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

  • Nephrology - Original Paper
  • Published:
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Abstract

Objective

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.

Design

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.

Results

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).

Conclusion

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.

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References

  1. Foley RN, Collins AJ (2007) End-stage renal disease in the United States: an update from the United States Renal Data System. J Am Soc Nephrol 8(10):2644–2648

    Article  Google Scholar 

  2. Collins AJ, Foley RN, Gilbertson DT, Chen SC (2015) United States renal data system public health surveillance of chronic kidney disease and end-stage renal disease. Kidney Int Suppl 5(1):2–7

    Article  Google Scholar 

  3. de Mutsert R, Grootendorst DC, Axelsson J et al (2008) NECOSAD study group. Excess mortality due to interaction between protein-energy wasting, inflammation and cardiovascular disease in chronic dialysis patients. Nephrol Dial Transplant 23(9):2957–2964

    Article  CAS  PubMed  Google Scholar 

  4. Ikizler TA (2013) Optimal nutrition in hemodialysis patients. Adv Chronic Kidney Dis 20(2):181–189

    Article  PubMed  PubMed Central  Google Scholar 

  5. Libby P (2012) Inflammation in atherosclerosis. Arterioscler Thromb Vasc Biol 32(9):2045–2051

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Iseki K, Tozawa M, Yoshi S, Fukiyama K (1999) Serum C-reactive protein (CRP) and risk of death in chronic dialysis patients. Nephrol Dial Transplant 14(8):1956–1960

    Article  CAS  PubMed  Google Scholar 

  7. Eleftheriadis T, Antoniadi G, Liakopoulos V et al (2007) Basic science and dialysis: disturbances of acquired immunity in hemodialysis patients. Sem Dial 20(5):440–451

    Article  Google Scholar 

  8. Okyay GU, İnal S, Öneç K et al (2013) Neutrophil to lymphocyte ratio in evaluation of inflammation in patients with chronic kidney disease. Ren Fail 35(1):29–36

    Article  CAS  PubMed  Google Scholar 

  9. Turkmen K, Guney I, Yerlikaya FH, Tonbul HZ (2012) The relationship between neutrophil-to-lymphocyte ratio and inflammation in end-stage renal disease patients. Ren Fail 34(2):155–159

    Article  CAS  PubMed  Google Scholar 

  10. Malhotra R, Marcelli D, Von Gersdorff G et al (2015) Relationship of neutrophil-to-lymphocyte ratio and serum albumin levels with C-reactive protein in hemodialysis patients: results from two international cohort studies. Nephron 130(4):263–270

    Article  CAS  PubMed  Google Scholar 

  11. Isaac V, Wu CY, Huang CT et al (2016) Elevated neutrophil to lymphocyte ratio predicts mortality in medical inpatients with multiple chronic conditions. Medicine (Baltimore) 95(23):3832

    Article  CAS  Google Scholar 

  12. Keizman D, Ish-Shalom M, Huang P et al (2012) The association of pre-treatment neutrophil to lymphocyte ratio with response rate, progression free survival and overall survival of patients treated with sunitinib for metastatic renal cell carcinoma. Eur J Cancer 48(2):202–208

    Article  CAS  PubMed  Google Scholar 

  13. Azab B, Daoud J, Naeem FB et al (2012) Neutrophil-to-lymphocyte ratio as a predictor of worsening renal function in diabetic patients (3-year follow-up study). Ren Fail 34(5):571–576

    Article  CAS  PubMed  Google Scholar 

  14. Neuen BL, Leather N, Greenwood AM et al (2016) Neutrophil–lymphocyte ratio predicts cardiovascular and all-cause mortality in hemodialysis patients. Ren Fail 38(1):70–76

    Article  PubMed  Google Scholar 

  15. An X, Mao HP, Wei X et al (2012) Elevated neutrophil to lymphocyte ratio predicts overall and cardiovascular mortality in maintenance peritoneal dialysis patients. Int Urol Nephrol 44(5):1521–1528

    Article  CAS  PubMed  Google Scholar 

  16. Li H, Lu X, Xiong R, Wang S (2017) High neutrophil-to-lymphocyte ratio predicts cardiovascular mortality in chronic hemodialysis patients. Mediat Inflamm. https://doi.org/10.1155/2017/9327136

