Abstract
Mean platelet volume (MPV) may be associated with trauma patients’ outcomes. However, the relationship between the MPV-to-platelet count ratio (MPR) and the result of severe trauma has not been reported. This study aimed to analyze and compare the prognostic performances of MPV and MPR in severe trauma. This retrospective observational study included adult patients admitted for severe trauma between January 2022 and December 2022. Multivariable logistic regression analysis assessed the association of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and MPR for 24-hour mortality. Receiver operating characteristic analysis was used to examine the prognostic performance of MPV, NLR, PLR, and MPR for 24-hour mortality. Among the 325 patients included in the study, 24-hour mortality was 10.8% (n = 35). At admission, non-survivors had lower PLR (26.1 vs 32.5) and higher MPR (0.07 vs 0.04) than survivors. The areas under the receiver operating characteristic curves for MPV, NLR, PLR, and MPR were 0.571 (95% confidence interval [CI], 0.515–0.625), 0.539 (95% CI, 0.484–0.595), 0.618 (95% CI, 0.563–0.671), and 0.715 (95% CI, 0.662–0.763), respectively. The MPR cutoff value for predicting 24-hour mortality was 0.06. Results from multivariable regression analysis revealed that an MPR > 0.06 was independently associated with 24-hour mortality (odds ratio, 3.400; 95% CI, 1.397–8.273), while NLR and PLR were not. MPR is associated with 24-hour mortality in severe trauma and has the potential capacity as a prognostic predictor. MPR could help quickly identify patients with severe trauma and implement appropriate interventions.
Keywords: mean platelet volume, platelet, prognosis, trauma
1. Introduction
Severe trauma is a significant cause of death in patients admitted to the emergency department (ED).[1] Approximately 40% to 60% of deaths caused by trauma occur within the first 24 hours after admission.[2–4] Among the major causes of death related to severe trauma, traumatic brain injuries were the most common cause of death, followed by hemorrhagic shock, accounting for approximately 60% of all traumatic deaths.[2,3] If hemorrhagic shock continues uncontrolled, severe adverse results, including metabolic acidosis, hypotension, and mental change, and death quickly occur.[5] Early transfusion of blood products and active hemostasis are strongly recommended to prevent these serious consequences.[5]
The mean platelet volume (MPV) reflects the size of platelets. Elevation of the MPV suggests platelet production and activation.[6] Studies have found that MPV is closely related to the severity of critically ill patients, including those with cardiovascular disease,[7] ischemic stroke,[8] and post-cardiac arrest syndrome.[9] Several studies reported the relationships between the MPV and severity in trauma patients.[10,11] In 1 study on a small sample of participants, the MPV was likely related to mortality in TBI patients.[10] In another study, MPV was reported to be associated with the Glasgow Coma Scale (GCS) and Revised Trauma Score, both of which reflect trauma severity.[11] Furthermore, the relationship between platelet count and trauma outcomes is well established.[12]
Recently, an inverse correlation between MPV and platelet count has been identified, and the MPV-to-platelet count ratio (MPR) has been shown to be more closely associated with clinical outcomes than either MPV or platelet count alone.[13–15] MPR has gained interest as a composite biomarker that combines 2 interrelated hematological parameters reflecting platelet activation and consumption. Considering the dynamic inflammatory and coagulative responses observed in patients with trauma, MPR may serve as a simple yet powerful marker to predict clinical severity and mortality. However, the association between MPR and the prognosis of patients with severe trauma has not been previously reported. Therefore, this study aimed to analyze and compare the prognostic value of MPV and MPR in cases of severe trauma.
2. Materials and methods
2.1. Study design and population
We conducted a retrospective observational study of adult patients (aged ≥ 18 years) with severe trauma who were admitted to Chonnam National University Hospital between January 2022 and December 2022. Severe trauma was defined as an Injury Severity Score (ISS) of 16 points or higher. Patients were excluded if they arrived at the ED more than 3 hours after injury, had hematological disorders, or did not undergo blood sampling. Our hospital Institutional Review Board approved this study. As this was a retrospective study, the requirement for informed consent was waived.
