Albumin–globulin ratio (AGR) as independent predictor of poor survival in renal cell carcinoma: A systematic review and meta-analysis

Figures & data

Figure 1. PRISMA diagram of the detailed process of selection of studies for inclusion in the systematic review and meta-analysis.

Table 1. Characteristics of the included studies.

Study	Sample size	Design	Type of intervention	Histopathological type	Tumor stage	Fuhrman grade	AGR cut-off value	Age (years)	Male (%)
Aktepe OH et al. [19] 2021 Turkey	163	Retrospective cohort	Targeted therapy: – Pazopanib: 68.1% – Sunitinib: 31.9%	– Clear cell: 78% – Others: 22%	TNM stage not mentioned	– I-II: 29.7% – III-IV: 70.3%	Low: ≤1.11 High: >1.11	60	72.7%
Chen Z et al. [13] 2017 China	416	Retrospective cohort	Surgery: radical or partial nephrectomy	– Clear cell: 100%	T1 (81.6%), T2 (10.7%), T3 (7.7%) N0 (97.6%), N1 (2.4%)	– I: 21.1% – II: 49.8% – III: 23.4% – IV: 5.7%	Low: ≤1.22 High: >1.22	56.3	62.2%
Chung JW et al. [20] 2020 South Korea	2,970	Retrospective cohort	Surgery: – Radical nephrectomy: 61.6% – Partial nephrectomy: 38.4%	– Clear cell: 79.3% – Others: 20.7%	T1 (80.8%), T2 (7.1%), T3 (11.5%), T4 (0.6%)	– I: 3.9% – II: 48.9% – III: 41.1% – IV: 6.1%	Low: <1.47 High: ≥1.47	55.6	69.2%
He X et al. [21] 2017 China	895	Retrospective cohort	Surgery: radical or partial nephrectomy	– Clear cell: 77.8% – Multilocular cystic: 7.2% – Chromophobe: 3.6% – Others: 11.5%	T1 (68.5%), T2 (18.3%), T3 (9.8%), T4 (3.4%) N0 (92.6%), N1 (7.4%) M0 (95.2%), M1 (4.8%)	– I: 22.9% – II: 36.8% – III: 9.5% – IV: 1.5% – Unknown: 29.4%	Low: ≤1.47 High: >1.47	51.4	67%
Hu J et al. [22] 2022 China	170	Retrospective cohort	Surgery: – Laparoscopic nephron sparing surgery: 100%	– Clear cell: 79.4% – Chromophobe: 5.9% – Oncocytoma: 4.7% – Papillary: 10%	TNM stage not mentioned	– I-II: 77.1% – III-IV: 22.9%	Low: <1.35 High: ≥1.35	52.5	70.6%
Koparal MY et al. [14] 2018	162	Retrospective cohort	Surgery: – Radical nephrectomy: 62.9% – Partical nephrectomy: 37.1%	– Clear cell: 100%	T1-T2 (78.4%), T3-T4 (21.6%)	– I-II: 62.3% – III-IV: 37.7%	Low: ≤1.40 High: >1.40	56.5	63%
Laukhtina E et al. [23] 2021 United States, Russia, France, Canada, Italy, Germany, Saudi Arabia, Iran, Japan, Czech Republic, Austria, Netherlands, Jordan	613	Retrospective cohort	Surgery: – Cytoreductive nephrectomy: 100%	– Clear cell: 86.3% – Others: 13.7%	TNM stage not mentioned	– I-II: 10.6% – III-IV: 89.4%	Low: <1.43 High: ≥1.43	57	69.8%
Mao W et al. [24] 2021 China	343	Retrospective cohort	Surgery: – Radical nephrectomy: 45.5% – Partial nephrectomy: 54.5%	Not mentioned	T1 (75.8%), T2 (6.8%), T3 (14.9%), T4 (2.6%) N0 (96.2%), N1 (3.8%) M0 (95.3%), M1 (4.7%)	– I: 16% – II: 63% – III: 18.7% – IV: 2.3%	Low: ≤1.33 High: >1.33	57.4	65.9%

Table 2. Newcastle-Ottawa quality assessment of observational studies.

