Neutrophil/lymphocyte ratio as a predictor of cardiovascular events in incident dialysis patients: a Japanese prospective cohort study

Exploring systemic inflammation in children with chronic kidney disease: correlates of interleukin 6

BACKGROUND

Systemic inflammation (SI) is linked to chronic kidney disease (CKD) progression and multiple complications. Data regarding SI biomarkers in pediatric patients are scarce. This case-control and cross-sectional study investigates the correlation of neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), total iron binding capacity (TIBC) and serum albumin to serum interleukin-6 (IL-6).

METHODS

NLR and PLR were measured in 53 patients (median age: 12.9 years), including 17 on dialysis and 36 with a median glomerular filtration rate of 39 ml/min/1.73m2, and in 25 age and sex-matched healthy controls. Iron profile, serum albumin and IL-6 were measured in the patient group. IL-6 levels > 3rd quartile were classified as high.

RESULTS

Patients presented higher NLR and PLR and particularly those on dialysis (p < 0.001 and p = 0.001). We observed a significant correlation between natural logarithm (ln) of IL-6 (lnIL-6) and NLR (rs = 0.344, p = 0.014), serum albumin (rs = -0.350, p = 0.011) and TIBC (rs = -0.345, p = 0.012) after adjustment for CKD stage, while the correlation between lnIL-6 and PLR was not significant (rs = 0.206, p = 0.151). Combination of NLR, serum albumin and TIBC predicted high IL-6 (13 patients) with an AUC of 0.771 (95% CI 0.608-0.943). Pairing of NLR ≥ 1.7 and TIBC ≤ 300 μg/dL exhibited the highest sensitivity (76.9%), while incorporating serum albumin ≤ 3.8 g/dL along with them achieved the highest specificity (95%) for detecting high IL-6 levels.

CONCLUSION

Both NLR and PLR levels increase in CKD, especially in patients on chronic dialysis. NLR, rather than PLR, along with TIBC and serum albumin, are associated with IL-6 in pediatric CKD.

Clinical significance of neutrophil-to-lymphocyte ratio on the risk of abdominal aortic calcification and decreased bone mineral density in patients with end-stage kidney disease

Inflammation plays a major role in the pathogenesis of chronic kidney disease (CKD), but the relationship between systemic inflammation and CKD-mineral bone disease is unclear. We aimed to investigate whether the neutrophil-to-lymphocyte ratio (NLR) is related to abdominal aortic calcification (AAC) and bone mineral density (BMD) in dialysis patients. In this cross-sectional analysis using baseline data of a multicenter cohort, a total of 759 patients were divided into three groups according to NLR level, and the associations between NLR and Kauppila AAC score (AACS) and BMD were assessed. The highest tertile NLR group had more males, alcohol consumers, higher diabetes prevalence, and higher comorbidity index than the lowest tertile NLR group. Fasting glucose and C-reactive protein levels were higher, while serum albumin, serum iron, and lipid profiles except triglycerides were lower in the highest tertile group. AACS was significantly higher in the highest tertile group than in the lowest and middle tertile groups (p = 0.017), but the mean areal BMD and T-score of the lumbar spine and femur were not different between groups. NLR level was positively correlated with AACS in all aortic wall segments except L1 and L3 anterior. In multivariable logistic regression analysis, the highest tertile NLR group was independently associated with AAC (odds ratio 2.876, 95% confidence interval 1.250-6.619, p = 0.013) but was not associated with osteoporosis in the lumbar spine and femur after adjusting for confounding factors. The NLR can be used as a potential indicator of AAC in dialysis patients.

Combined evaluation of Geriatric nutritional risk index and Neutrophil to lymphocyte ratio for predicting all-cause and cardiovascular mortality in hemodialysis patients

OBJECTIVE

Malnutrition, accompanied by an inflammatory profile, is a risk factor for poor prognosis in hemodialysis patients. The purpose of this study was to investigate the predictive value of NLR combined with GNRI for all-cause and cardiovascular mortality in hemodialysis patients.

METHODS

A total of 240 maintenance hemodialysis (MHD) patients in hemodialysis centers were enrolled in this retrospective study. The influencing factors of all-cause death in hemodialysis patients were analyzed by COX regression. The cut-off values of GNRI and NLR for predicting mortality in enrolled MHD patients were 89.01 and 4, respectively. Based on these cut-off values, the patients were divided into four groups: G1: high GNRI (≥ 89.01) + high NLR (≥ 4) group; G2: high GNRI (≥ 89.01) + low NLR (<4) group, G3: low GNRI (< 89.01) + high NLR (≥4) group; G4: low GNRI (< 89.01) + low NLR (<4).

RESULTS

During the follow-up period (average: 58 months), the all-cause mortality was 20.83%(50/240) and the cardiovascular mortality was 12.08%(29/240). Both NLR and GNRI were independent risk factors for the prognosis of MHD patients (P<0.05). Survival analysis showed that patients with low GNRI had a lower survival rate than those with high GNRI, whereas patients with high NLR had a lower survival rate than those with low NLR. Kaplan-Meier curve for all-cause mortality revealed that compared to G1, G2, and G4, G3 had the lowest survival rate, while G2 had the highest survival rate among all groups (P < 0.05). Kaplan-Meier curve for cardiovascular mortality showed that G3 had lower survival than G1, G2, and G4 (P < 0.001).

