Low lymphocyte-to-monocyte ratio, calcitriol level, and CD206 level predict the development of acute-on-chronic liver failure in patients cirrhosis with acute decompensation

Sep 29, 2026

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Cirrhosis-related acute-on-chronic liver failure (ACLF) carries high morbidity and mortality, yet few studies have examined predictors for ACLF onset and associated complications. This study measured serum calcitriol, CD206, and Mincle, calculated lymphocyte-to-monocyte ratio (LMR) and neutrophil-to-lymphocyte ratio, and followed patients with cirrhosis for 6 months. Low calcitriol and CD206 predicted ACLF, while LMR was protective. Low calcitriol also predicted hepatic encephalopathy (HE) and infection.

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Abstract

Background

Methods

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Introduction

J Chin MedAssoc Original article Low lymphocyte-to-monocyte ratio, calcitriol level, and CD206 level predict the development of acute-on-chronic liver failure in patients cirrhosis with acute decompensation Nai-Rong Kuoa,b, Ming-Chih Houb,c, Wei-Chi Chub,d, Ying-Ying Yanga,b,c,d,*, Chia-Chang Huanga,b,c,d, Tzu-Hao Lib,e, Tzung-Yan Leef, Chih-Wei Liub,d, Tsai-Ling Liaog, Shie-Liang Hsiehb,d,h, Han-Chieh Linb,c,* aDepartment of Medical Education, Medical Innovation and Research Office, Clinical Innovation Center, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; bFaculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC; cDepartment of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; dInstitute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC; eDivision of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, ROC; fGraduate Institute of Traditional Chinese Medicine, Linkou Chang Guang Memorial Hospital, Taoyuan, Taiwan, ROC; gDepartment of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan, ROC; hGenomics Research Center, Academia Sinica, Taipei, Taiwan, ROC Abstract Background: Cirrhosis-related acute-on-chronic liver failure (ACLF) is associated with high morbidity and mortality rates. Prognostic models of ACLF have been developed; however, few studies have focused on the occurrence of ACLF. This study aimed to identify the factors that predict the development of ACLF, hepatic encephalopathy (HE), and infection in patients with cirrhosis. Methods: Patients with cirrhosis were enrolled, and the serum levels of calcitriol, Cluster of Differentiation 26 (CD206), and macrophage-inducible lectin receptor (Mincle) were measured, and lymphocyte-to-monocyte ratio (LMR) and neutrophil-to-lymphocyte ratio were calculated; all the patients were tracked for 6 months. A generalized estimating equation (GEE) was used to assess the factors associated with ACLF development, HE, and infection. The aforementioned model was derived based on immunological markers, and receiver operating characteristic analysis with area under the curve (AUC) was adopted to evaluate accuracy. Results: After screening 325 patients with cirrhosis, 65 patients were eligible. In the GEE model, low levels of calcitriol (odds ratio [OR] = 3 .259; 95% confidence interval [CI] = 1 .118–8.929) and CD206 (OR = 2 .666; 95% CI = 1 .082–6.567) were associated with the development of ACLF, and the LMR was a protective factor (OR = 0 .356; 95% CI = 0 .147–0.861) . Low calcitriol levels were a risk factor for HE (OR = 3 .827) and infection (OR = 2 .489) . LMR was found to be a protective factor against HE (OR = 0 .388) . An immunological model for the discrimination of ACLF development within 6 months was proposed, with an AUC of 0.734 (95% CI = 0 .598–0.869) . Conclusion: Single and combined immunological markers, including low LMR and low levels of calcitriol and CD206, were promising for early prediction of the development of ACLF, HE, and infection in patients with cirrhosis. Keywords: Acute-on-chronic liver failure; Calcitriol; Cluster of differentiation 26; Hepatic encephalopathy; Lymphocyte-to-monocyte ratio 1. INTRODUCTION Acute-on-chronic liver failure (ACLF) is a clinical syndrome defined as extrahepatic organ failure in patients with acutely *Address correspondence. Dr. Ying-Ying Yang and Dr. Han-Chieh Lin, Department of Medical Education, Clinical Innovation Center, Medical Innovation and Research Office, Taipei Veterans General Hospital, 201, Section 2, Shi-Pai Road, Taipei 112, Taiwan, ROC. [E-mail address: yangyy@vghtpe.gov.tw](E-mail address: yangyy@vghtpe.gov.tw) (Y.-Y. Yang); [hclin@vghtpe.gov.tw](hclin@vghtpe.gov.tw) (H.-C. Lin). Author contributions: Dr. Nai-Rong Kuo and Prof. Ming-Chih Hou have contributed equally to this work. Conflicts of inter

FAQs

What was the study’s main goal?

To identify factors that predict the development of ACLF, hepatic encephalopathy (HE), and infection in patients with cirrhosis.

Which biomarkers were measured and how were ratios derived?

Serum calcitriol, CD206, and Mincle were measured; lymphocyte-to-monocyte ratio (LMR) and neutrophil-to-lymphocyte ratio were calculated.

What biomarkers were associated with developing ACLF?

Low calcitriol and low CD206 were associated with ACLF development, while a higher LMR acted as a protective factor.

Sep 29, 2026

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