Skip to main content

Prognostic nutritional index as a predictor of prognosis in patients with diffuse large B cell lymphoma



The prognostic nutritional index (PNI), an indicator of nutritional status and systemic inflammation, is associated with short-term and long-term outcomes of various malignancies. The prognostic value of PNI in diffuse large B cell lymphoma (DLBCL) remains unknown. The aim of the present study was to determine the prognostic value of baseline PNI in DLBCL patients.


We retrospectively analyzed data from 103 DLBCL patients treated with R‑CHOP or R‑CHOP-like regimens. We evaluated the significance of PNI as a predictor of response to treatment, overall survival (OS) and event-free survival (EFS).


Patients with a PNI ≤ 44.55, where the cut-off was calculated by receiver operating characteristics (Youden index) and the same was obtained for response to treatment with 76.2 % sensitivity and a specificity of 85.4 %, for OS with 72.4 % sensitivity and a specificity of 90.5 % and for EFS with 65.6 % sensitivity and a specificity of 90.1 %, had significantly worse 5‑year OS (18.3 % vs 86.4 %, P < 0.001, log rank test) and 5‑year EFS (15.1 % vs 82.3 %, P < 0.001, log rank test). Regression analysis showed that PNI ≤ 44.55 was an independent prognostic factor for response to treatment with an odds ratio (OR) of 4.88 for treatment failure, 95 % confidence interval (CI) 1.077–22.105, OS hazard ratio (HR) 4.24, 95 % CI 1.451–12.392 and EFS HR 4.007, 95 % CI 1.48–10.852. Lower PNI levels were found in patients with advanced Ann Arbor clinical stage (46.6 ± 7.77 vs. 52.7 ± 5.43) and in those with poor response to therapy (40.58 ± 7.26 vs. 50.67 ± 6.26).


The PNI is a simple and useful marker to predict long-term survival outcome in DLBCL patients. Low PNI predicted poor outcome. A limitation of the study is its retrospective design in which the prognostic value was tested in the derivation cohort only. Notwithstanding, this is the first study suggesting that PNI is an important prognostic factor in DLBCL.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 4
Fig. 3
Fig. 5


  1. Swerdlow SH, Campo E, Harris NL. et al. WHO classification of tumours of Haematopoietic and lymphoid tissues, 4th ed. Lyon: IARC Press; 2008.

    Google Scholar 

  2. Morton LM, Wang SS, Devess SS, Hartage P, Weisenburger DD, Linet MS. Lymphoma incidence patterns by WHO subtype in the United States, 1992–2001. Blood. 2006;107(1):265.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. The International Non-Hodgkin’s Lymphoma Prognostic Factors Project. A predictive model for aggressive non-Hodgkin’s lymphoma. N Engl J Med. 1993;329(14):987–94.

    Article  Google Scholar 

  4. Sehn LH, Berry B, Chhanabhai M, et al. The revised International Prognostic Index (R-IPI) is a better predictor of outcome than the standard IPI for patients with diffuse large B‑cell lymphoma treated with R‑CHOP. Blood. 2007;109(5):1857–61.

    Article  CAS  PubMed  Google Scholar 

  5. Oki Y, Yamamoto K, Kato H, et al. Low absolute lymphocyte count is a poor prognostic marker in patients with diffuse large B‑cell lymphoma and suggests patients survival benefit from rituximab. Eur J Haematol. 2008;81(6):448–53.

    Article  PubMed  Google Scholar 

  6. Kim DH, Baek JH, Chae YS, et al. Absolute lymphocyte count predicts response to chemotherapy and survival in diffuse large B‑cell lymphoma. Leukemia. 2007;21:2227–30.

    Article  CAS  PubMed  Google Scholar 

  7. Porrata LF, Ristow K, Habermann TM, Witzig TE, Inwards DJ, Markovic SN. Absolute lymphocyte count at the time of first relapse predicts survival in patients with diffuse large B‑cell lymphoma. Am J Hematol. 2009;84(2):93–7.

    Article  PubMed  Google Scholar 

  8. Aoki K, Tabata S, Yonetani N, Matsushita A, Ishikawa T. The prognostic impact of absolute lymphocyte and monocyte counts at diagnosis of diffuse large B‑cell lymphoma in the rituximab era. Acta Haematol. 2013;130(4):242–6.

    Article  CAS  PubMed  Google Scholar 

  9. Dalia S, Chavez J, Little B, et al. Serum albumin retains independent prognostic significance in diffuse large B‑cell lymphoma in the post-rituximab era. Ann Hematol. 2014;93(8):1305–12.

    Article  CAS  PubMed  Google Scholar 

  10. Buzby GP, Mullen JL, Matthews DC, Hobbs CL, Rosato EF. Prognostic nutritional index in gastrointestinal surgery. Am J Surg. 1980;139(1):160–7.

    Article  CAS  PubMed  Google Scholar 

  11. Onodera T, Goseki N, Kosaki G. Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients. Nihon Geka Gakkai Zasshi. 1984;85(9):1001–5.

    CAS  PubMed  Google Scholar 

  12. Sun K, Chen S, Xu J, Li G, He Y. The prognostic significance of the prognostic nutritional index in cancer: a systematic review and meta analysis. J Cancer Res Clin Oncol. 2014;140(9):1537–49.

    Article  PubMed  Google Scholar 

  13. Wang SH, Zhai ST, Lin H. Prognostic value of prognostic nutritional index for patients with gastric cancer: a meta-analysis. Minerva Med. 2016; Epub ahead of print.