First author, year	Study design	Selection^a	Comparability^b	Outcome^c	Total score	Result
Aktepe OH et al. [19] 2021	Cohort	***	**	**	7	Good
Chen Z et al. [13] 2017	Cohort	***	**	**	7	Good
ChungJW et al. [20] 2020	Cohort	***	**	***	8	Good
He X et al. [21] 2017	Cohort	***	**	***	8	Good
Hu J et al. [22] 2022	Cohort	***	**	***	8	Good
Koparal MY et al. [14] 2018	Cohort	***	**	***	8	Good
Laukhtina E et al. [23] 2021	Cohort	***	**	***	8	Good
Mao W et al. [24] 2021	Cohort	***	**	**	7	Good

^a(1) representativeness of the exposed cohort; (2) selection of the non-exposed cohort; (3) ascertainment of exposure; (4) demonstration that outcome of interest was not present at start of study.

^b(1) comparability of cohorts on the basis of design or analysis (maximum two stars).

^c(1) assessment of outcome; (2) was follow-up long enough for outcomes to occur; (3) adequacy of follow up of cohorts.

Figure 2. Forest plot demonstrating the adjusted hazard ratio for low albumin–globulin ratio (AGR) vs high AGR for predicting the overall survival (OS) (a), and cancer-specific survival (CSS) (b) outcomes..

Figure 3. Funnel plot for the adjusted hazard ratio for low albumin-globulin ratio (AGR) vs high AGR for predicting the overall survival (OS) (a), and cancer-specific survival (CSS) (b) outcomes.

Figure 4. Sensitivity analysis using leave-one-out plot of included studies in predicting the overall survival (OS) (a), and cancer-specific survival (CSS) (b) outcomes.

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Chen Z, Shao Y, Yao H, et al. Preoperative albumin to globulin ratio predicts survival in clear cell renal cell carcinoma patients. Oncotarg. 2017 Jul 18;8(29):48291–48302. doi: 10.18632/oncotarget.15162

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Chung JW, Park DJ, Chun SY, et al. The prognostic role of preoperative serum albumin/globulin ratio in patients with non-metastatic renal cell carcinoma undergoing partial or radical nephrectomy. Sci Rep. 2020 Jul 20;10(1):11999. doi: 10.1038/s41598-020-68975-3

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He X, Guo S, Chen D, et al. Preoperative albumin to globulin ratio (AGR) as prognostic factor in renal cell carcinoma. J Cancer. 2017 Jan 15;8(2):258–265. doi: 10.7150/jca.16525

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Hu J, Chen J, Li H, et al. A preoperative nomogram predicting the pseudocapsule status in localized renal cell carcinoma. Transl Androl Urol. 2020 Apr;9(2):462–472. doi: 10.21037/tau.2020.01.26

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Koparal MY, Polat F, Çetin S, et al. Prognostic role of preoperative albumin to globulin ratio in predicting survival of clear cell renal cell carcinoma. Int braz j urol. 2018 Sep–Oct;44(5):933–946. doi: 10.1590/S1677-5538.IBJU.2018.0012

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Laukhtina E, Pradere B, D’Andrea D, et al. Prognostic effect of preoperative serum albumin to globulin ratio in patients treated with cytoreductive nephrectomy for metastatic renal cell carcinoma. Transl Androl Urol. 2021 Feb;10(2):609–619. doi: 10.21037/tau-20-1101

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Mao W, Zhang N, Wang K, et al. Combination of albumin-globulin score and sarcopenia to predict prognosis in patients with renal cell carcinoma undergoing laparoscopic nephrectomy. Front Nutr. 2021 Sep 23;8:731466. doi: 10.3389/fnut.2021.731466

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