{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T05:59:30Z","timestamp":1792735170850,"version":"4.5.0"},"reference-count":37,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2024,11,9]],"date-time":"2024-11-09T00:00:00Z","timestamp":1731110400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: The best way to distinguish complicated acute appendicitis (CAA) from uncomplicated acute appendicitis (UCAA) is still under debate. The aim of this study was to investigate the potential use of the serum sodium (Na+) level and the neutrophil-to-lymphocyte ratio (NLR) to distinguish CAA from UCAA and to evaluate whether CAA is more reliably diagnosed using these two variables together. Materials and Methods: This was a retrospective, cross-sectional, two-center study of patients diagnosed with AA between 1 January 2016 and 31 December 2023. The demographic and analytical variables were analyzed. The NLR was defined as the quotient between the absolute values of neutrophils and lymphocytes. Hyponatremia was defined as a serum Na+ level of \u2264135 mmol\/L. The sensitivity and specificity of the NLR and the serum Na+ level in the diagnosis of CAA were determined by assessing the receiver operating characteristic curves. Results: Among the patients who underwent an appendectomy, 3066 histologically confirmed AA cases were identified and included in this study. The registered data revealed that 348 (11.3%) patients had CAA, and the remaining 2718 (88.7%) patients had UCAA. The mean ages were 49.47 \u00b1 18.97 and 38.16 \u00b1 14.50, respectively (p &lt; 0.001). The analysis revealed an exponential correlation between the NLR and the serum Na+ level with a moderate degree of agreement with CAA (Cohen\u2019s Kappa: 0.461, p &lt; 0.001). For CAA, using the NLR and the serum Na+ level, the areas under the curve and the cutoffs were 0.664, 4.2 with a confidence interval (CI) of 0.647\u20130.681 and 0.727, 135 mmol\/L with a CI of 0.711\u20130.742, respectively; all these values were significant with a p-value of &lt;0.001. Conclusions: Although the serum Na+ level is a more effective marker than the NLR, using these two variables together can help detect high-risk patients who may benefit from early management by limiting delays in surgery.<\/jats:p>","DOI":"10.3390\/medicina60111844","type":"journal-article","created":{"date-parts":[[2024,11,11]],"date-time":"2024-11-11T08:01:27Z","timestamp":1731312087000},"page":"1844","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Diagnostic Value of Serum Sodium Level and Neutrophil-to-Lymphocyte Ratio in Predicting Severity of Acute Appendicitis: A Retrospective Cross-Sectional Two-Center Study"],"prefix":"10.3390","volume":"60","author":[{"given":"Serdar","family":"Senol","sequence":"first","affiliation":[{"name":"Department of Surgical Gastroenterology, Samsun Training and Research Hospital, 55090 Samsun, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mustafa","family":"Kusak","sequence":"additional","affiliation":[{"name":"Department of General Surgery, Samsun Training and Research Hospital, 55090 Samsun, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3672-5738","authenticated-orcid":false,"given":"Dursun Burak","family":"\u00d6zdemir","sequence":"additional","affiliation":[{"name":"Department of Surgical Oncology, Faculty of Medicine, Eski\u015fehir Osmangazi University, 26040 Eski\u015fehir, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6307-5390","authenticated-orcid":false,"given":"Ahmet Murat","family":"Sendil","sequence":"additional","affiliation":[{"name":"Department of General Surgery, Faculty of Medicine, Eski\u015fehir Osmangazi University, 26040 Eski\u015fehir, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,11,9]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1186\/s13017-020-00306-3","article-title":"Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines","volume":"15","author":"Podda","year":"2020","journal-title":"World J. Emerg. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"722","DOI":"10.1097\/TA.0000000000002137","article-title":"Methods of conservative antibiotic treatment of acute uncomplicated appendicitis: A systematic review","volume":"86","author":"Talan","year":"2019","journal-title":"J. Trauma. Acute Care Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1186\/s13017-022-00408-0","article-title":"The SIFIPAC\/WSES\/SICG\/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition)","volume":"17","author":"Fugazzola","year":"2022","journal-title":"World J. Emerg. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"2299","DOI":"10.1001\/jama.2021.20502","article-title":"Diagnosis and management of acute appendicitis in adults: A review","volume":"326","author":"Moris","year":"2021","journal-title":"JAMA"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1016\/S0196-0644(86)80993-3","article-title":"A practical score for the early diagnosis of acute appendicitis","volume":"15","author":"Alvarado","year":"1986","journal-title":"Ann. Emerg. