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Journal of Peking University (Health Sciences) ›› 2023, Vol. 55 ›› Issue (1): 149-155. doi: 10.19723/j.issn.1671-167X.2023.01.023

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Pre-operative prognostic nutritional index as a predictive factor for prognosis in non-metastatic renal cell carcinoma treated with surgery

Quan ZHANG,Hai-feng SONG,Bing-lei MA,Zhe-nan ZHANG,Chao-hui ZHOU,Ao-lin LI,Jun LIU,Lei LIANG,Shi-yu ZHU,Qian ZHANG*()   

  1. Department of Urology, Peking University First Hospital; Institute of Urology, Peking University; National Urological Cancer Center, Beijing 100034, China
  • Received:2020-06-12 Online:2023-02-18 Published:2023-01-31
  • Contact: Qian ZHANG E-mail:zhangqianbjmu@126.com

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Abstract:

Objective: To evaluate the implications of the prognostic nutrition index (PNI) in non-metastatic renal cell carcinoma (RCC) patients treated with surgery and to compare it with other hematological biomarkers, including neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and systemic immune inflammation index (SII). Methods: A cohort of 328 non-metastatic RCC patients who received surgical treatment between 2010 and 2012 at Peking University First Hospital was analyzed retrospectively. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cutoff values of the hematological biomarkers. The Youden index was maximum for PNI was value of 47.3. So we divided the patients into two groups (PNI≤ 47. 3 and >47. 3) for further analysis. Categorical variables [age, gender, body mass index (BMI), surgery type, histological subtype, necrosis, pathological T stage and tumor grade] were compared using the Chi-square test and Student' s t test. The association of the biomarkers with overall survival (OS) and disease-free survival (DFS) was analyzed using Kaplan-Meier methods with log-rank test, followed by multivariate Cox proportional hazards model. Results: According to the maximum Youden index of ROC curve, the best cut-off value of PNI is 47. 3. Low level of PNI was significantly associated with older age, lower BMI and higher tumor pathological T stage (P < 0.05). Kaplan-Meier univariate analysis showed that lower PNI was significantly correlated with poor OS and DFS (P < 0.05). In addition, older age, lower BMI, tumor necrosis, higher tumor pathological T stage and Fuhrman grade were significantly correlated with poor OS (P < 0.05). Cox multivariate analysis showed that among the four hematological indexes, only PNI was an independent factor significantly associated with OS, whether as a continuous variable (HR=0.9, 95%CI=0.828-0.978, P=0.013) or a classified variable (HR=2.397, 95%CI=1.061-5.418, P=0.036). Conclusion: Low PNI was a significant predictor for advanced pathological T stage, decreased OS, or DFS in non-metastatic RCC patients treated with surgery. In addition, PNI was superior to the other hematological biomar-kers as a useful tool for predicting prognosis of RCC in our study. It should be externally validated in future research before the PNI can be used widely as a predictor of RCC patients undergoing nephrectomy.

Key words: Prognostic nutrition index, Renal cell carcinoma, Nephrectomy, Prognosis

CLC Number: 

  • R737.11

Figure 1

ROC curve for PNI, NLR, SII, and PLR PNI, prognostic nutritional index; NLR, neutrophil to lymphocyte ratio; PLR, platelet to lymphocyte ratio; SII, systemic immune inflammation index; ROC, receiver operating characteristic."

Table 1

The AUC, optimal cut-off values for PNI, NLR, SII, and PLR"

Items PNI NLR SII PLR
AUC 0.751 0.737 0.729 0.719
95%CI 0.700-0.796 0.685-0.784 0.678-0.776 0.667-0.767
P value < 0.000 1 < 0.000 1 < 0.000 1 < 0.000 1
Sensitivity/% 72.5 70.0 70.0 67.5
Specificity/% 67.36 72.57 67.71 67.36
Cut-off value ≤47.30 >2.52 >489.80 >131.25

Table 2

Associations of clinicopathological features with different groups of PNI, NLR, SII, and PLR in renal cell carcinoma patients underwent surgery"