2.2. Data collection
The following clinical variables were obtained from each patient’s electronic medical record: age, sex, trauma mechanism, preexisting illness, initial GCS score, systolic blood pressure (SBP, mm Hg) at admission, respiratory status at admission, transfusion amounts of packed red blood cells (PRC), fresh frozen plasma, platelet concentrate during the first 24 hours after admission, and the 24-hour mortality. Laboratory results, including white blood cells, neutrophil count, lymphocyte count, hemoglobin level, platelet count, and MPV, were obtained at the time of arrival at the ED. The MPR was calculated by dividing the MPV by the platelet concentrate. The neutrophil-to-lymphocyte ratio (NLR) values were calculated from the neutrophil and the lymphocyte. The platelet-to-lymphocyte ratio (PLR) values were calculated from the platelet count and the lymphocyte. The abbreviated injury scale and the ISS were obtained using information from the electronic medical record. Massive transfusion was defined as a transfusion of > 10 units of PRCs within the first 24 hours of admission or > 4 units within 1 hour of admission.[16] The primary outcome was the 24-hour mortality, and the secondary outcome was massive transfusion.
2.3. Statistical analysis
Continuous variables that did not show a normal distribution were analyzed using the Mann–Whitney U test. The chi-square test was used to compare categorical variables. Continuous variables are presented as median values with interquartile ranges, and categorical variables are presented as frequencies and percentages. Receiver operating characteristic (ROC) analysis was used to examine the prognostic performance of the MPV, NLR, PLR, and MPR for 24-hour mortality and massive transfusion. A comparison of dependent ROC curves was performed using the DeLong et al method.[17] The optimal cutoff values were determined using the Youden index.
We conducted a multivariable analysis using logistic regression of relevant covariates for 24-hour mortality. The multivariable regression model included variables with P < .10 in univariate comparisons. We used a backward stepwise approach, sequentially eliminating variables with a threshold of P > .10 to build a final adjusted regression model. Finally, malignancy, GCS score, and SBP were identified as adjustment variables (Table S1, Supplemental Digital Content, https://links.lww.com/MD/P773). Additionally, age, male gender, type of trauma, and ISS, which are important prognostic factors for patients with trauma, were included in the final model. Then, each of the following markers was separately entered into the final model for analysis: NLR, PLR, and MPR. According to the optimal cutoff value determined by ROC analysis, MPR was dichotomized at > 0.06 for use in the multivariable regression model. Logistic regression analysis results are presented as odds ratios (OR) and 95% confidence intervals (CI). All analyses were performed using PASW/SPSS™ software, version 18 (IBM Inc., Chicago) and MedCalc, version 19.0 (MedCalc Software, bvba, Ostend, Belgium). A 2-sided significance level of 0.05 was defined as statistically significant.
3. Results
3.1. Patient selection and baseline characteristics
A total of 411 adult patients with severe trauma presented to the ED during the study period, of whom 325 were included in the final analysis, with the rest excluded owing to hematological disorders (n = 3), delayed presentation (>3 hours post-injury; n = 82), and lack of blood sampling (n = 1) (Fig. 1). The median age of the patients was 62.0 (46.0–72.0) years, and the median ISS was 22 (17–25). The 24-hour mortality was 10.8% (n = 35), and MT was performed in 24 (7.4%) patients. Non-survivors had higher ISS and lower GCS scores and SBP compared with survivors (Table 1). In laboratory findings, non-survivors had lower hemoglobin levels, platelet counts, PLR, and higher MPR than survivors. Non-survivors received more PRC within 24 hours after admission and massive transfusion than survivors (Table 1).
Figure 1.
Patient selection flow diagram. ED = emergency department; ISS = Injury Severity Score.
Table 1.