CONCLUSIONS

Our study demonstrates that bothGNRI and NLR are associated with all-cause mortality and cardiovascular mortality in MHD patients. Combining these two factorsmay contribute to a prognostic evaluation for MHD patients.

Neutrophil:lymphocyte ratio correlates with the uremic toxin indoxyl sulfate and predicts the risk of death in patients on hemodialysis

BACKGROUND

Chronic kidney disease (CKD) is a major public health issue associated with increased cardiovascular, infectious and all-cause mortality. The neutrophil:lymphocyte ratio (NLR) is a predictive marker of the risk of death and cardiovascular events. Uremic toxins, notably indoxyl sulfate (IS), are involved in immune deficiency and cardiovascular complications associated with CKD. The aim of this study was to assess whether the NLR was related to uremic toxins and could predict clinical outcome in hemodialysis (HD) patients.

METHODS

We conducted a prospective cohort study of 183 patients on chronic HD. The main objective was to study the correlation between the NLR and uremic toxin serum levels. The secondary objective was to test if the NLR can predict the incidence of mortality, cardiovascular events and infectious events.

RESULTS

Patients were separated into two groups according to the NLR median value (3.49). The NLR at inclusion was correlated with the NLR at the 6-month (r = 0.55, P < 0.0001) and 12-month (r = 0.62, P < 0.0001) follow-up. Among uremic toxins, IS levels were higher in the group with high NLR (104 µmol/L versus 81 µmol/L; P = 0.004). In multivariate analysis, the NLR remained correlated with IS (P = 0.03). The incidence of death, cardiovascular events and severe infectious events was higher in the group with high NLR [respectively, 38% versus 18% (P = 0.004), 45% versus 26% (P = 0.01) and 33% versus 21% (P = 0.02)] than in the low NLR group. Multivariate analysis showed an independent association of the NLR with mortality (P = 0.02) and cardiovascular events (P = 0.03) but not with severe infectious events.

CONCLUSIONS

In HD patients, the NLR predicted mortality and cardiovascular events but not severe infections and correlated positively with the level of the uremic toxin IS. The NLR could be an interesting marker for monitoring the risk of clinical events in CKD patients.

Increased Monocyte/Lymphocyte Ratio as Risk Marker for Cardiovascular Events and Infectious Disease Hospitalization in Dialysis Patients

Introduction

In dialysis patients, cardiovascular disease (CVD) and infectious disease contribute to poor clinical outcomes. We investigated if a higher monocyte/lymphocyte ratio (MLR) is associated with an increased risk of CVD events and infectious disease hospitalizations in incident dialysis patients.

Methods

In an ongoing observational prospective cohort study, 132 Japanese dialysis patients (age 58.7 ± 11.7 years; 70% men) starting dialysis therapy were enrolled and followed up for a median of 48.7 months. Laboratory biomarkers, including white blood cell count and its differential count, were determined at baseline. Event-free time and relative risks (RRs) were calculated using the Kaplan-Meier curves and Cox models, respectively.

Results

When divided into 2 groups according to median MLR (0.35 [range, 0.27–0.46]), the periods without CVD events were significantly shorter in the high MLR group than in the low MLR group (log-rank test = 5.60, p = 0.018). The RR of CVD events, after adjusting for age, sex, and diabetes, was 2.43 (1.22–4.84) in the high MLR group compared to the low MLR group. The periods without infections requiring hospitalization were also shorter (log-rank test = 4.16, p = 0.041). The RR of infections requiring hospitalization was 1.98 (1.02–3.83) after the same adjustments. The number of CVD events was higher in the high MLR group (18.6 events per 100 person-years at risk [pyr]) than the low MLR group (11.1 events per 100 pyr). The duration of infectious disease hospitalization was longer in the high MLR group (6.3 days per pyr) than in the low MLR group (2.8 days per pyr).

Conclusion

A higher MLR is associated with increased risks of both CVD events and infectious disease hospitalization in dialysis patients.

Diagnostic and prognostic value of peripheral blood leucocyte ratios in sick cats

The objective of this study was to assess the diagnostic and prognostic utility of feline neutrophil-to-lymphocyte (NLR) and lymphocyte-to-monocyte ratios (LMR) in a variety of underlying diseases. Five-year medical records from cats presenting to the internal medicine unit of a veterinary teaching hospital were retrospectively reviewed. Cats were considered for inclusion based on complete medical records. ADVIA 120 was used for the complete blood counts; the NLR and LMR were calculated by dividing the absolute numbers of the respective leucocytes. Two hundred and nineteen sick and 20 healthy cats were included in the study. The median NLR and LMR were significantly (P < 0.05) elevated and decreased, respectively, in cats with infectious, neoplastic and chronic kidney diseases compared to controls. Additionally, cats with neoplasia had significantly higher median NLR compared to cats with urinary tract and gastrointestinal diseases. Non-survivors had significantly higher NLR and lower LMR compared to survivors. Both ratios had suboptimal prognostic performance for the outcome of sick cats (NLR sensitivity: 37.9%, specificity: 86.4%; LMR sensitivity: 69.0%, specificity: 61.0%). Many different disease categories were associated with increased NLR and decreased LMR compared to controls, but the overall prognostic performance of the two leucocyte ratios was suboptimal.

