Abstract
Background
The neutrophil-to-lymphocyte ratio (NLR) is calculated from the white cell differential blood count. Recently, NLR was identified as a potential biomarker for the prediction of acute kidney injury (AKI). We conducted this systematic review and meta-analysis to evaluate the diagnostic value of NLCR for AKI in adult patients.
Methods
Studies in the PubMed, EMBASE, Web of Science and Cochrane Library databases were systematically searched from the date of database inception to February 28, 2019. The predictive value of NLR for AKI was evaluated by the pooled sensitivity, specificity, and summary receiver operating characteristic curve (SROC) analyses. Review Manager and Stata were used for all statistical analyses. The sources of potential heterogeneity were explored by a sensitivity analysis and subgroup analysis.
Results
This meta-analysis returned 89 reports, of which 9 fulfilled the inclusion criteria, accounting for 9766 patients. Bivariate analysis yielded a mean sensitivity of 0.736 (95% CI 0.675–0.790) and specificity of 0.686 (95% CI 0.601–0.759). The SROC was 0.77 (95% CI 0.74–0.81). The studies had no significant heterogeneity (Q = 0.675, p = 0.357, I2 = 0).
Conclusions
Our findings indicate that the NLR may be a reliable biomarker for the early detection of AKI. Our findings also provide important information and assistance for clinicians in the prediction of AKI.
Similar content being viewed by others
References
Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005;16(11):3365–70. https://doi.org/10.1681/asn.2004090740.
Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012;120(4):c179–84. https://doi.org/10.1159/000339789.
Kam Tao Li P, Burdmann EA, Mehta RL. Acute kidney injury: global health alert. J Nephropathol. 2013;2(2):90–7. https://doi.org/10.12860/jnp.2013.15.
Peralta CA, Katz R, Bonventre JV, Sabbisetti V, Siscovick D, Sarnak M, Shlipak MG. Associations of urinary levels of kidney injury molecule 1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL) with kidney function decline in the Multi-Ethnic Study of Atherosclerosis (MESA). Am J Kidney Dis. 2012;60(6):904–11. https://doi.org/10.1053/j.ajkd.2012.05.014.
Levey AS, James MT. Acute kidney injury. Ann Intern Med. 2017;167(9):itc66–80. https://doi.org/10.7326/aitc201711070.
Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Critical care (London, England). 2004;8(4):R204–12. https://doi.org/10.1186/cc2872.
Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care (London, England). 2007;11(2):R31. https://doi.org/10.1186/cc5713.
Kellum JA, Lameire N. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care (London, England). 2013;17(1):204. https://doi.org/10.1186/cc11454.
Waikar SS, Betensky RA, Emerson SC, Bonventre JV. Imperfect gold standards for kidney injury biomarker evaluation. J Am Soc Nephrol JASN. 2012;23(1):13–21. https://doi.org/10.1681/asn.2010111124.
de Jager CP, van Wijk PT, Mathoera RB, de Jongh-Leuvenink J, van der Poll T, Wever PC. Lymphocytopenia and neutrophil-lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit. Crit Care (London, England). 2010;14(5):R192. https://doi.org/10.1186/cc9309.
Yoldas H, Karagoz I, Ogun MN, Velioglu Y, Yildiz I, Bilgi M, Demirhan A. Novel mortality markers for critically ill patients. J Intensiv Care Med. 2018. https://doi.org/10.1177/0885066617753389.
Sharfuddin AA, Molitoris BA. Pathophysiology of ischemic acute kidney injury. Nat Rev Nephrol. 2011;7(4):189–200. https://doi.org/10.1038/nrneph.2011.16.
Moher D, Liberati A, Tetzlaff J, Altman D. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.
Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155(8):529–36. https://doi.org/10.7326/0003-4819-155-8-201110180-00009.
Kaya A, Kaya Y, Topcu S, Gunaydin ZY, Kurt M, Tanboga IH, Kalkan K, Aksakal E. Neutrophil-to-lymphocyte ratio predicts contrast-induced nephropathy in patients undergoing primary percutaneous coronary intervention. Angiology. 2014;65(1):51–6. https://doi.org/10.1177/0003319713484789.
Kim WH, Park JY, Ok SH, Shin IW, Sohn JT. Association between the neutrophil/lymphocyte ratio and acute kidney injury after cardiovascular surgery: a retrospective observational study. Medicine (Baltimore). 2015;94(43):e1867. https://doi.org/10.1097/md.0000000000001867.
