Mehmet Ali EREN, Ali Erdal GÜNEŞ, İdris KIRHAN, Tevfik SABUNCU

The role of the platelet-to-lymphocyte ratio and neutrophilto-lymphocyte ratio in the prediction of length and cost of hospital stay in patients with infected diabetic foot ulcers: A retrospective comparative study

Objective: The aim of this study was to determine the role of new inflammatory markers, including the platelet-to-lymphocyte ratio(PLR) and neutrophil-to-lymphocyte ratio (NLR), in the prediction of length and cost of hospital stay in patients with infecteddiabetic foot ulcers (DFUs).Methods: A total of 78 patients with DFUs who were admitted to our endocrinology clinic between January 2016 and July 2017were included. Patients were then divided into three groups according to the Wagner DFU classification system: group 1: 18 patients with grade 2 DFU (11 men, 7 women; mean age = 57.5±7 years); group 2: 44 patients with grade 3 DFU (18 men, 26 women;mean age = 59.7±8.7 years); and group 3: 16 patients with grade 4 DFU (10 men, 6 women; mean age = 59.9±11.6 years). Laboratory findings were retrospectively obtained from hospital records; the PLR and NLR were calculated in all groups. Length and costof hospital stay were recorded. Hospital costs were estimated in Turkish Lira (TL) based on the evaluation of glucose regulation,wound care, and antibiotic treatment.Results: The mean NLR was significantly lower in group 1 (2.8±0.9) than in group 2 (6.0±5.2; p=0.017) and group 3 (6.9±5.3;p=0.011). The mean PLR was significantly lower in group 1 (140.8±42.6) than in group 3 (222.1±95.5; p=0.006). The mean lengthof stay was 7.9±2.7 days in group 1, 15.0±8.9 days in group 2, and 12.5±8.9 days in group 3. The mean cost was 1,310.8±500 TLin group 1, 2,966.9±2105 TL in group 2, and 3,488.1±3603.1 TL in group 3. Length and cost of stay were both significantly lowerin group 1 than in groups 2 and 3 (p=0.011 and p=0.002, respectively). Comparative results showed that the length and cost ofhospital stay increased with increasing severity of DFUs. Furthermore, correlation analyses demonstrated no correlation of lengthof stay with PLR and NLR but an obvious correlation between cost of stay and PLR (r=0.412; p0.05).Conclusion: The PLR is inflammatory marker that can be measured by an inexpensive and easily accessible test and can aid in theprediction of length and cost of hospital stay in patients with DFUs.

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1. Pickwell K, Siersma V, Kars M, et al. Predictors of lower-extremity amputation in patients with an infected diabetic foot ulcer. Diabetes Care 2015; 38: 852-7. [CrossRef]

2. Lavery LA, Armstrong DG, Wunderlich RP, et al. Risk factors for foot infections in individuals with diabetes. Diabetes Care 2006; 29:1288-93. [CrossRef]

3. Beyaz S, Güler ÜÖ, Bağır GŞ. Factors affecting lifespan following below-knee amputation in diabetic patients. Acta Orthop Traumatol Turc 2017; 51: 393-7. [CrossRef]

4. Yazdanpanah L, Nasiri M, Adarvishi S. Literature review on the management of diabetic foot ulcer. World J Diabetes 2015; 6: 37-53. [CrossRef]

5. Yesil S, Akinci B, Yener S, et al. Predictors of amputation in diabetics with foot ulcer: single center experience in a large Turkish cohort. Hormones (Athens) 2009; 8: 286-95. [CrossRef]

6. Callahan D, Keeley J, Alipour H, et al. Predictors of severity in diabetic foot infections. Ann Vasc Surg 2016; 33: 103-8. [CrossRef]

7. Yusof NM, Rahman JA, Zulkifly AH, et al. Predictors of major lower limb amputation among type II diabetic patients admitted for diabetic foot problems. Singapore Med J 2015; 56: 626-31. [CrossRef]

8. Ignatyeva VI, Severens JL, Ramos IC, Galstyan GR, Avxentyeva MV. Costs of hospital stay in specialized diabetic foot department in Russia. Value Health Reg Issues 2015; 7: 80-6. [CrossRef]

9. Tabur S, Eren MA, Çelik Y, et al. The major predictors of amputation and length of stay in diabetic patients with acute foot ulceration. Wien Klin Wochenschr 2015; 127: 45-50. [CrossRef]