Comparison of the baseline characteristics of patients with severe trauma according to mortality within 24 hours.
| Variables | Total patients (N = 325) | Survivors (n = 290) | Non-survivors (n = 35) | P |
|---|---|---|---|---|
| Age (yr) | 62.0 (46.0–72.0) | 60.0 (44.0–72.0) | 69.0 (56.0–75.0) | .050 |
| Male, n (%) | 242 (74.5) | 213 (73.4) | 29 (82.9) | .317 |
| Mechanism of trauma, n (%) | .757 | |||
| Blunt | 297 (91.4) | 266 (91.7) | 31 (88.6) | |
| Penetrating | 28 (8.6) | 24 (8.3) | 4 (11.4) | |
| Preexisting illness, n (%) | ||||
| Congestive heart failure | 7 (2.2) | 6 (2.1) | 1 (2.9) | 1.000 |
| Arrythmia | 4 (1.2) | 3 (1.0) | 1 (2.9) | .911 |
| Coronary artery disease | 17 (5.2) | 15 (5.2) | 2 (5.7) | 1.000 |
| Hypertension | 94 (28.9) | 85 (29.3) | 9 (25.7) | .806 |
| Diabetes | 62 (19.1) | 59 (20.3) | 3 (8.6) | .148 |
| Stroke | 14 (4.3) | 14 (4.8) | 0 (0.0) | .374 |
| Renal impairment | 4 (1.2) | 4 (1.4) | 0 (0.0) | 1.000 |
| Pulmonary disease | 5 (1.5) | 3 (1.0) | 2 (5.7) | .162 |
| Liver cirrhosis | 6 (1.8) | 4 (1.4) | 2 (5.7) | .256 |
| Malignancy | 22 (6.8) | 17 (5.9) | 5 (14.3) | .129 |
| Injury Severity Score | 22 (17–25) | 21 (17–25) | 25 (25–34) | <.001 |
| Glasgow Coma Scale score | 15 (9–15) | 15 (11–15) | 3 (3–7) | <.001 |
| Systolic blood pressure, mm Hg | 120 (80–140) | 120 (90–140) | 70 (60–140) | <.001 |
| Respiratory rate, /min | 20 (20–20) | 20 (20–20) | 20 (20–20) | .642 |
| Laboratory findings at admission | ||||
| White blood cell count, ×109/L | 12.2 (9.0–16.9) | 12.1 (9.1–17.0) | 13.3 (8.7–16.7) | .933 |
| Hemoglobin, g/dL | 12.7 (11.3–14.2) | 12.8 (11.4–14.2) | 11.7 (8.9–14.1) | .016 |
| Platelet counts, ×109/L | 211 (164–256) | 213 (169–258) | 153 (105–213) | <.001 |
| MPV, fL | 9.6 (9.0–10.2) | 9.6 (9.0–10.1) | 9.7 (9.2–10.2) | .172 |
| NLR | 0.45 (0.20–1.30) | 0.45 (0.19–1.38) | 0.53 (0.27–1.03) | .445 |
| PLR | 30.52 (17.33–59.84) | 32.54 (18.28–63.56) | 26.13 (13.76–34.77) | .023 |
| MPR | 0.05 (0.04–0.06) | 0.04 (0.04–0.06) | 0.07 (0.04–0.09) | <.001 |
| PRC within 24 h | 0 (0–3)1 | 0 (0–1) | 2 (0–4) | <.001 |
| FFP within 24 h | 0 (0–0) | 0 (0–0) | 0 (0–2) | .165 |
| PC within 24 h | 0 (0–0) | 0 (0–0) | 0 (0–0) | .432 |
| Massive transfusion, n (%) | 24 (7.4) | 14 (4.8) | 10 (28.6) | <.001 |
FFP = fresh frozen plasma, MPR = mean platelet volume-to-platelet count ratio, MPV = mean platelet volume, NLR = neutrophil-to-lymphocyte ratio, PC = platelet concentrate, PLR = platelet-to-lymphocyte ratio, PRCs = packed red blood cells.