Neutrophil/lymphocyte ratio is correlated with levels of inflammatory markers and is significantly reduced by smoking cessation

Previous studies have reported that the neutrophil to lymphocyte ratio (NLR) is associated with onset and prognosis of cardiovascular disease (CVD). Smoking is a major risk factor for CVD and smoking cessation significantly reduces CVD risk. However, the effects of smoking cessation on the NLR remain unknown. Among smokers visiting our smoking cessation clinics, we examined changes in the NLR and CVD biomarkers before and after smoking cessation. A total of 389 individuals (301 men and 88 women) were enrolled in the study. The median NLR was significantly reduced after successful smoking cessation (before: 1.8, interquartile range [IQR] 1.5, 2.5; after: 1.7, IQR 1.3, 2.4). In a linear regression model adjusted for sex, percent change in NLR comparing before and after smoking cessation was significantly and positively correlated with percent changes in C-reactive protein (β = 0.260), α1-antitrypsin-low density lipoprotein (β = 0.151, p < 0.05), and serum amyloid A-low density lipoprotein (β = 0.325). Our study demonstrated for the first time that smoking cessation significantly reduces the NLR in tandem with markers of inflammation and oxidative stress.

Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Nondialysis Chronic Kidney Patients

BACKGROUND

The Neutrophil-to-Lymphocyte Ratio (NLR) and the Platelet-to-Lymphocyte Ratio (PLR) are inflammatory biomarkers for several diseases, such as cancer and cardiovascular morbidities; however, there are currently few studies on kidney diseases. We aimed to evaluate nondialysis patients and determine the association of NLR and PLR with inflammation in these patients.

METHODS

A prospective cross-sectional study was conducted with 85 patients at different stages of chronic kidney disease (CKD), treated at the Kidney Disease Prevention Center of the University Hospital of the Federal University of Maranhão. This study included adult nondialysis patients diagnosed with CKD. The participants' blood samples were collected for a high-sensitivity C-reactive protein (hs-CRP) test and blood count. They were divided into two groups according to the presence or absence of inflammation based on the hs-CRP value (<0.5 mg/dL). NLR and PLR were calculated based on the absolute number of neutrophils, lymphocytes, and platelets and were compared between them and with hs-CRP. Statistical analysis was performed using the Stata software, with the Shapiro-Wilk, Mann-Whitney, Spearman's Correlation, and receiver operating characteristic curve tests. This study was approved by the local ethics committee.

RESULTS

The participants were categorized into two groups: with inflammation (n = 64) and without inflammation (n = 21). The mean age was 61.43 ± 14.63 y. The NLR and PLR values were significantly different between the groups with and without inflammation (p=0.045and p=0.004, respectively). However, only PLR showed a significant positive correlation with hs-CRP (p=0.015). The best cutoff point for NLR to detect inflammation was 1.98, with 76.19% sensitivity and 48.44% specificity. For PLR, it was 116.07, with 85.71% sensitivity and 51.56% specificity. There was no significant difference between the area under the NLR and PLR curve (0.71 vs. 0.64; p=0.186) for this population.

CONCLUSIONS

This study showed that PLR was positively correlated with hs-CRP in nondialysis CKD patients and can be used to identify inflammation in this population.

High Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio Are Associated with Poor Survival in Patients with Hemodialysis

Background

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are markers for systemic inflammation condition. Although NLR has emerged as a risk factor for poor survival in end-stage renal disease (ESRD) patients, the relationship between PLR and mortality is still unknown. We aimed to explore the interaction of NLR and PLR in predicting mortality in hemodialysis (HD) patients.

Method

We enrolled 360 HD patients for a 71-month follow-up. The endpoint was all-cause and cardiovascular (CV) mortality. Pearson correlation analysis was conducted to evaluate the relationship between factors and NLR or PLR. Kaplan-Meier curves and Cox proportional analysis were used to assess the prognostic value of NLR and PLR.

Results

NLR was positively correlated with neutrophil and negatively correlated with lymphocyte, hemoglobin, and serum albumin. PLR was positively correlated with neutrophil and platelet and negatively correlated with lymphocyte and hemoglobin. In multivariate Cox regression, a higher NLR level was independently associated with all-cause mortality (OR 2.011, 95% CI 1.082-3.74, p = 0.027), while a higher PLR level might predict CV mortality (OR 2.768, 95% CI 1.147-6.677, p = 0.023) in HD patients.

Conclusion

NLR and PLR are cheap and reliable biomarkers for all-cause and CV mortality to predict survival in HD patients.

Neutrophil to Lymphocyte Ratio as a Predictor of Long-Term Outcome in Peritoneal Dialysis Patients: A 5-Year Cohort Study

INTRODUCTION

The mortality of peritoneal dialysis (PD) patients remains high. The neutrophil to lymphocyte ratio (NLR), as an indicator of systemic inflammation, has been considered to be a predictor of cardiovascular and all-cause mortality in hemodialysis patients. The present study aims to investigate the relationship between NLR and long-term outcome in PD patients.

