Higher C-reactive protein/albumin ratio is a potential marker for predicting amputation in patients with diabetic foot infection

Zhang, Li; Gao, Xufeng; He, Meifang; Wang, Wenyan; Zhao, Yuebin

doi:10.20945/2359-4292-2024-0397

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original • Arch. Endocrinol. Metab. 69 (3) • 2025 • https://doi.org/10.20945/2359-4292-2024-0397 linkcopy

Higher C-reactive protein/albumin ratio is a potential marker for predicting amputation in patients with diabetic foot infection

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective: Non-traumatic amputation resulting from diabetic foot infection (DFI) poses significant clinical and public health concerns. The C-reactive protein (CRP)/albumin ratio represents a combination of the infection level and nutritional status. This study investigated the relationship between the CRP/albumin ratio and amputation in patients with diabetic foot infections.

Subjects and methods: Patients with a DFI of Wagner grade. 3 diagnosed between January 2020 and September 2023 were retrospectively analyzed. The association between the CRP/albumin ratio and amputation was explored using multivariable logistic regression modeling. Stratified analyses were also performed to ensure the reliability of the findings.

Results: Of 301 enrolled patients, 226 underwent amputation and 75 did not. The amputation rate increased with a greater CRP/albumin ratio in the non-adjusted, minimally adjusted, and fully adjusted models, regardless of whether the CRP/albumin ratio was regarded as a categorical or continuous variable.

Conclusion: An increased CRP/albumin ratio was associated with a greater risk of amputation in individuals with DFI.

Keywords:
Diabetic foot infection; C-reactive protein; albumin; amputation

Variables	CRP to albumin ratio				P value
Variables	Total	Triples 1 (≤1.239)	Triples 2 (1.239-3.841)	Triples 3 (≥3.841)	P value
Baseline characteristics
Sex, n (%)					0.88
Male	208 (69.1)	71 (71)	68 (68)	69 (68.3)
Female	93 (30.9)	29 (29)	32 (32)	32 (31.7)
Age, years, mean ± SD	65.2 ± 12.0	66.8 ± 11.7	65.5 ± 11.5	63.3 ± 12.6	0.113
BMI, kg/m², mean ± SD	23.2 ± 3.5	23.6 ± 3.1	22.9 ± 3.9	23.1 ± 3.5	0.34
MAP, mmHg, mean ± SD	59.0 ± 16.9	59.6 ± 18.3	58.6 ± 15.2	58.8 ± 17.1	0.916
Smoking status, n (%)					0.639
Current	60 (19.9)	20 (20)	19 (19)	21 (20.8)
Never	107 (35.5)	41 (41)	32 (32)	34 (33.7)
Former	134 (44.5)	39 (39)	49 (49)	46 (45.5)
Diabetes duration, years, mean ± SD	15.4 ± 9.5	14.8 ± 8.7	15.6 ± 9.1	15.7 ± 10.5	0.777
DFI severity
DFI microbial community, n (%)					0.97
G+ bacterial	100 (34.2)	30 (31.9)	34 (34.3)	36 (36.4)
G- bacterial	74 (25.3)	25 (26.6)	24 (24.2)	25 (25.3)
Mixed infection	118 (40.4)	39 (41.5)	41 (41.4)	38 (38.4)
IWGDF classification, n (%)					<0.001
Mild and moderate	235 (78.1)	98 (98)	82 (82)	55 (54.5)
Severe infection	66 (21.9)	2 (2)	18 (18)	46 (45.5)
Comorbidities
Hypertension, n (%)					0.026
Yes	153 (50.8)	43 (43)	48 (48)	62 (61.4)
No	148 (49.2)	57 (57)	52 (52)	39 (38.6)
CAD, n (%)					0.319
Yes	214 (71.1)	71 (71)	76 (76)	67 (66.3)
No	87 (28.9)	29 (29)	24 (24)	34 (33.7)
Cerebrovascular disease, n (%)					0.38
Yes	205 (68.6)	70 (70.7)	71 (71.7)	64 (63.4)
No	94 (31.4)	29 (29.3)	28 (28.3)	37 (36.6)
Laboratory examination
FBG, mmol/L, mean ± SD	10.4 ± 4.9	9.2 ± 4.4	10.4 ± 4.7	11.7 ± 5.3	<0.001
HbA1c, %, mean ± SD	9.0 ± 2.3	8.5 ± 2.4	8.9 ± 2.1	9.5 ± 2.3	0.027
RBC, ×10¹²/L, mean ± SD	3.8 ± 0.7	4.0 ± 0.8	3.8 ± 0.6	3.7 ± 0.7	0.004
Hemoglobin, g/L, mean ± SD	112.8 ± 22.7	120.5 ± 23.5	111.9 ± 20.5	106.1 ± 22.0	<0.001
WBC, ×10⁹/L, mean ± SD	11.6 ± 5.8	8.1 ± 2.7	10.5 ± 3.9	16.1 ± 6.6	<0.001
Neutrophil, %, mean ± SD	78.5 ± 10.4	70.8 ± 10.2	78.7 ± 7.2	86.0 ± 7.5	<0.001
Platelet, ×10⁹/L, mean ± SD	296.4 ± 115.9	258.2 ± 87.7	309.8 ± 120.4	320.9 ± 126.7	<0.001
CRP, mg/L median (IQR)	73.5 (28.2, 136.7)	14.8 (9.3, 27.3)	73.7 (61.3, 91.0)	169.8 (136.7, 218.2)	<0.001
Albumin, g/L, mean ± SD	30.8 ± 6.0	35.0 ± 4.7	30.8 ± 4.2	26.5 ± 5.6	<0.001