3.2. Association of MPV, NLR, PLR, and MPR for 24-hour mortality and massive transfusion
The areas under the ROC curves (AUCs) for MPV, NLR, PLR, and MPR in predicting 24-hour mortality and massive transfusion are presented in Figure 2 and Table 2.
Figure 2.
Receiver operating characteristics curve analyses of the MPV, NLR, PLR, and MPR for 24-hour mortality (A) and massive transfusion (B). MPR = mean platelet volume-to-platelet count ratio; MPV = mean platelet volume; NLR = neutrophil-to-lymphocyte ratio; PLR = platelet-to-lymphocyte ratio.
Table 2.
ROC curve analysis of MPV, NLR, PLR, and MPR for predicting 24-hour mortality and massive transfusion.
| Variables | Cutoff | AUC (95% CI) | P | Sensitivity (95% CI) | Specificity (95% CI) | |
|---|---|---|---|---|---|---|
| For 24-h mortality | MPV | >9.9 | 0.571 (0.515–0.625) | .150 | 45.7 (28.8–63.4) | 71.0 (65.4–76.2) |
| NLR | >0.21 | 0.539 (0.484–0.595) | .369 | 88.6 (73.3–96.8) | 29.0 (23.8–34.6) | |
| PLR | ≤34.8 | 0.618 (0.563–0.671) | .020 | 77.1 (59.9–89.6) | 47.6 (41.7–53.5) | |
| MPR | >0.06 | 0.715 (0.662–0.763) | <.001 | 60.0 (42.1–76.1) | 79.7 (74.6–84.1) | |
| For massive transfusion | MPV | >9.5 | 0.659 (0.605–0.711) | .002 | 79.2 (57.8–92.9) | 48.8 (43.1–54.6) |
| NLR | >0.68 | 0.602 (0.546–0.655) | .049 | 58.3 (36.6–77.9) | 64.8 (59.1–70.2) | |
| PLR | ≤15.0 | 0.555 (0.499–0.610) | .437 | 37.5 (18.8–59.4) | 82.4 (77.6–86.5) | |
| MPR | >0.05 | 0.743 (0.692–0.790) | <.001 | 75.0 (53.3–90.2) | 69.1 (63.5–74.3) |
AUC = area under the receiver operating characteristic curve, CI = confidence interval, MPR = mean platelet volume-to-platelet count ratio, MPV = mean platelet volume, NLR = neutrophil-to-lymphocyte ratio, PLR = platelet-to-lymphocyte ratio, ROC = receiver operating characteristic.
With respect to 24-hour mortality, the AUCs for MPV, NLR, PLR, and MPR were 0.571 (95% CI, 0.515–0.625), 0.539 (95% CI, 0.484–0.595), 0.618 (95% CI, 0.563–0.671), and 0.715 (95% CI, 0.662–0.763), respectively (Fig. 2A and Table 2). The MPR cutoff value for predicting 24-hour mortality was 0.06, with a sensitivity of 60.0% and a specificity of 79.7% (Table 2). Moreover, the AUC for MPR was significantly different from the AUCs for MPV, NLR, and PLR.
Regarding massive transfusion, the AUCs for MPV, NLR, PLR, and MPR were 0.659 (95% CI, 0.605–0.711), 0.602 (95% CI, 0.546–0.655), 0.555 (95% CI, 0.499–0.610), and 0.743 (95% CI, 0.692–0.790), respectively (Fig. 2B and Table 2). The MPR cutoff value for predicting massive transfusion was 0.05, with a sensitivity of 75.0% and a specificity of 69.1% (Table 2). The AUC for MPR was significantly higher than that for PLR, but not significantly different from that for MPV or NLR.
Table 3 shows the results of the multivariable analysis for 24-hour mortality. After confounders were adjusted for, MPR > 0.06 was found to be independently associated with 24-hour mortality (OR, 3.400; 95% CI, 1.397–8.273), whereas NLR and PLR exhibited no association with 24-hour mortality in the multivariable analysis (Table 3).
Table 3.