MATERIALS AND METHODS

The study included patients who initiated PD for at least 3 months between January 1, 2013, and December 31, 2015. All the patients were followed up until death, cessation of PD, or to the end of the study (June 31, 2018). NLR was calculated as the ratio of neutrophils to lymphocytes.

RESULTS

A total of 140 patients were included in this study. The median NLR reported was 2.87. Patients with lower NLR showed a higher survival rate than patients with higher NLR (log rank 6.886, p = 0.009). Furthermore, patients with higher NLR had a significantly higher cardiovascular mortality (log rank 5.221, p = 0.022). Multivariate Cox proportional hazards model showed that older age (HR 1.054, 95% CI 1.017-1.092, p = 0.004), higher Ca × P (HR 1.689, 95% CI 1.131-2.523, p = 0.010), and higher NLR (HR 2.603, 95% CI 1.037-6.535, p = 0.042) were independent predictors of increased all-cause mortality. NLR was also independently associated with cardiovascular mortality (HR 2.886, 95% CI 1.005-8.283, p = 0.039). Higher NLR (HR 2.667, 95% CI 1.333-5.337, p = 0.006), older age (HR 1.028, 95% CI 1.005-1.052, p = 0.016), and history of cardiovascular disease (HR 1.426, 95% CI 1.195-3.927, p = 0.031) were significantly independently associated with poor peritonitis-free survival in this study.

CONCLUSIONS

NLR could be a strong predictor of long-term outcome in PD patients.

Neutrophil-to-lymphocyte ratio in relation to the risk of all-cause mortality and cardiovascular events in patients with chronic kidney disease: a systematic review and meta-analysis

Aim

To systematically evaluate the relationship between the neutrophil-to-lymphocyte ratio (NLR) and the risk of all-cause mortality or cardiovascular events in patients with chronic kidney disease (CKD).

Methods

PubMed, Embase, and Web of Science databases were searched for cohort studies that were published since the databases were launched, until 1 April 2020. We selected papers according to specific inclusion and exclusion criteria, extracted data, and evaluated the quality of the citations. Data from eligible studies were used to calculate the combined hazard ratios (HRs) and 95% confidence intervals (CI).

Results

The search identified 1048 potentially eligible records, and 10 studies (n = 1442) were selected. Eight studies reported all-cause mortality, and two studies reported cardiovascular events. The combined HR of all-cause mortality was 1.45 (95% CI 1.20–1.75) and the HR of cardiovascular events was 1.52 (95% CI 1.33–1.72) when NLR was considered as a categorical variable. Similarly, the association between NLR and all-cause mortality was confirmed (HR 1.35; 95% CI 1.23–1.48) when NLR was used as a continuous variable.

Conclusion

NLR is a predictor of all-cause mortality and cardiovascular events in patients with chronic kidney disease.

Association of neutrophil-to-lymphocyte ratio and risk of cardiovascular or all-cause mortality in chronic kidney disease: a meta-analysis

BACKGROUND

It is currently controversial whether neutrophil-to-lymphocyte ratio (NLR) has a prognostic role in patients with chronic kidney disease (CKD). We aimed to investigate whether NLR was an independent predictor of cardiovascular or all-cause mortality in CKD patients with or without hemodialysis by performing a meta-analysis.

METHODS

Pubmed, Embase, and Cochrane Library databases are systematically searched for relevant literature that investigated NLR and subsequent cardiovascular or all-cause mortality risk in CKD with or without dialysis. Pooled hazard risk (HR) with 95% confidence interval (CI) was calculated for the high vs. low NLR category.

RESULTS

A total of thirteen studies enrolling 116,709 patients were identified and analyzed. In summary, high NLR was associated with an increased risk of all-cause mortality (HR 1.93, 95% CI 1.87-2.00; P < 0.00001) and cardiovascular mortality (HR 1.45, 95% CI 1.18-1.79, P < 0.001). Subgroup analysis indicated that high NLR are independently associated with all-cause mortality risk in dialysis patients (HR 1.94, 95% CI 1.87-2.01; P < 0.00001).

CONCLUSIONS

This meta-analysis indicates a high NLR is related to all-cause mortality and cardiovascular mortality in patients with chronic kidney disease. Dialysis patients with high NLR are candidates at high risk of mortality to allow for earlier interventions. Further large scale and more rigorously designed studies are warranted to confirm the prognostic value of NLR in the different stages of CKD.

Neutrophil to Lymphocyte Ratio Predicts Adverse Cardiovascular Outcome in Peritoneal Dialysis Patients Younger than 60 Years Old

Background

Neutrophil to lymphocyte ratio (NLR) is a new inflammatory marker; the relationship between NLR and adverse cardiovascular (CV) prognosis has been gradually emphasized in the general population. However, their association in peritoneal dialysis (PD) patients remains unclear.

Methods

From January 1, 2010, to May 31, 2017, a total of 1652 patients were recruited. NLR was categorized in triplicates: NLR ≤ 2.74, 2.74 < NLR ≤ 3.96, and NLR > 3.96. Kaplan-Meier cumulative incidence curve and multivariable COX regression analysis were used to determine the relationship between NLR and the incidence of adverse CV outcome, while a competitive risk model was applied to assess the effects of other outcomes on adverse CV prognosis. Besides, forest plot was investigated to analyze the adverse CV prognosis in different subgroups.

