The relationship of blood neutrophil-to-lymphocyte ratio with nutrition markers and health outcomes in hemodialysis patients

  • Janet Diaz-MartinezEmail author
  • Adriana Campa
  • Ivan Delgado-Enciso
  • Debra Hain
  • Florence George
  • Fatma Huffman
  • Marianna Baum
Nephrology - Original Paper



Adverse outcomes in hemodialysis patients have been attributed, in part, to the pro-inflammatory state prevalent in this population. This study examines the relationship between blood neutrophil-to-lymphocyte ratio (NLR) with nutrition markers and health outcomes in hemodialysis (HD) patients.


This is a 12-month prospective cohort study that recruited 77 participants from May to Jun 2017.

Settings and subjects

Patients receiving maintenance hemodialysis.

Main outcomes

Hospitalization, transplants and mortality.


Of the 77 participants, 63.8% were hospitalized, 10 (13%) died of cardiovascular diseases and 6 (7.8%) had a kidney transplant. Spearman correlations using baseline values showed an inverse significant correlation between the total number of hospitalizations and BMI kg/m2 (BMI rho = − 0.37, P <0.001); a significant inverse correlation between NLR and albumin (rho = − 0.22, P  = 0.028); and a significant direct correlation between baseline NLR and BMI kg/m2 (rho = 0.22, P  = 0.028). Participants were grouped by their NLR value into quartiles for outcomes analysis: quartile 1 (NLR ≤ 1.75), quartile 2 (NLR 1.76–2.6), quartile 3 (NLR 2.7–3.9) and quartile 4 (NLR ≥ 4). The percentage of patients with the lowest level of inflammation (NLR ≤ 1.75) was greater for not hospitalized patients than for hospitalized (39.3% vs 16.3%, P  = 0.025) and not hospitalized participants had higher BMI kg/m2 (mean ± SD) at baseline compared to those hospitalized (29.11 ± 5.4 vs 26.22 ± 5.34, P  = 0.026). In a multivariate cox regression analysis, participants in the lowest quartile (NLR ≤ 1.75) were compared to the rest on hospitalization, mortality and transplant. Years in dialysis, BMI kg/m2 and NLR ≤ 1.75 were significant predictors of hospitalization after adjustment (P  = 0.021, P  = 0.005, P  = 0.039; respectively) and we observed an association of low NLR with a hazard ratio (HR 0.44, 95% CI 0.20–0.96, P  =  0.039), BMI (HR 0.90, 95% CI 0.85–0.97, P  = 0.005) and years in dialysis (HR 0.90, 95% CI 0.83–0.98, P  = 0.021) for hospitalization in overall participants. In a further analysis comparing the effect of low NLR in the subgroup of diabetic vs non-diabetics, it was observed that BMI kg/m2 was a significant predictor for hospitalization in the non-diabetic subgroup (P  = 0.040) but not significant in the case of diabetics (P  = 0.128) after adjustments. Years in dialysis and NLR ≤ 1.75 were significant predictors of hospitalizations in the subgroup of diabetic before and after adjustment (P  = 0.049, P  = 0.044; respectively). Having a low NLR decreased 73% the risk for hospitalization (HR 0.27 95% CI 0.07–0.96, P  = 0.044) in this subgroup. Survival and hospitalization curves were analyzed by comparing all participants and the diabetic subgroup, in the lowest inflammation quartile vs the rest (NLR ≤ 1.75 vs NLR > 1.75). Participants with NLR ≤ 1.75 had 100% survival rate (log-rank test, P  = 0.059) and lower hospitalization rate (log-rank test, P  = 0.025); participants with diabetes had lower hospitalization rate (log-rank test, P  = 0.039).


NLR at baseline was associated with nutritional markers (albumin, BMI). Low NLR at baseline was a predictor of lower risk for hospitalizations in HD patients with diabetes.


Hemodialysis Inflammation NLR Mortality Hospitalization 



The authors thank the participants and the staff from DaVita Tamarac Kidney Center. The views expressed in this manuscript are those of the authors and do not necessarily represent the views of DaVita Inc.


This is not a funded study; it is a part of the doctoral dissertation research.

Compliance with ethical standards

Conflict of interest

Author Janet Diaz-Martinez declares that she has no conflict of interest. Author Adriana Campa declares that she has no conflict of interest. Author Ivan Delgado-Enciso declares that he has no conflict of interest. Author Debra Hain declares that she has no conflict of interest. Author Florence George declares that she has no conflict of interest. Author Fatman Huffman declares that she has no conflict of interest. Author Marinna Baum declares that she has no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. IRB Protocol Approval #: IRB-17-0198-CR01.


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Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  1. 1.Department of Dietetics and NutritionRobert Stempel College of Public Health and Social Work, Florida International UniversityMiamiUSA
  2. 2.Department of Molecular Medicine, School of MedicineUniversity of ColimaColimaMexico
  3. 3.Christine E. Lynn College of NursingFlorida Atlantic UniversityBoca RatonUSA
  4. 4.Department of Mathematics and StatisticsFlorida International UniversityMiamiUSA

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