The AST/ALT (De Ritis) ratio as a significant prognostic factor in myelodysplastic syndrome

Figures & data

Table 1. AST/ALT ratio in relation to clinical and laboratory features in MDS patients.

Characteristic	All patients	Low AST/ALT (n = 109)	High AST/ALT (n = 156)	P value
Gender, n (%)				0.220
Male	156(59.3)	69(63.3)	87(55.8)
Female	109(40.7)	40(36.7)	69(44.2)
Age, years median (range)	63(16-91)	63(16-86)	66(18-91)	<0.001
ANC, (×10^9/L) median (range)	1.2(0-7.4)	1.2(0.1-6.9)	1.1(0-7.4)	0.132
HB (g/L) median (range)	7.4(2.2-14.2)	7.35(2.5-14.2)	7.3(2.2-14.2)	0.946
PLT (109/L) median (range)	55(2-434)	55(2-434)	58(2-332)	0.796
Bone marrow blast (%) median (range)	5(0-19.5)	5.25(0-19.5)	6(0-19.5)	0.439
SF, μg/L median (range)	302.8(5.52-2612)	303.9(12.5-1500)	301.6(5.52-2612)	0.808
β2-MG, μg/L median (range)	2.00(0.04-7.76)	1.73(0.04-4.57)	2.18(0.4-7.76)	<0.001
LDH, U/L median (range)	200(54-1083)	198(106-789)	203(54-1083)	0.980
IPSS-R risk, n (%)				0.076
Very good	11(4.78)	5(5.4)	6(4.3)
Good	40(17.4)	17(18.5)	23(16.7)
Intermediate	74(32.2)	26(28.3)	48(34.8)
Poor	52(22.6)	15(16.3)	37(26.8)
Very poor	53(23.0)	29(31.5)	24(17.4)
IPSS-M risk, n (%)				0.555
Very low	7(6.5)	5(10.0)	2(3.5)
Low	14(13.1)	6(12.0)	8(14.0)
Moderate low	12(11.2)	6(12.0)	6(10.5)
Moderate high	19(17.8)	6(12.0)	13(22.8)
High	19(17.8)	10(20.0)	9(15.8)
Very high	36(33.6)	17(34.0)	19(33.4)
2016 WHO classification, n (%)				0.441
MDS-SLD	18(6.8)	8(7.3)	10(6.4)
MDS-MLD	74(27.9)	35(32.1)	39(25.0)
MDS-RS-SLD	9(3.4)	4(3.7)	5(3.2)
MDS-RS-MLD	8(3.0)	5(4.6)	3(1.9)
MDS-5q-	6(2.3)	2(1.8)	4(2.6)
MDS-EB1	60(22.6)	21(19.3)	39(25.0)
MDS-EB2	75(28.3)	31(28.4)	44(28.2)
MDS-U	15(5.7)	3(2.8)	12(7.7)
MDS-SF3B1^&, n (%)	2(1.9)	1(2.0)	1(1.8)	1.000
MDS-biTP53^&, n (%)	6(5.6)	3(5.9)	3(5.4)	1.000
Gene mutation*, n (%)	84(78.5)	39(76.5)	45(80.4)	0.625
Co-mutation (>4 genes)	6(5.6)	0(0)	6(10.7)	0.028

*: at least one mutation

^& : new subtypes proposed in 2022 WHO

Figure 1. Gene mutation distribution and survival analysis. (A) Common genes carrying mutations in MDS patients. (B) Overall survival of 265 patients with primary MDS stratified by AST/ALT ratio ≤1.19 vs AST/ALT ratio >1.19 (P = 0.013). (C) Leukemia-free survival of 265 patients with primary MDS stratified by AST/ALT ratio ≤1.19 vs AST/ALT ratio >1.19 (P = 0.044).

No significant differences were observed in the two groups, but the higher AST/ALT ratio was associated with number of co-mutations (>4). The high AST/ALT group had a significantly shorter OS and LFS.