Results

During follow-up, 213 new-onset CV events and 153 CV disease (CVD) deaths were recorded. Multivariable COX regression models showed that the highest tertile of NLR level was associated with increased risk of CV events (HR = 1.39, 95%CI = 1.01‐1.93, P = 0.046) and CVD mortality (HR = 1.81, 95%CI = 1.22‐2.69, P = 0.003), while compared to the lowest tertile. Competitive risk models showed that the differences in CV event (P < 0.001) and CVD mortality (P = 0.004) among different NLR groups were still significant while excluding the effects of other outcomes. In subgroups, with each 1 increased in the NLR level, adjusted HR of new-onset CV event was 2.02 (95%CI = 1.26 − 3.23, P = 0.003) and CVD mortality was 2.98 (95%CI = 1.58 − 5.62, P = 0.001) in the younger group (age < 60 years).

Conclusions

NLR is an independent risk factor for adverse CV prognosis in PD patients younger than 60 years old.

Controlling Nutritional Status (CONUT) score as immune-nutritional predictor of outcomes in patients undergoing peritoneal dialysis

BACKGROUND & AIMS

The Controlling Nutritional Status (CONUT) score was designed to assess the immune-nutritional status in patients. The aim of this study was to investigate the prognostic value of the CONUT score at the commencement of peritoneal dialysis (PD) for all-cause mortality, cardiovascular disease (CVD), and technique failure.

METHODS

This is a STROBE-compliant, retrospective, observational, single center study. A total of 252 patients with end stage renal disease initially undergoing PD were enrolled in the study. Baseline data were collected from The Third Affiliated Hospital of Soochow University Peritoneal Dialysis database. The primary outcome during follow-up was all-cause mortality. The secondary outcomes were CVD and technique failure. Univariate and multivariate Cox regression analyses were performed to estimate the association between confounding factors and outcomes. The area under the curve represented the test discriminative power of CONUT score and relevant clinical parameters. The Kaplan-Meier curve was used to compare the outcomes of the patients according to the cut-off CONUT score.

RESULTS

During a median follow-up period of 1.9 years, 35 patients (13.9%) died, 38 (15.1%) experienced CVD events, 58 (23.0%) experienced technique failure. The high CONUT group (CONUT score > 3) had significantly higher all-cause mortality (p = 0.02), CVD prevalence (p < 0.01), and technique failure rates (p < 0.01) than the low CONUT group (CONUT score ≤ 3). The CONUT score was an independent predictor of all-cause mortality (hazard ratio [HR]: 1.565; 95% CI: 1.305-1.876; p < 0.001), CVD (HR: 1.346; 95% CI: 1.136-1.594; p = 0.001), and technique failure (HR: 1.144; 95% CI: 1.006-1.302; p = 0.041).

CONCLUSION

The CONUT score is a straightforward and inexpensive indicator to evaluate the immune-nutritional status; it could be a reliable prognostic marker of all-cause mortality, CVD, and technique failure risk in patients undergoing PD.

Inter-leg systolic blood pressure difference predicts cardiovascular events and mortality in incident hemodialysis patients

BACKGROUND

High inter-arm blood pressure difference, a marker of vascular disease, may be difficult to assess in hemodialysis patients with arm arteriovenous fistulae. We investigated if high inter-leg systolic blood pressure difference associates with cardiovascular events and increased mortality in hemodialysis patients.

METHODS

Among 118 incident Japanese dialysis patients, bilateral leg blood pressure, arm blood pressure, brachial-ankle pulse wave velocity, and ankle-brachial index were measured, and the relative risk associated with inter-leg systolic blood pressure difference and other indices of vascular status was analyzed.

RESULTS

During follow-up (median, 46 months), 18 deaths and 75 cardiovascular events occurred in 38 patients. Kaplan-Meier curves showed that higher inter-leg systolic blood pressure difference was associated with overall (log-rank 9.35, p = 0.002) and cardiovascular (log-rank 5.81, p = 0.02) mortality. The period from the start of dialysis therapy to the first cardiovascular event was shorter as inter-leg systolic blood pressure difference increased (log-rank 23.7, p < 0.0001). In Cox hazard models, inter-leg systolic blood pressure difference greater than median independently predicted deaths (relative risk, 3.8; 95% confidence interval, 1.3-13.9) and cardiovascular events (relative risk, 3.9; 95% confidence interval, 1.9-9.21) after adjustments for age, sex, nutritional status, and diabetes, whereas other indices were not related to the risks. For well-nourished, moderately malnourished, and severely malnourished patients, the cumulative number of cardiovascular events in the high-inter-leg systolic blood pressure difference patients were 4.96, 31.44, and 55.18 events per 100 patient-years.

CONCLUSIONS

Higher inter-leg systolic blood pressure difference associated with increased risk of mortality and cardiovascular events suggesting that wider application of inter-leg systolic blood pressure difference measurements may be warranted in hemodialysis patients.