Yilmaz H, Cakmak M, Inan O, Darcin T, Akcay A. Can neutrophil-lymphocyte ratio be independent risk factor for predicting acute kidney injury in patients with severe sepsis? Ren Fail. 2015;37(2):225–9. https://doi.org/10.3109/0886022x.2014.982477.
Kurtul A, Yarlioglues M, Duran M, Murat SN. Association of neutrophil-to-lymphocyte ratio with contrast-induced nephropathy in patients with non-ST-elevation acute coronary syndrome treated with percutaneous coronary intervention. Heart Lung Circ. 2016;25(7):683–90. https://doi.org/10.1016/j.hlc.2016.01.007.
Yuan Y, Qiu H, Hu X, Luo T, Gao X, Zhao X, Zhang J, Wu Y, Qiao S, Yang Y, Gao R. Predictive value of inflammatory factors on contrast-induced acute kidney injury in patients who underwent an emergency percutaneous coronary intervention. Clin Cardiol. 2017;40(9):719–25. https://doi.org/10.1002/clc.22722.
Abu Alfeilat M, Slotki I, Shavit L. Single emergency room measurement of neutrophil/lymphocyte ratio for early detection of acute kidney injury (AKI). Intern Emerg Med. 2018;13(5):717–25. https://doi.org/10.1007/s11739-017-1715-8.
Kim HY, Kong YG, Park JH, Kim YK. Acute kidney injury after burn surgery: preoperative neutrophil/lymphocyte ratio as a predictive factor. Acta Anaesthesiol Scand. 2018. https://doi.org/10.1111/aas.13255.
Sun XP, Li J, Zhu WW, Li DB, Chen H, Li HW, Chen WM, Hua Q. Platelet to lymphocyte ratio predicts contrast-induced nephropathy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Angiology. 2018;69(1):71–8. https://doi.org/10.1177/0003319717707410.
Bu X, Zhang L, Chen P, Wu X. Relation of neutrophil-to-lymphocyte ratio to acute kidney injury in patients with sepsis and septic shock: a retrospective study. Int Immunopharmacol. 2019;70:372–7. https://doi.org/10.1016/j.intimp.2019.02.043.
Yuan Y, Qiu H, Hu X, Luo T, Gao X, Zhao X, Zhang J, Wu Y, Qiao S, Yang Y, Gao R. Predictive value of inflammatory factors on contrast-induced acute kidney injury in patients who underwent an emergency percutaneous coronary intervention. Clin Cardiol. 2017;40(9):719–25. https://doi.org/10.1002/clc.22722.
Sun X-p, Li J, Zhu W-w, Li D-b, Chen H, Li H-w, Chen W-m, Hua Q. Platelet to lymphocyte ratio predicts contrast-induced nephropathy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Angiology. 2018;69(1):71–8. https://doi.org/10.1177/0003319717707410.
Kim WH, Park JY, Ok S-H, Shin I-W, Sohn J-T. Association between the neutrophil/lymphocyte ratio and acute kidney injury after cardiovascular surgery a retrospective observational study. Medicine. 2015. https://doi.org/10.1097/md.0000000000001867.
Yilmaz H, Cakmak M, Inan O, Darcin T, Akcay A. Can neutrophil–lymphocyte ratio be independent risk factor for predicting acute kidney injury in patients with severe sepsis? Ren Fail. 2015;37(2):225–9. https://doi.org/10.3109/0886022X.2014.982477.
Kim HY, Kong Y-G, Park JH, Kim Y-K. Acute kidney injury after burn surgery: preoperative neutrophil/lymphocyte ratio as a predictive factor. Acta Anaesthesiol Scand. 2019;63(2):240–7. https://doi.org/10.1111/aas.13255.
Abu Alfeilat M, Slotki I, Shavit L. Single emergency room measurement of neutrophil/lymphocyte ratio for early detection of acute kidney injury (AKI). Intern Emerg Med. 2018;13(5):717–25. https://doi.org/10.1007/s11739-017-1715-8.