Multivariable logistic regression analysis of NLR, PLR, and MPR for predicting 24-hour mortality.
| Unadjusted OR (95% CI) | P | Adjusted OR (95% CI)* | P | |
|---|---|---|---|---|
| NLR | 0.955 (0.835–1.091) | .495 | 0.950 (0.783–1.153) | .604 |
| PLR | 1.001 (0.996–1.005) | .816 | 1.000 (0.999–1.001) | .602 |
| MPR > 0.06 | 5.873 (2.818–12.238) | <.001 | 3.400 (1.397–8.273) | .007 |
Each variable was individually entered into the final model and analyzed separately.
CI = confidence interval, GCS = Glasgow Coma Scale, ISS = Injury Severity Score, MPR = mean platelet volume-to-platelet count ratio, NLR = neutrophil-to-lymphocyte ratio, OR = odds ratio, PLR = platelet-to-lymphocyte ratio, SBP = systolic blood pressure.
Adjusted for age, male gender, mechanism of trauma, malignancy, ISS, GCS, and SBP.
4. Discussion
Our study represents one of the few investigations of the association of the MPR with prognosis and its role as a prognostic predictor in patients with severe trauma. We found that elevated MPR value was associated with worse outcomes in patients with severe trauma. This association remained consistent even after adjusting for the effects of other factors, and the ROC analysis also showed that MPR was higher than the NLR and the PLR, suggesting its potential as a prognostic predictor.
Overproduction of pro-inflammatory cytokines and acute-phase reactants may inhibit the release of small-sized platelets from the bone marrow, leading to increased MPV in the acute-phase inflammatory response.[18,19] In a study by Zampieri et al, the 24-hour change rate of the MPV in critically ill patients had a significant relationship with prognosis. Still, the MPV at admission was not associated with survival rate.[20] Yolcu et al investigated MPV in patients with trauma and showed that initial MPV was associated with trauma severity but not with survival.[12] Similarly, Alper et al, who compared trauma patients with non-traumatized patients, found no significant differences between the 2 groups.[21] In the present study, there was no difference in the MPV between the survivors and non-survivors.
Recent studies have suggested that the MPV and platelet count combination can be more significant than the MPV or platelet count alone.[13–15] The MPR in patients with ascending thoracic aortic aneurysm was higher than that in healthy groups, and the MPR had better performance for inflammation than the MPV in ROC analysis.[13] In patients with glioblastoma, high MRP was associated with the progression of the disease, not with overall survival.[14] In community-acquired pneumonia, the MPR was related to 60-day mortality.[15] In pediatric trauma admitted to the intensive care unit, the MPR of non-survivors was higher than that of survivors at admission (0.07 vs 0.03), consistent with the present study.[22] In a study involving injured patients admitted to the surgical intensive care unit, MPR was reported to be higher in non-survivors than in survivors (0.047 vs 0.034).[23] Additionally, in patients with aneurysmal subarachnoid hemorrhage, MPR was higher in the deceased patients (Modified Rankin Scale [mRS] = 6) than those with poor (3 ≤ mRS ≤ 5) or favorable (mRS ≤ 2) outcomes (0.059 vs 0.0.48 vs 0.046, respectively).[24] Hence, MPR appears to be a promising marker for early mortality prediction; however, its cutoff values require further validation in prospective studies.