Variable PNI NLR SII PLR
≤47.30 (n = 123) >47.30 (n=205) P ≤2.52 (n =220) >2.52 (n= 108) P ≤489.80 (n=206) >489.80 (n = 122) P ≤131.25 (n=207) >131.25 (n = 121) P
Age/years 60.11 ±11.93 53.89 ±13.51 < 0.001 54.78 ±13.98 59. 18 ±11.19 0.005 55.78 ±13.65 56.98 ±12.63 0.432 55.67 ±13.15 57.18 ±13.47 0.319
BMI 23.76 ±3.08 25.54 ±3.40 < 0.001 25.24 ±3.46 24. 12 ±3. 13 0.005 25.17 ±3.46 24.38 ±3.21 0.041 25.47 ±3.44 23.84 ±3.05 < 0.001
Gender 0.802 0.500 0.281 < 0.001
  Male 86 (37.1) 146 (62.9) 153 (65.9) 79 (34.1) 150 (64.7) 82 (35.3) 160 (69.0) 72 (31.0)
  Female 37 (38.5) 59 (61.5) 67 (69.8) 29 (30.2) 56 (58.3) 40 (41.7) 47 (49.0) 49 (51.0)
Surgery 0.060 0.003 0.001 0.005
  PN 25 (29.1) 61 (70.9) 69 (80.2) 17 (19.8) 67 (77.9) 19 (22.1) 65 (75.6) 21 (24.4)
  RN 98 (40.5) 144 (59.5) 151 (62.4) 91 (37.6) 139 (57.4) 103 (42.6) 142 (58.7) 100 (41.3)
Histopalhology 0.723 0.561 0.745 0.708
  Clear cell 105 (37.9) 172 (62.1) 184 (66.4) 93 (33.6) 175 (63.2) 102 (36.8) 176 (63.5) 101 (36.5)
  No dear cell 18 (35.3) 33 (64.7) 36 (70.6) 15 (29.4) 31 (60.8) 20 (39.2) 31 (60.8) 20 (39.2)
Necrosis 0.628 0.096 0.013 0.005
  Yes 93 (36.6) 161 (63.4) 176 (69.3) 78 (30.7) 169 (66.5) 85 (33.5) 171 (67.3) 83 (32.7)
  No 29 (39.7) 44 (60.3) 43 (58.9) 30 (41.1) 37 (50.7) 36 (49.3) 36 (49.3) 37 (50.7)
pT stage < 0.001 < 0.001 < 0.001 < 0.001
  pT1-2 77 (30.4) 176 (69.6) 192 (75.9) 61 (24.1) 175 (69.2) 78 (30.8) 179 (70.8) 74 (29.2)
  pT3-4 46 (61.3) 29 (38.7) 28 (37.3) 47 (62.7) 31 (41.3) 44 (58.7) 28 (37.3) 121 (62.7)
Fuhnnan grade 0.327 0.002 0.002 0.001
  G1-2 106 (36.6) 184 (63.4) 203 (70.0) 87 (20.0) 191 (65.9) 99 (34.1) 192 (66.2) 98 (33.8)
  G3-4 17 (44.7) 21 (55.3) 17 (44.7) 21 (55.3) 15 (39.5) 23 (60.5) 15 (39.5) 23 (60.5)

Figure 2

Kaplan-Meier curves of OS(A) and DFS(B) in renal cell carcinoma patients underwent surgery based on the PNI OS, overall survival; DFS, disease free survival; PNI, prognostic nutritional index."

Table 3

Univariate and multivariate analyses of clinicopathological parameters and the biomarkers to predict OS in non-metastatic renal cell carcinoma patients underwent surgery"

VariableOS
Univariate Multivariate Multivariate
HR (95%CI) P HR (95%CI) P HR (95%CI) P
Age (continuous) 1.035 (1.009-1.062) 0.007 1.022 (0.994-1.052) 0.124 1.026 (0.997-1.055) 0.080
Gender (female) 0.797 (0.390-1.631) 0.534
BMI (continuous) 0.854 (0.773-0.944) 0.002 0.961 (0.864-1.069) 0.465 0.948 (0.854-1.053) 0.322
Surgery method 0.028 0.801 0.829
  PN 1 1 1
  RN 2.852 (1.117-7.285) 0.871 (0.296-2.558) 0.890 (0.308-2.570)
Histopathology (no clear cell) 2.018 (0.959-4.245) 0.064 2.065 (0.920-4.637) 0.079 2.708 (1.236-5.933) 0.013
Necrosis (yes) 4.071 (2.188-7.575) < 0.001 1.673 (0.735-3.807) 0.220 2.143 (0.935-4.910) 0.072
pT stage < 0.001 0.052 0.221
  pT1-2 1 1 1
  pT3-4 5.611 (2.995-10.512) 2.130 (0.993-4.571) 1.625 (0.747-3.533)
Fuhrman grade < 0.001 0.010 0.044
  G1-2 1 1 1
  G3-4 6.668 (3.559-12.493) < 0.001 3.150 (1.323-7.500) 2.363 (1.024-5.454)
PNI (continuous) 0.831 (0.785-0.879) < 0.001 0.900 (0.828-0.978) 0.013
NLR (continuous) 1.204 (1.108-1.309) < 0.001 0.765 (0.568-1.032) 0.080
SII (continuous) 1.001 (1.001-1.001) < 0.001 1.000 (0.999-1.001) 0.790
PLR (continuous) 1.005 (1.003-1.006) < 0.001 1.007 (1.001-1.014) 0.025
PNI (≤47.30) 5.252 (2.619-10.529) < 0.001 2.397 (1.061-5.418) 0.036
NLR (>2.52) 5.383 (2.735-10.593) < 0.001 1.797 (0.660-4.895) 0.252
SII (>489.80) 4.525 (2.299-8.906) < 0.001 1.587 (0.527-4.780) 0.412
PLR (>131.25) 4.390 (2.263-8.516) < 0.001 1.140 (0.451-2.879) 0.782
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