  14. Pinato DJ, North BV, Sharma R. A novel, externally validated inflammation-based prognostic algorithm in hepatocellular carcinoma: the prognostic nutritional index (PNI). Br J Cancer. 2012;106(8):1439–45.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Chen KL, Liu YH, Li WY, et al. The prognostic nutritional index predicts survival for patients with extranodal natural killer/T cell lymphoma, nasal type. Ann Hematol. 2015;94(8):1389–400.

    Article  CAS  PubMed  Google Scholar 

  16. Raffeti E, Donato F, Castelnuovo F, MASTER Cohort, et al. The prognostic role of systemic inflammatory markers on HIV-infected patients with non-Hodgkin lymphoma, a multicenter cohort study. J Transl Med. 2015;13(1):89. doi:10.1186/s12967-015-0446-8.

    Article  Google Scholar 

  17. Cheson BD, Pfistner B, Juweid ME, et al. International Harmonization Project on Lymphoma: Revised response criteria for malignant lymphoma. J Clin Oncol. 2007;25(5):579–86.

    Article  PubMed  Google Scholar 

  18. Youden WJ. Index for rating diagnostic tests. Cancer. 1950;3:32–5.

    Article  CAS  PubMed  Google Scholar 

  19. Kanda M, Fujii T, Kodera Y, Nagai S, Takeda S, Nakao A. Nutritional predictors of postoperative outcome in pancreatic cancer. Br J Surg. 2011;98(2):268–74.

    Article  CAS  PubMed  Google Scholar 

  20. Nozoe T, Kimura Y, Ishida M, Saeki H, Korenaga D, Sugimachi K. Correlation of pre-operative nutritional condition with post-operative complications in surgical treatment for oesophageal carcinoma. Eur J Surg Oncol. 2002;28(4):396–400.

    Article  CAS  PubMed  Google Scholar 

  21. Nozoe T, Ninomiya M, Maeda T, Matsukuma A, Nakashima H, Ezaki T. Prognostic nutritional index: a tool to predict the biological aggressiveness of gastric carcinoma. Surg Today. 2010;40(5):440–3.

    Article  PubMed  Google Scholar 

  22. McMillan DC. Systemic inflammation, nutritional status and survival in patinets with cancer. Curr Opin Clin Nutr Metab Care. 2009;12(3):223–6.

    Article  PubMed  Google Scholar 

  23. Aviles A, Yanez J, Lopez T, Garcia EL, Guzman R, Diaz-Maqueo JC. Malnutrition as an adverse prognostic factor in patients with diffuse large cell lymphoma. Arch Med Res. 1995;26(1):31–4.

    CAS  PubMed  Google Scholar 

  24. Gupta D, Lis CG. Pretreatment serum albumin as a predictor of cancer survival: a systemic review of the epidemiological literature. Nutr J. 2012;22(9):69. doi:10.1186/1475-2891-9-69.

    Google Scholar 

  25. Ray-Coquard I, Cropet C, Van Glabbeke M, European Organization for Research and Treatment of Cancer Soft Tissue and Bone Sarcoma Group, et al. Lymphopenia as a prognostic factor for overall survival in advanced carcinomas, sarcomas, and lymphomas. Cancer Res. 2009;69(13):5383–91.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Henning B, Honchel R, Goldblum SE, MaClain CJ. Tumor necrosis factor-mediated hypoalbuminemia in rabbits. J Nutr. 1988;118(12):1586–90.

    Google Scholar 

  27. McMillan DC, Watson WS, O’Gorman P, Preston T, Scott HR, McArdle CS. Albumin concentration are primarily determined by the body cell mass and the systemic inflammatory response in cancer patients with weight loss. Nutr Cancer. 2001;39(2):210–3.

    Article  CAS  PubMed  Google Scholar 

  28. Zhou K, Xu D, Cao Y, Wang J, Yang Y, Huang M. C‑MYC aberrations as prognostic factors in diffuse large B‑cell Lymphoma: A meta-analysis of epidemiological studies. PLOS ONE. 2014;9(4):e95020.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Kawamoto K, Miyoshi H, Yoshida N, et al. MYC translocation and/or BCL 2 protein expression are associated with poor prognosis in diffuse large B‑cell lymphoma. Cancer Sci. 2016;107(6):853–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Bodoor K, Matalka I, Hayajneh R, Haddad Y, Gharaibeh W. Evaluation of BCL-6, CD10, CD138 and MUM-1 expression in diffuse large B‑cell lymphoma patients: CD138 is a marker of poor prognosis. Asian Pac J Cancer Prev. 2012;13(7):3037–46.

    Article  PubMed  Google Scholar 

  31. Xie Y, Bulbul MA, Ji L, et al. p53 expression is a strong marker of inferior survival in de novo diffuse large B‑cell lymphomaand may have enhanced negative effect with MYC coexpression: a single institutional clinicopathologic study. Am J Clin Pathol. 2014;141(4):593–604.

    Article  CAS  PubMed  Google Scholar 

Download references


We have not received substantial contributions from non-authors.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Vlatka Periša.

Ethics declarations

Conflict of interest

V. Periša, L. Zibar, A. Knezović, I. Periša, J. Sinčić-Petričević, and I. Aurer declare that they have no competing interests.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Periša, V., Zibar, L., Knezović, A. et al. Prognostic nutritional index as a predictor of prognosis in patients with diffuse large B cell lymphoma. Wien Klin Wochenschr 129, 411–419 (2017).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Lymphoma, large B-cell, diffuse
  • Prognostic nutritional index
  • Prognostic marker
  • Prognosis