Platelet-to-C-reactive Protein Ratio Stratifies Surgical Risk and Mortality in Necrotizing Enterocolitis Neonates with Portal Venous Gas

Xinyin Zhang¹Huan Wei¹Qi Tan¹Zheng-Li Wang¹Zhenhua Guo²Wei Liu²Jian Cao^2*

• ¹Children's Hospital of Chongqing Medical University Department of Neonatology, Chongqing, China
• ²Children's Hospital of Chongqing Medical University Department of General and Neonatal Surgery, Chongqing, China

Background: Portal venous gas (PVG) represents a severe complication of necrotizing enterocolitis (NEC), typically signaling disease progression and poor prognosis. While traditionally regarded as an indication for surgical intervention in NEC, accumulating clinical evidence indicates that not all cases of PVG require operative management. Currently, surgical decision-making for NEC neonates with PVG primarily relies on physicians' subjective clinical assessments, resulting in substantial management uncertainty. The platelet-to-C-reactive protein ratio (PCR), an objective and convenient biomarker integrating information on disseminated intravascular coagulation and systemic inflammation, has demonstrated predictive value in neonatal sepsis and other conditions. However, its utility has not yet been explored in NEC-PVG patients. This study retrospectively evaluates the predictive value of PCR for surgical intervention and prognosis in this high-risk population, aiming to facilitate early identification and improve clinical outcomes. Methods: This retrospective single-center cohort study analyzed 186 neonates with NEC (Bell stage ≥IIa) and ultrasonographically confirmed PVG (2021 - 2024). We evaluated the PCR, calculated at PVG diagnosis, for predicting surgical intervention and 30-day mortality by employing multivariate logistic regression (with collinearity assessment and bootstrap validation) to identify independent factors and receiver operating characteristic (ROC) analysis to assess predictive performance and optimal cut-offs, supplemented by sensitivity analyses. Results: The cohort demonstrated a surgical intervention rate of 37.10% (69/186) and 30-day mortality of 13.98% (26/186). Multivariate analysis identified PCR as an independent predictor for both surgical intervention (aOR = 0.77, 95% CI: 0.69 - 0.86) and mortality (aOR = 0.80, 95% CI: 0.69 - 0.92). ROC curve analysis established PCR thresholds of ≤4.84×109/mg for surgical intervention (AUC 0.84; sensitivity 80%, specificity 85%) and ≤2.57×109/mg for mortality prediction (AUC 0.80; sensitivity 69%, specificity 91%). Conclusions: This study suggests that the PCR is a promising predictor of surgical intervention and mortality risk in NEC-PVG patients, with superior predictive performance compared to individual parameters. Based on these findings, we propose the incorporation of PCR testing into standard clinical monitoring protocols, using 4.84 × 109/mg as a potential cutoff value to inform therapeutic decision-making, which may improve clinical management and outcomes in this high-risk population.