Observational Study
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 21, 2024; 30(7): 685-704
Published online Feb 21, 2024. doi: 10.3748/wjg.v30.i7.685
Red cell distribution width/platelet ratio estimates the 3-year risk of decompensation in Metabolic Dysfunction-Associated Steatotic Liver Disease-induced cirrhosis
Marcello Dallio, Mario Romeo, Paolo Vaia, Salvatore Auletta, Simone Mammone, Marina Cipullo, Luigi Sapio, Angela Ragone, Marco Niosi, Silvio Naviglio, Alessandro Federico
Marcello Dallio, Mario Romeo, Paolo Vaia, Salvatore Auletta, Simone Mammone, Marina Cipullo, Marco Niosi, Alessandro Federico, Department of Precision Medicine, Hepatogastroenterology Division, University of Campania Luigi Vanvitelli, Naples 80138, Italy
Luigi Sapio, Angela Ragone, Silvio Naviglio, Department of Precision Medicine, Clinical Biochemistry Division, University of Campania Luigi Vanvitelli, Naples 80138, Italy
Co-first authors: Marcello Dallio and Mario Romeo.
Author contributions: Romeo M is responsible for guarantor of the article, conceptualization, methodology, investigation, and writing the original draft; Vaia P, Auletta S, Mammone S, Dallio M are responsible for conceptualization, methodology, formal analysis, investigation, and writing the original draft; Cipullo M, Niosi M are responsible for investigation, resources, data curation, and visualization; Naviglio S, Sapio L are responsible for reviewing the original draft; Ragone A is responsible for visualization; Federico A is responsible for conceptualization, data curation, supervision; all authors approved the final version of the manuscript. In light of the shared collaborative effort, as well as the distribution of responsibilities and burdens to complete the study, Dallio M and Romeo M were designated as co-first authors.
Institutional review board statement: The study was reviewed and approved by the Comitato Etico Università degli Studi della Campania "Luigi Vanvitelli" -Azienda Ospedaliera Universitaria “Luigi Vanvitelli”- AORN “Ospedali dei Colli" Institutional Review Board (Approval No. 417).
Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: The authors declare no competing interests.
Data sharing statement: The data presented in this study are available on request from the corresponding author.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Silvio Naviglio, MD, PhD, Full Professor, Department of Precision Medicine, Clinical Biochemistry Division, University of Campania Luigi Vanvitelli, Via L. De Crecchio 7, Naples 80138, Italy. silvio.naviglio@unicampania.it
Received: December 11, 2023
Peer-review started: December 11, 2023
First decision: December 14, 2023
Revised: December 19, 2023
Accepted: January 17, 2024
Article in press: January 17, 2024
Published online: February 21, 2024

For compensated advanced chronic liver disease (cACLD) patients, the first decompensation represents a dramatically worsening prognostic event. Based on the first decompensation event (DE), the transition to decompensated advanced chronic liver disease (dACLD) can occur through two modalities referred to as acute decompensation (AD) and non-AD (NAD), respectively. Clinically Significant Portal Hypertension (CSPH) is considered the strongest predictor of decompensation in these patients. However, due to its invasiveness and costs, CSPH is almost never evaluated in clinical practice. Therefore, recognizing non-invasively predicting tools still have more appeal across healthcare systems. The red cell distribution width to platelet ratio (RPR) has been reported to be an indicator of hepatic fibrosis in Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD). However, its predictive role for the decompensation has never been explored.


In this observational study, we investigated the clinical usage of RPR in predicting DEs in MASLD-related cACLD patients.


Fourty controls and 150 MASLD-cACLD patients were consecutively enrolled and followed up (FUP) semiannually for 3 years. At baseline, biochemical, clinical, and Liver Stiffness Measurement (LSM), Child-Pugh (CP), Model for End-Stage Liver Disease (MELD), aspartate aminotransferase/platelet count ratio index (APRI), Fibrosis-4 (FIB-4), Albumin-Bilirubin (ALBI), ALBI-FIB-4, and RPR were collected. During FUP, DEs (timing and modaities) were recorded. CSPH was assessed at the baseline and on DE occurrence according to the available Clinical Practice Guidelines.


Of 150 MASLD-related cACLD patients, 43 (28.6%) progressed to dACLD at a median time of 28.9 months (29 NAD and 14 AD). Baseline RPR values were significantly higher in cACLD in comparison to controls, as well as MELD, CP, APRI, FIB-4, ALBI, ALBI-FIB-4, and LSM in dACLD-progressing compared to cACLD individuals [all P < 0.0001, except for FIB-4 (P: 0.007) and ALBI (P: 0.011)]. Receiving operator curve analysis revealed RPR > 0.472 and > 0.894 as the best cut-offs in the prediction respectively of 3-year first DE, as well as its superiority compared to the other non-invasive tools examined. RPR (P: 0.02) and the presence of baseline-CSPH (P: 0.04) were significantly and independently associated with the DE. Patients presenting baseline-CSPH and RPR > 0.472 showed higher risk of decompensation (P: 0.0023).


Altogether these findings suggest the RPR as a valid and potentially applicable non-invasive tool in the prediction of timing and modalities of decompensation in MASLD-related cACLD patients.

Keywords: Liver cirrhosis, Red blood cell distribution width, Red blood cell distribution width to platelet ratio, Translational Medicine, Prognostic biomarker

Core Tip: The availability of non-invasive tools predicting the first decompensation event (DE) in Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)-related compensated advanced chronic liver disease (cACLD) context is still demanded. Red cell distribution width to platelet ratio (RPR) has been shown to predict fibrosis in MASLD. Herein, we demonstrate that: (1) RPR predicts the first DE in MASLD-cACLD; (2) RPR predicts acute decompensation as the first DE in these patients; and (3) Patients presenting baseline Clinically Significant Portal Hypertension and RPR > 0.472 show higher risk of 3-year decompensation occurrence. Overall, RPR predicts time and modalities of DE in MASLD-related-ACLD patients, presenting the potential to be a valuable, easy-to perform, non-invasive clinical index.