Neutrophil/lymphocyte ratio elevation in renal dysfunction is caused by distortion of leukocyte hematopoiesis in bone marrow

Objective: We investigate the mechanism of neutrophil/lymphocyte ratio (NLR) elevation, a useful prognostic marker in patients with cardiovascular diseases (CVDs).

Methods: In this clinical study, we retrospectively searched for factors associated with NLR elevation in cardiovascular outpatients. In animal experiments using mice with adenine-induced nephropathy, we further examined the hematopoietic process in bone marrow and explored the mechanism of NLR elevation.

Result: In patients with CVDs or their risk factors, multiple regression analysis revealed that decrease in estimated glemerular filtration rate and increase in white blood cell count were significantly associated with increase in NLR. In mice with adenine-induced nephropathy, NLR and serum indoxyl sulfate (IS) levels were increased. Fluorescence-activated cell sorting revealed the increase in the number of myeloid progenitors and decrease in the number of common lymphoid progenitors, suggesting biased granulocyte side in the hematopoietic process in bone marrow. Treatment with oral charcoal adsorbent AST-120 decreased serum concentration of IS and normalized NLR and bone marrow abnormalities in mice with adenine-induced nephropathy.

Conclusion: Renal function was a strong determinant of NLR in cardiovascular outpatients. NLR elevation due to renal impairment is caused by distortion of the hematopoietic process in bone marrow. IS plays a significant role in these processes.

High neutrophil/lymphocyte ratio is associated with poor renal outcomes in Japanese patients with chronic kidney disease

Background: Several studies have shown that the neutrophil/lymphocyte ratio (NLR) is a marker that reflects the state of systemic inflammation. A high NLR was reported to be associated with cardiovascular events and mortality. However, little is known about the association between NLR and kidney disease progression in patients with chronic kidney disease (CKD). Therefore, the aim of the present study was to determine whether NLR is associated with renal outcomes in CKD patients.

Methods: This prospective observational study included 350 consecutive patients with stage 1–4 CKD treated between June 2009 and November 2016. Data were collected until June 2017. The endpoint was the composite of end-stage renal disease requiring dialysis or death. Subjects were divided into two groups according to high and low NLR levels. A Cox proportional hazards model was used to determine the risk factors for composite outcomes.

Results: The composite endpoint was observed in 83 patients during the median follow-up period of 31.8 months: 29 in the low NLR group and 54 in the high NLR group. Multivariable analysis showed that the high NLR group had a significant increase in the hazard ratio (HR) for composite outcomes (HR 1.67, 95% confidence interval 1.02–2.77) compared with the low NLR group.

Conclusion: The present study demonstrated that a high NLR was associated with poor renal outcomes, suggesting that NLR may be a useful marker for prognostic prediction in patients with CKD.

Neutrophil Lymphocyte Ratio and Cardiovascular Disease Risk: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review aimed to measure the association between neutrophil lymphocyte ratio (NLR) and cardiovascular disease (CVD) risk.

METHODS

Relevant studies were identified from Medline and Scopus databases. Observational studies with NLR as a study factor were eligible for review. The outcomes of interest were any type of CVD including acute coronary syndrome, coronary artery disease, stroke, or a composite of these cardiovascular events. Mean differences in NLR between CVD and non-CVD patients were pooled using unstandardized mean difference (USMD). Odds ratios of CVD between high and low NLR groups were pooled using a random effects model.

RESULTS

Thirty-eight studies (n=76,002) were included. High NLR was significantly associated with the risks of CAD, ACS, stroke, and composite cardiovascular events with pooled ORs of 1.62 (95% CI: 1.38-1.91), 1.64 (95% CI: 1.30, 2.05), 2.36 (95% CI: 1.44, 2.89), and 3.86 (95% CI: 1.73, 8.64), respectively. In addition, mean NLRs in CAD, ACS, and stroke patients were significantly higher than in control groups.

CONCLUSION

High NLR was associated with CAD, ACS, stroke, and composite cardiovascular events. Therefore, NLR may be a useful CVD biomarker.

Single emergency room measurement of neutrophil/lymphocyte ratio for early detection of acute kidney injury (AKI)

Neutrophil-to-lymphocyte ratio (NLR) is considered a readily available biomarker of systemic inflammation. An association between elevated NLR and adverse outcomes in a variety of medical and surgical conditions including CKD has been demonstrated in several studies. In this study, we evaluated the accuracy of single Emergency Department (ED) measurement of NLR for early diagnosis of acute kidney injury (AKI). We prospectively studied 294 patients aged 71.6 ± 17. We measured NLR at presentation to the ED. AKI is defined as a new-onset 1.5-fold or more increase in serum creatinine or a 25% decrease in estimated GFR sustained for at least 3 days despite volume resuscitation. The primary outcome is AKI. Secondary outcome is in-hospital mortality. A multivariate model and ROC analysis were performed to evaluate the association and eventual predictive capacity of NLR for the outcomes. 36 patients (12.2%) developed AKI and 26 (9%) died, 8 (22%) of the AKI group and 17 patients (7%) of the non-AKI group. The Mean NLR is significantly higher in AKI compare to non-AKI patients (11.7 ± 15.2 vs 6.45 ± 7.19, p = 0.048). A multivariate model adjusted for age, gender, blood pressure, plasma albumin and hemoglobin levels confirms that the NLR is higher in AKI patients (p = 0.031). Receiver operating characteristics curve reveals an AUC of 0.715 (95% CI 0.63-0.8) sensitivity 0.78, specificity 0.65, and OR 6.423 (CI 2.659-16.026) for a cutoff value of NLR 5.5. The relation between NLR and in-hospital mortality is not statistically significant (p = 0.92). Single ED measurement of NLR might be a useful tool for early diagnosis of AKI. This finding is particularly important in light of the low cost and widespread availability of NLR, especially compared with other biomarkers currently under study in the context of AKI.