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2081","DOI":"10.1007\/s00268-021-06042-2","article-title":"Validation of the Appendicitis Inflammatory Response (AIR) Score","volume":"45","author":"Andersson","year":"2021","journal-title":"World J. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1016\/j.amjsurg.2019.04.018","article-title":"Neutrophil-to lymphocyte ratio predicts acute appendicitis and distinguishes between complicated and uncomplicated appendicitis: A systematic review and meta-analysis","volume":"219","author":"Hajibandeh","year":"2020","journal-title":"Am. J. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Anand, S., Krishnan, N., Birley, J.R., Tintor, G., Bajpai, M., and Pogoreli\u0107, Z. (2022). Hyponatremia-A new diagnostic marker for complicated acute appendicitis in children: A systematic review and meta-analysis. Children, 9.","DOI":"10.3390\/children9071070"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1907","DOI":"10.1056\/NEJMoa2014320","article-title":"A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis","volume":"383","author":"Flum","year":"2020","journal-title":"N. Engl. J. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"933","DOI":"10.1002\/bjs.10873","article-title":"Meta-analysis of in-hospital delay before surgery as a risk factor for complications in patients with acute appendicitis","volume":"105","author":"Dijkgraaf","year":"2018","journal-title":"Br. J. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"zraa030","DOI":"10.1093\/bjsopen\/zraa030","article-title":"Discriminating complicated from uncomplicated appendicitis by ultrasound imaging, computed tomography or magnetic resonance imaging: Systematic review and meta-analysis of diagnostic accuracy","volume":"5","author":"Bom","year":"2020","journal-title":"BJS Open"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"343","DOI":"10.1001\/jamasurg.2020.6357","article-title":"Risk of hematologic malignant neoplasms from abdominopelvic computed tomographic radiation in patients who underwent appendectomy","volume":"156","author":"Lee","year":"2021","journal-title":"JAMA Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1016\/j.amsu.2019.10.013","article-title":"Accuracy of neutrophil lymphocyte ratio for diagnosis of acute appendicitis in children: A diagnostic study","volume":"48","author":"Prasetya","year":"2019","journal-title":"Ann. Med. Surg."},{"key":"ref_14","first-page":"185","article-title":"Neutrophil-to-lymphocyte ratio as a predictor of peritonitis in acute appendicitis in children","volume":"32","author":"Velayos","year":"2019","journal-title":"Cir. Pediatr."},{"key":"ref_15","first-page":"e48203","article-title":"The diagnostic accuracy of hyperbilirubinemia in predicting appendicitis and appendiceal perforation","volume":"15","author":"Khalid","year":"2023","journal-title":"Cureus"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"3663","DOI":"10.1177\/0300060519856155","article-title":"Hyperbilirubinemia as a predictor of severity of acute appendicitis","volume":"7","author":"Akai","year":"2019","journal-title":"J. Int. Med. Res."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Shuaib, A., Alhamdan, N., Arian, H., Sallam, M.A., and Shuaib, A. (2022). Hyperbilirubinemia and hyponatremia as predictors of complicated appendicitis. Med. Sci., 10.","DOI":"10.3390\/medsci10030036"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"171","DOI":"10.14740\/jocmr3724","article-title":"Hyperbilirubinemia as a predictor of appendiceal perforation: A systematic review and diagnostic test meta-analysis","volume":"11","author":"Gavriilidis","year":"2019","journal-title":"J. Clin. Med. Res."},{"key":"ref_19","first-page":"5","article-title":"Ratio of neutrophil to lymphocyte counts rapid and simple parameter of systemic inflammation and stress in critically ill","volume":"102","author":"Zahorec","year":"2001","journal-title":"Bratisl. Lek. Listy"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"R192","DOI":"10.1186\/cc9309","article-title":"Lymphocytopenia and neutrophil-lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit","volume":"14","author":"Mathoera","year":"2010","journal-title":"Crit. Care"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1159\/000322238","article-title":"Hyponatremia and inflammation: The emerging role of interleukin-6 in osmoregulation","volume":"118","author":"Swart","year":"2011","journal-title":"Nephron Physiol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1016\/0304-3940(94)90933-4","article-title":"Penetration of interleukin-6 across the murine blood-brain barrier","volume":"179","author":"Banks","year":"1994","journal-title":"Neurosci. Lett."