10. Kim TG, Moon SY, Park MS, et al. Factors Affecting Length of Hospital Stay and Mortality in Infected Diabetic Foot Ulcers Undergoing Surgical Drainage without Major Amputation. J Korean Med Sci 2016; 31: 120-4. [CrossRef]

11. Uzun F, Erturk M, Cakmak HA, et al. Usefulness of the platelet-to-lymphocyte ratio in predicting long-term cardiovascular mortality in patients with peripheral arterial occlusive disease. Postepy Kardiol Interwencyjnej 2017; 13: 32-8. [CrossRef]

12. Liu S, Zheng H, Zhu X, et al. Neutrophil-to-lymphocyte ratio is associated with diabetic peripheral neuropathy in type 2 diabetes patients. Diabetes Res Clin Pract 2017; 130: 90-7. [CrossRef]

13. Lipsky BA, Sheehan P, Armstrong DG, Tice AD, Polis AB, Abramson MA. Clinical predictors of treatment failure for diabetic foot infections: data from a prospective trial. Int Wound J 2007; 4: 30-8. [CrossRef]

14. DiGangi C. Neutrophil-lymphocyte ratio: Predicting cardiovascular and renal complications in patients with diabetes. J Am Assoc Nurse Pract 2016; 28: 410-4. [CrossRef]

15. Mertoglu C, Gunay M. Neutrophil-Lymphocyte ratio and Platelet-Lymphocyte ratio as useful predictive markers of prediabetes and diabetes mellitus. Diabetes Metab Syndr 2017; 11: 127-31. [CrossRef]

16. Demirtas L, Degirmenci H, Akbas E, et al. Association of hematological indicies with diabetes, impaired glucose regulation and microvascular complications of diabetes. Int J Clin Exp Med 2015; 8: 11420-7.

17. Akbas EM, Demirtas L, Ozcicek A, et al. Association of epicardial adipose tissue, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio with diabetic nephropathy. Int J Clin Exp Med 2014; 7: 1794-1801.

18. Teperman J, Carruthers D, Guo Y, et al. Relationship between neutrophil-lymphocyte ratio and severity of lower extremity peripheral artery disease. Int J Cardiol 2017; 228: 201-4. [CrossRef]

19. Gary T, Pichler M, Belaj K, et al. Platelet-to-lymphocyte ratio: a novel marker for critical limb ischemia in peripheral arterial occlusive disease patients. PLoS One 2013; 8: e67688. doi: 10.1371/ journal.pone.0067688. [CrossRef]

20. Vatankhah N, Jahangiri Y, Landry GJ, et al. Predictive value of neutrophil-to-lymphocyte ratio in diabetic wound healing. J Vasc Surg 2017; 65: 478-83. [CrossRef]

21. Barshes NR, Saedi S, Wrobel J, Kougias P, Kundakcioglu OE, Armstrong DG. A model to estimate cost-savings in diabetic foot ulcer prevention efforts. J Diabetes Complications 2017; 31: 700-7. [CrossRef]

22. Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: the economic case for the limb salvage team. J Vasc Surg 2010; 52(3 Suppl): S17-22. [CrossRef]

23. Stockl K, Vanderplas A, Tafesse E, Chang E. Costs of lower-extremity ulcers among patients with diabetes. Diabetes Care 2004; 27: 2129-34. [CrossRef]

24. Oksuz E, Malhan S, Sonmez B, Numanoglu Tekin R. Cost of illness among patients with diabetic foot ulcer in Turkey. World J Diabetes 2016; 7: 462-9. [CrossRef]

25. Benotmane A, Mohammedi F, Ayad F, Kadi K, Medjbeur S, Azzouz A. Management of diabetic foot lesions in hospital: costs and benefits. Diabetes Metab 2001; 27: 688-94.

26. Currie CJ, Morgan CL, Peters JR. The epidemiology and cost of inpatient care for peripheral vascular disease, infection, neuropathy, and ulceration in diabetes. Diabetes Care 1998; 21: 42-8. [CrossRef]

27. Hicks CW, Selvarajah S, Mathioudakis N, et al. Burden of Infected Diabetic Foot Ulcers on Hospital Admissions and Costs. Ann Vasc Surg 2016; 33: 149-58. [CrossRef]

28. Kubo T, Fujino Y, Murata A, et al. Prevalence of type 2 diabetes among acute inpatients and its impact on length of hospital stay in Japan. Intern Med 2011; 50: 405-11. [CrossRef]

29. Zhao L, Dai Q, Chen X, et al. Neutrophil-to-lymphocyte ratio predicts length of stay and acute hospital cost in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis 2016; 25: 739-44. [CrossRef]