Evaluation of the Predictive Value of the Serum Calcium-Magnesium Ratio for All-Cause and Cardiovascular Mortality in Incident Dialysis Patients

Background/Aim

Cardiovascular disease is the most serious cause of death in patients on hemodialysis. Low serum magnesium (Mg) and high serum calcium (Ca) levels have been associated with poor outcome and cardiovascular mortality in patients on maintenance and initiation dialysis. As a more accurate marker is warranted, we evaluated the efficacy of a novel serum Ca-Mg marker of all-cause and cardiovascular mortality that indicates vessel calcification.

Methods

We recruited 378 consecutive patients with end-stage renal disease who started dialysis between January 2009 and December 2015 at the Japanese Red Cross Ishinomaki Hospital. We collected data of patients' demographic characteristics and comorbidities from their electronic medical records. We retrospectively examined the association of the serum Ca-Mg ratio with all-cause and cardiovascular mortality using the Cox proportional hazard model, and determined the value that predicted cardiovascular death using the receiver operating characteristic (ROC) curve.

Results

Overall, 253 patients with serum Mg and Ca data were analyzed. The 3-year survival rate of this group was 0.70 (95% confidence interval [CI] 0.55-0.80), and the hazard ratio for the risk of death was 3.94 (95% CI 1.37-11.31). The 3-year cardiovascular mortality rate was 0.12 (95% CI 0.05-0.23), which was significantly higher than that of the other groups. The ROC curve of cardiovascular mortality with the Ca-Mg ratio was greater than that of Mg (area under the curve 0.75 vs. 0.69, p = 0.037).

Conclusion

A high Ca-Mg ratio was significantly associated with all-cause and cardiovascular mortality, and it was more accurate than serum Mg.

Pre-Dialysis Neutrophil-Lymphocyte Ratio, a Novel and Strong Short-Term Predictor of All-Cause Mortality in Patients With Diabetic Nephropathy: Results From a Single-Center Study

Neutrophil-lymphocyte ratio (NLR) is an inflammatory marker affecting the prognosis of end-stage renal disease (ESRD) patients. This study aimed to evaluate NLR levels predicting all-cause mortality in ESRD patients with diabetic nephropathy (DN), which have not been evaluated. We recruited 151 isolated DN patients who started hemodialysis between January 2009 and December 2014 at the Japanese Red Cross Ishinomaki Hospital. The primary outcomes were 1- and 3-year survival rates. The association between NLR and survival rate was evaluated using the Kaplan-Meier method and Cox proportional hazard regression analysis. Patients with an NLR ≥ 3.5 had a significantly higher mortality rate than did those with an NLR < 3.5 (log rank P = 0.02). The area under the curve (AUC) of 1-year survival for NLR was significantly larger than that for other commonly used nutritional and inflammatory variables. NLR was a more accurate predictor than other well-known markers.

Monocyte/lymphocyte ratio as a better predictor of cardiovascular and all-cause mortality in hemodialysis patients: A prospective cohort study

INTRODUCTION

Patients with chronic kidney disease, especially those with end-stage renal disease, have an increased risk of death. Previous studies have suggested neutrophil/lymphocyte ratio (NLR) was related to worse outcome in patients undergoing hemodialysis (HD). However, monocyte/lymphocyte ratio (MLR) has not been evaluated in HD patients. In this study, we prospectively studied the predictive value of MLR for all-cause and cardiovascular mortality in HD patients and compared it with NLR.

METHODS

Patients who had been on a HD treatment for at least 6 months were enrolled. MLR was calculated by dividing the monocyte count by the lymphocyte count. Survival outcomes were estimated using the Kaplan-Meier method and compared by the log-rank test. Univariate and multivariate analyses were performed to evaluate the prognostic impact of MLR and other clinical factors on all-cause and cardiovascular mortality.

RESULTS

Mortality rates for the lowest, middle, and highest MLR tertile group were 3.65, 7.02, and 11.15, respectively per 100 patient-years. The Kaplan-Meier analysis revealed that survival rates were significantly different among three MLR groups (P < 0.001). In multivariate Cox regression analyses, MLR was independently associated with all-cause mortality (HR 4.842; 95% CI, 2.091-11.214; P < 0.001) and cardiovascular mortality (HR 6.985, 95% CI 1.943-25.115, P = 0.003) as continuous variables. NLR was not an independent predictor of all-cause nor cardiovascular mortality after adjusted with MLR.

CONCLUSIONS

The main finding of the study suggest that higher MLR was a strong and independent predictor of all-cause and cardiovascular mortality and overwhelmed NLR among HD patients.