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1016\/j.surge.2020.01.002","article-title":"Hyponatremia as a marker of complicated appendicitis: A systematic review","volume":"18","author":"Giannis","year":"2020","journal-title":"Surgeon"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2009","DOI":"10.1016\/j.asjsur.2022.04.058","article-title":"Hyponatremia as a predictor of complicated appendicitis in children: A systematic review and meta-analysis","volume":"45","author":"Zhan","year":"2022","journal-title":"Asian J. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1816","DOI":"10.1016\/j.jpedsurg.2020.09.066","article-title":"Hyponatremia as a predictor of perforated acute appendicitis in pediatric population: A prospective study","volume":"56","year":"2021","journal-title":"J. Pediatr. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Messias, B., Cubas, I., Oliveira, C., Hashimoto, F., Mocchetti, E., Ichinose, T., Waisberg, J., and Ribeiro Junior, M.A.F. (2023). Usefulness of serum sodium levels as a novel marker for predicting acute appendicitis severity: A retrospective cohort study. BMC Surg., 23.","DOI":"10.1186\/s12893-023-02224-y"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1007\/s00383-023-05561-4","article-title":"Acute appendicitis in children: Is preoperative hyponatremia a predictive factor of perforation\/gangrene? A prospective study","volume":"39","author":"Elgendy","year":"2023","journal-title":"Pediatr. Surg. Int."},{"key":"ref_28","first-page":"e28619","article-title":"Predicting the severity of acute appendicitis in children using neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR)","volume":"14","author":"Ayeni","year":"2022","journal-title":"Cureus"},{"key":"ref_29","first-page":"317","article-title":"Neutrophil-to-lymphocyte ratio in the diagnosis of acute appendicitis. Assessment of its diagnostic accuracy","volume":"120","year":"2022","journal-title":"Arch. Argent. Pediatr."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Al Amri, F.S., Fihrah, R.S., Al Jabbar, I., Alqahtani, R., Alnujaymi, B., Alshehri, R.M., and Asiri, S.S. (2023). Accuracy of neutrophil-to-lymphocyte ratio in predicting the severity of acute appendicitis: A single-center retrospective study. Cureus, 15.","DOI":"10.7759\/cureus.45923"},{"key":"ref_31","first-page":"e29177","article-title":"Single-center retrospective analysis of neutrophil, monocyte, and platelet to lymphocyte ratios as predictors of complicated appendicitis","volume":"14","author":"Halaseh","year":"2022","journal-title":"Cureus"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"463","DOI":"10.1097\/SLE.0b013e318262edf1","article-title":"Laparoscopy grading system of acute appendicitis: New insight for future trials","volume":"22","author":"Gomes","year":"2012","journal-title":"Surg. Laparosc. Endosc. Percutaneous Tech."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., G\u00f8tzsche, P.C., Vandenbroucke, J.P., and STROBE Initiative (2007). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. PLoS Med., 4.","DOI":"10.1371\/journal.pmed.0040296"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"159","DOI":"10.2307\/2529310","article-title":"The measurement of observer agreement for categorical data","volume":"33","author":"Landis","year":"1997","journal-title":"Biometrics"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Friziero, A., Rosso, E., Zuin, I.S., Vallese, L., Serafini, S., Amico, A., Valli, V., Re, C.D., Baldan, N., and Valmasoni, M. (2024). Neutrophil to lymphocyte ratio predicts bowel ischemia in non-strangulated adhesive small bowel occlusions: A retrospective analysis from an acute care surgical service. BMC Surg., 24.","DOI":"10.1186\/s12893-024-02476-2"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Xia, Z., Liu, Y., Sun, S., Shan, E., and Liu, Y. (2023). The value of preoperative neutrophil\/lymphocyte ratio in predicting the severity of cholecystolithiasis with cholecystitis in elderly patients. BMC Surg., 23.","DOI":"10.1186\/s12893-023-02267-1"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"45","DOI":"10.4240\/wjgs.v12.i2.45","article-title":"Hyponatremia is associated with more severe biliary disease","volume":"12","author":"Zobel","year":"2020","journal-title":"World J. Gastrointest. Surg."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/60\/11\/1844\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T16:29:14Z","timestamp":1760113754000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/60\/11\/1844"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,11,9]]},"references-count":37,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2024,11]]}},"alternative-id":["medicina60111844"],"URL":"https:\/\/doi.org\/10.3390\/medicina60111844","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,11,9]]}}}