Stacul F, van der Molen AJ, Reimer P, Webb JA, Thomsen HS, Morcos SK, Almen T, Aspelin P, Bellin MF, Clement O, Heinz-Peer G. Contrast induced nephropathy: updated ESUR Contrast Media Safety Committee guidelines. Eur Radiol. 2011;21(12):2527–41. https://doi.org/10.1007/s00330-011-2225-0.
Kokkoris S, Pipili C, Grapsa E, Kyprianou T, Nanas S. Novel biomarkers of acute kidney injury in the general adult ICU: a review. Ren Fail. 2013;35(4):579–91. https://doi.org/10.3109/0886022x.2013.773835.
Azab B, Bhatt VR, Phookan J, Murukutla S, Kohn N, Terjanian T, Widmann WD. Usefulness of the neutrophil-to-lymphocyte ratio in predicting short- and long-term mortality in breast cancer patients. Ann Surg Oncol. 2012;19(1):217–24. https://doi.org/10.1245/s10434-011-1814-0.
Sarraf KM, Belcher E, Raevsky E, Nicholson AG, Goldstraw P, Lim E. Neutrophil/lymphocyte ratio and its association with survival after complete resection in non-small cell lung cancer. J Thorac Cardiovasc Surg. 2009;137(2):425–8. https://doi.org/10.1016/j.jtcvs.2008.05.046.
Parlar H, Saskin H. Are pre and postoperative platelet to lymphocyte ratio and neutrophil to lymphocyte ratio associated with early postoperative AKI following CABG? Braz J Cardiovasc Surg. 2018;33(3):233–41. https://doi.org/10.21470/1678-9741-2017-0164.
Takaki S, Shehabi Y, Pickering JW, Endre Z, Miyashita T, Goto T. Perioperative change in creatinine following cardiac surgery with cardiopulmonary bypass is useful in predicting acute kidney injury: a single-centre retrospective cohort study. Interact Cardiovasc Thorac Surg. 2015;21(4):465–9. https://doi.org/10.1093/icvts/ivv184.
Menez S, Parikh CR. Assessing the health of the nephron in acute kidney injury: biomarkers of kidney function and injury. Curr Opin Nephrol Hypertens. 2019. https://doi.org/10.1097/mnh.0000000000000538.
Arellano DL. Acute kidney injury following cardiothoracic surgery. Crit Care Nurs Clin N Am. 2019;31(3):407–17. https://doi.org/10.1016/j.cnc.2019.05.008.
Basu RK. Targeting acute kidney injury: can an innovative approach to existing and novel biomarkers shift the paradigm? Nephron. 2019. https://doi.org/10.1159/000500421.
Waikar SS, Bonventre JV. Creatinine kinetics and the definition of acute kidney injury. J Am Soc Nephrol. 2009;20(3):672–9. https://doi.org/10.1681/asn.2008070669.
Palevsky PM, Liu KD, Brophy PD, Chawla LS, Parikh CR, Thakar CV, Tolwani AJ, Waikar SS, Weisbord SD. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for acute kidney injury. Am J Kidney Dis. 2013;61(5):649–72. https://doi.org/10.1053/j.ajkd.2013.02.349.
Obermuller N, Geiger H, Weipert C, Urbschat A. Current developments in early diagnosis of acute kidney injury. Int Urol Nephrol. 2014;46(1):1–7. https://doi.org/10.1007/s11255-013-0448-5.
Kashani K, Cheungpasitporn W, Ronco C. Biomarkers of acute kidney injury: the pathway from discovery to clinical adoption. Clin Chem Lab Med. 2017;55(8):1074–89. https://doi.org/10.1515/cclm-2016-0973.
Author information
Authors and Affiliations
Contributions
JG designed and supervised the study, gathered some data and conducted a rigorous review of the final version of the manuscript. DC performed the statistical analyses, and drafted the manuscript. DX, BC helped to acquire the data and assessed the risk of bias of the trials. ZGW helped to draft the manuscript and interpret the data. All authors read and approved the final manuscript.
Corresponding author
Ethics declarations
Conflict of interest
All the authors declare no conflict of interest in this work.
Ethical approval
This article does not contain any studies with human participants or animals performed by any of the authors.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Chen, D., Xiao, D., Guo, J. et al. Neutrophil–lymphocyte count ratio as a diagnostic marker for acute kidney injury: a systematic review and meta-analysis. Clin Exp Nephrol 24, 126–135 (2020). https://doi.org/10.1007/s10157-019-01800-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10157-019-01800-y