Variable	OR (95% CI)	P
Gender	1.2 (0.68~2.14)	0.531
Age	1.01 (0.99~1.04)	0.249
BMI	0.93 (0.86~1.01)	0.076
MAP	1.02 (1~1.04)	0.015
Never Smoking	0.45 (0.2~1.03)	0.06
Former Smoking	0.48 (0.21~1.07)	0.074
Diabetes duration (years)	1.03 (1~1.06)	0.095
G+ bacterial	0.82 (0.42~1.59)	0.557
G- bacterial	1.53 (0.81~2.88)	0.19
Severe infection	1.65 (0.83~3.28)	0.155
Hypertension	1.23 (0.73~2.07)	0.443
CAD	1.39 (0.76~2.54)	0.281
Cerebral.infarction1	1.24 (0.7~2.21)	0.459
FBG	1.02 (0.96~1.08)	0.468
HbA1c	0.87 (0.77~0.98)	0.017
RBC	0.64 (0.44~0.94)	0.021
Hemoglobin	0.98 (0.97~0.99)	0.004
WBC	1.06 (1~1.11)	0.045
Neutrophil	1.03 (1~1.05)	0.026
Platelet	1 (1~1)	0.191
CRP	1.01 (1~1.01)	0.008
Albumin	0.96 (0.92~1)	0.075
CRP to albumin ratio	1.13 (1.03~1.25)	0.012

Variable	Crude model, N = 301	P value	Minimally adjusted model N = 301	P value	Fully adjusted model N = 301	P value
CRP to albumin ratio	1.13 (1.03~1.25)	0.012	1.14 (1.03~1.25)	0.008	1.19 (1.07~1.34)	0.002
CRP to albumin ratio
≤1.239	Reference		Reference		Reference
1.239-3.841	1.49 (0.8~2.78)	0.209	1.52 (0.81~2.84)	0.191	1.37 (0.69~2.72)	0.373
≥3.841	2.03 (1.06~3.9)	0.033	2.16 (1.11~4.18)	0.023	2.73 (1.25~5.98)	0.012
P for Trend	0.032	0.022	0.013

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[1] Note – Abbreviations: BMI, body mass index; CAD, coronary heart disease; CRP, C-reactive protein; DFI, diabetic foot infections; FBG, fasting blood glucose; G+, Gram-positive bacterial; G-, Gram-negative bacterial; HbA1c, glycosylated hemoglobin; IQR, interquartile range; IWGDF, International Working Group on the Diabetic Foot; MAP, mean arterial pressure; RBC, red blood cell counts; SD, standard deviation; WBC, white blood cell count.