowel disease, or incomplete laboratory data were excluded. Baseline characteristic, surgical parameters and clinical outcome of the patient were recorded in preformed proforma. CRP and Albumin level were measured preoperatively on the day before surgery and on third post -op day. Post-operative complications that occurred during hospital stay or within 30 days of discharge were recorded and graded as per validated Clavien-Dindo scale[6]; grades I-II were considered as minor and III-IV were considered as major complications, respectively. Categorical and continuous data was statistically analysed using Pearson's Chi-squared test and Student's t-test. For logistic regression analysis, a univariate analysis was performed and statistically significance value was set at P < 0.05 and then Binary logistic regression analysis done to identify the risk factor independently associated with post op complication.[7] ROC curve was drawn for CAR and CRP, to compare cut-off values, diagnostic accuracy by calculating PPV, sensitivity and specificity.[7] All of the data was analysed using SPSS statistical software version 22.0.

  Results Top

In the present study out of 100 patients enrolled, 62 (62%) developed complications. there was no significant difference in mean age of patient in complication and non-complication group (45.9 yr vs 46.5 yrs). majority of surgeries were hepatobiliary (48%) followed by lower G.I surgery (28%). But there was statistically significant difference in other Parameters like pre-op. CRP, serum albumin, haemoglobin, ASA grade and post-op. CRP on day3, CAR on day 3, duration of surgery, blood loss between two group. [Table 1]. In complication group 37 patient (60%) had major complications, (Clavien-Dindo grade III − IV). After univariate analysis, statistically significant (p < 0.05) factors were entered in to forward stepwise pattern in binomial logistic regression and CAR on post-op. day 3, pre op haemoglobin were found to be statistically significant independent risk factor for post op complications. (p value < 0.05). [Table 2] further diagnostic accuracy of CAR and CRP on post-op. day 3 was analysed using ROC curve and compared. [Table 3], [Figure 1] CAR found to have more diagnostic accuracy with area under curve of .86 (CRP,.82) and PPV of 90.4%(CRP,89.5%), Since both had close PPV so, Youden's index was calculated which was higher for CAR (.57 vs .53). [Table 3] Thus, CAR appears to have better predictive value than CRP in predicting post-op. complications.
Figure 1: ROC curve showing postoperative CAR levels and CRP on POD 3 levels predictive of postoperative overall complications

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Table 1: Baseline parameters of patients in both groups

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Table 2: Binary logistic regression analysis of risk factors associated with postoperative complications

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Table 3: ROC curve analysis to compare the diagnostic accuracy of CAR and CRP on post-op. day 3 in predicting post-op. complications

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  Discussion Top

Post-op. complications following major surgery not only brings psychological trauma but also increases hospital stay, treatment cost and delayed return to premorbid state. In the present stage of constrained medical resources and expensive medical treatment, we need a reliable and inexpensive marker which is easily available in general setting to identify impending post-op. complications for early and safe discharge. In our study, we found that CAR on day 3 with a cut-off value of 2.16 can be used as a reliable marker for predicting post-op. complications and it has a higher diagnostic accuracy than CRP alone (AUC of 0.862 vs 0.818). Any surgical intervention is associated with systemic inflammatory response which if increases or persists for longer time is associated with negative outcome therefore various inflammatory markers like modified Glasgow Prognostic Score (mGPS), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), postoperative Glasgow Prognostic Score (poGPS), and CRP to albumin ratio (CAR) have been studied to predict complications following surgery.[8],[9]

Watt et al.[9] (2017) suggested prognostic role postoperative systemic inflammation score including postoperative C-reactive protein and albumin levels (C-reactive protein and albumin thresholds of >150 mg/L and <25 g/L, respectively) were associated with the development of infective complications (p < 0.01). Similar study conducted by Karayiannis et al.[10] (2018); concluded that CAR on the post-op. day 3 has a better predictive value than CRP (AUC 0.721 vs 0.656). Patients with CAR > 2.0 suffered more complications following abdominal surgery (49.3% vs 22.1%, P < 0.05)). Shibutani et al.[4] (2016) found high preoperative CAR in colorectal cancer patients associated with worse relapse free (p = 0.0015) and tumour specific survival (p = 0.0131) and may be superior modified Glasgow prognostic score (mGPS). Kim et al.[11] reported that the CRP/albumin ratio at admission was positively correlated with prognosis in patients with severe sepsis or septic shock and also acts as a guide for early goal directed therapy.