NLR is a reliable marker for diagnosing bacteremia, sepsis, cancer, and cardiovascular disease.[25] One previous study revealed that high NLR is associated with mortality in critically ill trauma patients, and the NLRs at day 2 and day 5 have values of 0.774 and 0.714 for mortality in ROC analysis.[26] In this study, the NLR was not associated with 24-hour mortality, which is consistent with the present study.[26] Previous studies have proven that the NLR can change rapidly within a short period after an injury, so caution is required when interpreting its relationship to prognosis.[27]
The PLR is a marker reflecting changes in platelet and lymphocyte counts indicative of acute inflammatory and thrombotic conditions and has been extensively studied in the context of immunosuppression and tumor diseases associated with thrombosis.[28] In a study by El-Menyar et al, the PLR was correlated with the ISS and revised trauma score, and the AUC value of the PLR was 0.77 for in-hospital mortality.[29] Another study for patients with traffic accidents showed AUC PLC values for in-hospital mortality of 0.82 (95% CI, 0.74–0.89).[30] However, the PLR was not associated with 24-hour mortality in the present study. We assume that these differences are due to differences in sampling time. In trauma patients with massive transfusion, platelet count at admission was not associated with 24-hour mortality in multivariable analysis.[31] Lymphocytes showed no difference between survivors and dead until 2 hours after injury in a study conducted at a major urban trauma center.[32] Studies on the prognosis of trauma using the PLR over time are needed to investigate these differences.
Our study has several limitations. First, retrospective studies may limit the ability to establish causal relationships and may reflect inherent biases in data collection. Second, findings from studies conducted at a single institution may not be generalizable to different populations or healthcare settings. Third, further consideration was needed for factors affecting the NLR, PLR, and MPR. Although sufficient adjustments were made within our study, it is difficult to take into account factors that may influence due to the nature of the factors investigated. Fourth, this study lacked internal validation across different patient groups or time periods to confirm MPR as a prognostic factor. Thus, future studies are needed to investigate the reliability and stability of MPR as a prognostic factor for patients with trauma. Finally, the relationship between the NLR, PLR, and MPR according to cause of death was not investigated. It would be better to understand the inflammatory response if the relationship between each variable for exsanguination, central nervous system injury, or multiple organ failure was investigated. Future studies on the relationship between causes of death and inflammatory response are needed.
5. Conclusion
The MPR is associated with 24-hour mortality in severe trauma and has a potential capacity as a prognostic predictor. The MPR, which can be detected early with an inexpensive test, could help quickly identify patients with severe trauma and allow for the implementation of appropriate interventions.
Author contributions
Conceptualization: Donghun Lee, Jiho Lee.
Data curation: Seokjin Ryu, Donghun Lee.
Formal analysis: Seokjin Ryu, Donghun Lee, Jiho Lee.
Funding acquisition: Jiho Lee.
Investigation: Seokjin Ryu, Donghun Lee.
Methodology: Donghun Lee, Byungkook Lee.
Project administration: Donghun Lee.
Resources: Donghun Lee.
Software: Donghun Lee.
Supervision: Byungkook Lee.
Writing – original draft: Seokjin Ryu, Donghun Lee, Jiho Lee.
Writing – review & editing: Seokjin Ryu, Donghun Lee, Jiho Lee, Byungkook Lee.
Supplementary Material
Abbreviations:
- AUC
- areas under the receiver operating characteristic curve
- CI
- confidence interval
- ED
- emergency department
- GCS
- Glasgow Coma Scale
- ISS
- Injury Severity Score
- MPR
- mean platelet volume-to-platelet count ratio
- MPV
- mean platelet volume
- mRS
- Modified Rankin Scale
- NLR
- neutrophil-to-lymphocyte ratio
- OR
- odds ratio
- PLR
- platelet-to-lymphocyte ratio
- PRC
- packed red blood cells
- ROC
- receiver operating characteristic
- SBP
- systolic blood pressure
This research was supported by a grant from Chonnam National University Hospital Biomedical Research Institute (BCRI-24079).
Chonnam National University Hospital’s Institutional Review Board approved the study (CNUH-2023-153) and informed consent was waived because of the retrospective nature of the study.
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Supplemental Digital Content is available for this article.
How to cite this article: Ryu S, Lee D, Lee J, Lee B. Association of mean platelet volume-to-platelet count ratio for 24-hour mortality in patients with severe trauma. Medicine 2025;104:35(e44165).
Contributor Information
Seokjin Ryu, Email: samahalak@naver.com.
Jiho Lee, Email: bbukkuk@hanmail.net.
Byungkook Lee, Email: bbukkuk@hanmail.net.
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