Predictive value of neutrophil/lymphocyte ratio in renal prognosis of patients with granulomatosis with polyangiitis

Introduction: Granulomatosis with polyangiitis (GPA) is a rare necrotizing vasculitis, which usually involves the upper and lower respiratory systems and kidneys and often have a relapsing course. Neutrophil/lymphocyte ratio (NLR) has been shown to be a useful marker predicting not only progressive disease, but also mortality in various inflammatory diseases. We aimed to investigate the roles of NLR in predicting the extend of clinical involvement and prognosis of patients with GPA.

Materials and methods: Consecutive newly diagnosed GPA patients who had follow-up for at least 6 months between 2010 and 2016 at Gazi University Internal Medicine-Rheumatology clinic were retrospectively analyzed.

Results: Fifty-three newly diagnosed GPA patients were studied. NLR was significantly higher in the GPA group compared with the control group (4.50 [min–max: 0.07–34.81] vs 1.77 [min–max: 1.04–2.90], respectively, p < .001). NLR significantly correlated with ESR and CRP levels (r = .40 and r = .48, respectively, p < .001 for both).

Discussion: GPA is a vasculitis with a significant morbidity and mortality (REF). Renal involvement usually presents with crescentric glomerulonephritis, resulting in significant and permanent loss of renal functions and end-stage kidney disease. Higher NLR at baseline is associated with worse renal outcome. Our findings suggest that baseline NLR could have a predictive value for renal prognosis. We have also demonstrated a significant correlation between NLR and BVAS activity scores. Our data suggest that GPA patients with a significantly high NLR at baseline might need closer follow-up for persistent disease activity.

Platelet to Lymphocyte Percentage Ratio Is Associated With Brachial-Ankle Pulse Wave Velocity in Hemodialysis

Increased arterial stiffness in patients receiving hemodialysis (HD) is highly prevalent and is associated with cardiovascular morbidity and mortality. In HD, inflammation is one of the major causes of increased arterial stiffness. Activation of platelets and decreased lymphocyte percentage (LYMPH%) may exhibit inflammation. The aim of this study is to examine the relationship between platelet to LYMPH% ratio and arterial stiffness in HD patients.A total of 220 patients receiving HD were enrolled in this study. The brachial-ankle pulse wave velocity (baPWV) was measured using an ankle-brachial index form device. Multivariate linear regression analysis was performed to investigate the relations of the platelet to LYMPH% ratio and baPWV. The value of the platelet to LYMPH% ratio was 59.2 ± 33.3 (10 cells/L/%). After multivariate stepwise analysis, diabetes (β: 163.973, P = 0.02), high systolic blood pressure (per 1 mm Hg, β: 9.010, P < 0.001), high platelet to LYMPH% ratio (per 10 cells/L/%, β: 3.334, P < 0.01), and low albumin (per 0.1 mg/dL, β: -55.912, P < 0.001) were independently associated with an increased baPWV. Furthermore, high white blood cells (per 10 cells/L, β: 3.941, P < 0.001), high neutrophil percentage (per 1%, β: 1.144, P < 0.001), and high CRP (per 1 mg/L, β: 9.161, P = 0.03) were independently associated with an increased platelet to LYMPH% ratio.An increased platelet to LYMPH% ratio is associated with an increased baPWV in HD patients. An easy and inexpensive laboratory measure of platelet to LYMPH% ratio may provide an important information regarding arterial stiffness in patients with HD.

Routinely analyzed leukocyte characteristics improve prediction of mortality after coronary angiography

BACKGROUND

Inflammation and leukocyte infiltration are hallmarks of atherosclerosis. Clinically routine hematology analyzers mostly perform an entire differential blood count by default, irrespective of the requested parameter. We hypothesize that these normally unreported leukocyte characteristics associate with coronary artery disease (CAD) severity and can improve prediction of mortality in coronary angiography patients.

METHODS

We studied coronary angiography patients suspected of CAD (n = 1015) from the Utrecht Coronary Biobank cohort. Leukocyte characteristics were routinely assessed in blood drawn directly prior to angiography using an automated hematology analyzer and extracted from the Utrecht patient oriented database (UPOD) database. Patients were followed up for a median duration of 805 days, during which 65 patients died. We evaluated the association of leukocyte characteristics with synergy between PCI with taxus and cardiac surgery (SYNTAX) score as a measure of CAD severity, all-cause and cardiovascular mortality and major adverse cardiovascular events (MACEs). In order to determine the improvement of risk prediction, we calculated continuous net reclassification improvement (cNRI) and integrated discrimination improvement (IDI).

RESULTS

Monocyte percentage showed strong independent predictive value for all-cause mortality (hazard ratio (HR) 1.44 (1.19-1.74), p < 0.001), and the monocyte-to-lymphocyte ratio performed best for cardiovascular mortality (HR 1.42 (1.11-1.81), p = 0.005). The cNRIs and IDIs of leukocyte characteristics for all-cause mortality confirmed the improvement in mortality risk prediction. No significantly predictive leukocyte characteristics were found for MACEs.

CONCLUSION

Readily available yet unreported leukocyte characteristics from routine hematology analyzers significantly improved prediction of mortality in coronary angiography patients on top of clinical characteristics.