    Article  Google Scholar 

  17. Erdem E, Coşkun KA, Karatas A, Dilek M, Akpolat T (2013) Neutrophil to lymphocyte ratio in predicting short-term mortality in hemodialysis patients. J Exp Clin 30(2):129–132

    Article  Google Scholar 

  18. Azab B, Chainani V, Shah N, McGinn JT (2012) Neutrophil-lymphocyte ratio as a predictor of major adverse cardiac events among diabetic population: a 4-year follow-up study. Angiology 4(6):456–465

    Article  Google Scholar 

  19. Jensen MD, Ryan DH, Apovia CM et al (2014) AHA/ACC/TOS Guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation 129:S102

    Article  PubMed  Google Scholar 

  20. Rahimlu M, Shab-Bidar S, Djafaria K (2017) Body mass index and all-cause mortality in chronic kidney disease: a dose–response meta-analysis of observational studies. J Ren Nutr 27(4):225–232

    Article  PubMed  Google Scholar 

  21. Leavey SF, McCullough K, Hecking E et al (2001) Body mass index and mortality in ‘healthier’ as compared with ‘sicker’ haemodialysis patients: results from the dialysis outcomes and practice patterns study (DOPPS. Nephrol Dial Transplant 16(12):2386–2394

    Article  CAS  PubMed  Google Scholar 

  22. Kalantar-Zadeh K, Kopple JD, Humphreys MH, Block G (2004) Comparing outcome predictability of markers of malnutrition–inflammation complex syndrome in hemodialysis patients. Nephrol Dial Transplant 19(6):1507–1519

    Article  CAS  PubMed  Google Scholar 

  23. Doweiko JP, Nompleggi DJ (1991) Reviews. The role of albumin in human physiology and pathophysiology. Albumin and disease states. JPEN J Parenter Enteral Nutr 15(4):476–483

    Article  CAS  PubMed  Google Scholar 

  24. Delgado C, Chertow G, Kaysen GA et al (2017) Associations of body mass index and body fat with markers of inflammation and nutrition among patients receiving hemodialysis. Am J Kidney Dis 70(6):817–825

    Article  PubMed  Google Scholar 

  25. Zimmermann J, Herrlinger S, Pruy A et al (1999) Inflammation enhances cardiovascular risk and mortality in hemodialysis patients. Kidney Int 55(2):648–658

    Article  CAS  PubMed  Google Scholar 

  26. Pecoits-Filho R, Stenvinkel P, Wang AY et al (2004) Chronic inflammation in peritoneal dialysis: the search for the holy grail? Perit Dial Int 24(4):327–339

    CAS  PubMed  Google Scholar 

  27. Kalantar-Zadeh K, Fouque D, Kopple JD (2004) Outcome research, nutrition, and reverse epidemiology in maintenance dialysis patients. J Ren Nutr 14(2):64–71

    Article  PubMed  Google Scholar 

  28. Nowak KL, Chonchol M (2018) Does inflammation affect outcomes in dialysis patients? Semin Dial 31(4):388–397

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

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.

Funding

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

Author information

Authors and Affiliations

  1. Department of Dietetics and Nutrition, Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8th Street, Miami, FL, 33199, USA

    Janet Diaz-Martinez, Adriana Campa, Fatma Huffman & Marianna Baum

  2. Department of Molecular Medicine, School of Medicine, University of Colima, Av. Universidad 333, Colonia las Viboras, Colima, Mexico

    Ivan Delgado-Enciso

  3. Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Road, Boca Raton, FL, 33431, USA

    Debra Hain

  4. Department of Mathematics and Statistics, Florida International University, 11200 SW 8th Street, DM 405, Miami, FL, 33199, USA

    Florence George

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  1. Janet Diaz-Martinez
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Corresponding author

Correspondence to Janet Diaz-Martinez.

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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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Diaz-Martinez, J., Campa, A., Delgado-Enciso, I. et al. The relationship of blood neutrophil-to-lymphocyte ratio with nutrition markers and health outcomes in hemodialysis patients. Int Urol Nephrol 51, 1239–1247 (2019). https://doi.org/10.1007/s11255-019-02166-6

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