In combination, CRP and albumin may be more valuable prognostic markers for outcomes across various diseases, providing both inflammatory and nutritional information.[12] The combination of albumin and CRP into a single index has been suggested previously, and subsequent studies have shown that the CRP/albumin ratio is more consistent with prognosis than CRP or albumin alone.[8] The CRP/albumin ratio has been extensively studied as an independent prognostic marker in patients with infection, malignancy, and other diseases.[8],[11] Results of our study were consistent with above mentioned study. the strength of our study was mix case load population of patients as most of other studies were conducted in single type of cases thus have a wider applicability but it has also limitation like single centre study, small sample size and Inclusion of cancer patients which usually have depleted nutritional status and an ongoing inflammation due malignancy. Despite of limitations, easy availability of test in general settings and consistent results of good diagnostic accuracy in various studies, CAR on third post-op. day can be used as a prognostic marker in predicting complications.

  Conclusion Top

The current study established that an increased CRP/albumin ratio in post-operative period suggests ongoing deranged inflammatory and nutritional status and serves as a marker for likelihood of post-op. complications. Patients with CRP/albumin ratio greater than 2.16 should be intensively monitored for early detection of postoperative outcome to reduce postoperative complications, shorten hospital stay, and quickly return to premorbid functional activity. However further large center trials are needed to confirm the accuracy of this novel marker.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Alves A, Panis Y, Mathieu P, Mantion G, Kwiatkowski F, Slim K. Postoperative mortality and morbidity in French patients undergoing colorectal surgery: Results of a prospective multicentre study. Arch Surg 2005;140:278-83.  Back to cited text no. 1
Velasco E, Thuler LCS, Martins CAdS, de Castro Dias LM. Risk factors for infectious complications after abdominal surgery for malignant disease. Am J Infect Control 1996;24:1-6.  Back to cited text no. 2
Haruki K, Shiba H, Shirai Y, Horiuchi T, Iwase R, Fujiwara Y, et al. The C-reactive protein to albumin ratio predicts long-term outcomes in patients with pancreatic cancer after pancreatic resection. World J Surg 2016;40:2254-60.  Back to cited text no. 3
Shibutani M, Maeda K, Nagahara H, Iseki Y, Ikeya T, Hirakawa K. Prognostic significance of the preoperative ratio of C-reactive protein to albumin in patients with colorectal cancer. Anticancer Res 2016;36:995-1001.  Back to cited text no. 4
Ishizuka M, Nagata H, Takagi K, Iwasaki Y, Shibuya N, Kubota K. Clinical significance of the C-reactive protein to albumin ratio for survival after surgery for colorectal cancer. Ann Surg Oncol 2016;23:900-7.  Back to cited text no. 5
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-13.  Back to cited text no. 6
Zhang Z. Model building strategy for logistic regression: Purposeful selection. Ann Transl Med 2016;4:111.  Back to cited text no. 7
Ranzani OT, Zampieri FG, Forte DN, Azevedo LCP, Park M. C-reactive protein/albumin ratio predicts 90-day mortality of septic patients. PloS One 2013;8:e59321.  Back to cited text no. 8
Watt DG, McSorley ST, Park JH, Horgan PG, McMillan DC. A postoperative systemic inflammation score predicts short-and long-term outcomes in patients undergoing surgery for colorectal cancer. Ann Surg Oncol 2017;24:1100-9.  Back to cited text no. 9
Karayiannis D, Bouloubasi Z, Baschali A, Constantinou D, Daskalaki E, Kalatzis V, et al. Postoperative C-reactive protein to albumin ratio as a diagnostic tool for predicting complications after abdominal surgery. Clin Nutrition ESPEN 2018;24:176.  Back to cited text no. 10
Kim MH, Ahn JY, Song JE, Choi H, Ann HW, Kim JK, et al. The C-reactive protein/albumin ratio as an independent predictor of mortality in patients with severe sepsis or septic shock treated with early goal-directed therapy. PLoS One 2015;10:e0132109.  Back to cited text no. 11
Park JE, Chung KS, Song JH, Kim SY, Kim EY, Jung JY, et al. The C-reactive protein/albumin ratio as a predictor of mortality in critically ill patients. J Clin Med 2018;7:333.  Back to cited text no. 12


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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