Table 2. Multivariate analyses involving IPSS-R for overall survival and leukemia-free survival in primary MDS patients.

	OS				LFS
	Univariate analysis		Multivariate analysis		Univariate analysis		Multivariate analysis
	OR(95%CI)	P-value	OR(95%CI)	P-value	OR(95%CI)	P-value	OR(95%CI)	P-value
AST/ALT ratio (>1.19)	1.597(1.098–2.323)	0.014	1.793(1.114–2.887)	0.016	1.456(1.011–2.097)	0.044	1.656(1.052–2.606)	0.029
Age (>60 years)	2.302(1.561–3.395)	<0.001	2.087(1.303–3.342)	0.002	2.105(1.432–3.092)	<0.001	1.726(1.088–2.740)	0.020
Gender (male)	0.566(0.390–0.823)	0.003	0.582(0.369–0.917)	0.020	0.551(0.380–0.801)	0.002	0.568(0.363–0.889)	0.013
IPSS-R risk	1.954(1.614–2.366)	<0.001	1.997(1.599–2.495)	<0.001	2.015(1.665–2.439)	<0.001	2.001(1.608–2.490)	<0.001
Treatment methods^※	1.885(1.252–2.837)	0.008	0.879(0.653–1.185)	0.398	2.209(1.463–3.336)	<0.001	1.209(0.793–1.335)	0.831
Albumin (>40 mg/dl)	0.548(0.381–0.787)	0.001	0.879(0.653–1.185)	0.796	0.568(0.397–0.814)	0.002	1(0.649–1.541)	1.000
β2-MG (>3μg/L)	2.429(1.646–3.584)	<0.001	1.479(0.887–2.465)	0.134	2.000(1.342–2.981)	0.001	1.196(0.711–2.010)	0.500
LDH (>250U/L)	2.963(2.073–4.234)	<0.001	2.291(1.508–3.482)	<0.001	2.674(1.869–3.824)	<0.001	1.935(1.268–2.954)	0.002

^※ : including HMAs, chemotherapy, supportive treatment and transplantation

Table 3. Multivariate analyses involving IPSS-M for overall survival and leukemia-free survival in primary MDS patients.

	OS				LFS
	Univariate analysis		Multivariate analysis		Univariate analysis		Multivariate analysis
	OR (95%CI)	P-value	OR (95%CI)	P-value	OR (95%CI)	P-value	OR (95%CI)	P-value
AST/ALT ratio (>1.19)	1.597(1.098–2.323)	0.014	1.029(0.395–2.681)	0.954	1.456(1.011–2.097)	0.044	0.824(0.343–1.977)	0.664
Gender (male)	0.566(0.390–0.823)	0.003	0.418(0.157–1.117)	0.082	0.551(0.380–0.801)	0.002	0.410(0.167–1.009)	0.052
IPSS-M risk	1.979(1.406–2.785)	<0.001	1.917(1.298–2.831)	0.001	1.953(1.414–2.697)	<0.001	1.885(1.318–2.697)	0.001
Treatment methods^※	1.885(1.252–2.837)	0.008	0.934(0.554–1.576)	0.798	2.209(1.463–3.336)	<0.001	1.225(0.805–1.863)	0.344
Albumin (>40 mg/dl)	0.548(0.381–0.787)	0.001	2.673(0.900–7.940)	0.077	0.568(0.397–0.814)	0.002	2.370(0.893–6.292)	0.083
β2-MG (>3μg/L)	2.429(1.646–3.584)	<0.001	1.552(0.449–5.364)	0.487	2.000(1.342–2.981)	0.001	0.922(0.262–3.240)	0.899
LDH (>250U/L)	2.963(2.073–4.234)	<0.001	6.119(1.975–18.955)	0.002	2.674(1.869–3.824)	<0.001	4.074(1.499–11.074)	0.006

^※ : including HMAs, chemotherapy, supportive treatment and transplantation

Data availability statement

The data that support the findings of this study are available at https://doi.org/10.17632/ntvnbvnznm.2.