Incidence of renal outcomes according to NLR quartiles. * Renal outcomes include death and composite endpoints (ESRD, dialysis initiation, double serum creatine from baseline). Q1 (NLR ≤ 2.10), Q2 (NLR = 2.11–2.72), Q3 (NLR = 2.73–3.75), and Q4 (NLR ≥ 3.76). Composite endpoints are further evaluated as commencement of dialysis, doubling of serum creatinine, and advance to ESRD
The authors extend their gratitude towards all the participants and those who carried out the extensive clinical and laboratory work at the clinical site.
Author contributions
IR: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing—original draft. PT: Conceptualization, Methodology, Supervision, Validation, Writing—original draft. SDC and SJ: Conceptualization, Methodology, Supervision, Validation. All authors contributed to manuscript revision, read and approved the submitted version.
Conflicts of interest
The authors declare that they have no conflicts of interest.
Ethical approval
This study is approved by the Institutional Ethics Committee GMCH & NIPER and Research Committee GMCH and complies with the Declaration of Helsinki.
Consent to participate
Informed consent to participate in the study was obtained from all participants.
Levin A, Tonelli M, Bonventre J, Coresh J, Donner JA, Fogo AB, et al.; ISN Global Kidney Health Summit participants. Global kidney health 2017 and beyond: a roadmap for closing gaps in care, research, and policy.Lancet. 2017;390:1888–917. [DOI] [PubMed]
Lv JC, Zhang LX. Prevalence and disease burden of chronic kidney disease. In: Liu BC, Lan HY, Lv LL, editors. Renal fibrosis: mechanisms and therapies. Singapore: Springer Singapore; 2019. pp. 3–15. [DOI] [PubMed]
Centers for Disease Control and Prevention. Chronic kidney disease in the United States, 2021 [Internet]. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; [cited 2022 Nov 29]. Available from: https://www.cdc.gov/kidneydisease/publications-resources/ckd-national-facts.html
Singh AK, Farag YMK, Mittal BV, Subramanian KK, Reddy SRK, Acharya VN, et al. Epidemiology and risk factors of chronic kidney disease in India - results from the SEEK (Screening and Early Evaluation of Kidney Disease) study.BMC Nephrol. 2013;14:114. [DOI] [PubMed] [PMC]
Rashid I, Katravath P, Tiwari P, D’Cruz S, Jaswal S, Sahu G. Hyperuricemia—a serious complication among patients with chronic kidney disease: a systematic review and meta-analysis.Explor Med. 2022;3:249–59. [DOI]
Manabe I. Chronic inflammation links cardiovascular, metabolic and renal diseases.Circ J. 2011;75:2739–48. [DOI] [PubMed]
Meuwese CL, Stenvinkel P, Dekker FW, Carrero JJ. Monitoring of inflammation in patients on dialysis: forewarned is forearmed.Nat Rev Nephrol. 2011;7:166–76. [DOI] [PubMed]
Stenvinkel P, Ketteler M, Johnson RJ, Lindholm B, Pecoits-Filho R, Riella M, et al. IL-10, IL-6, and TNF-α: central factors in the altered cytokine network of uremia—the good, the bad, and the ugly.Kidney Int. 2005;67:1216–33. [DOI] [PubMed]
Snaedal S, Heimbürger O, Qureshi AR, Danielsson A, Wikström B, Fellström B, et al. Comorbidity and acute clinical events as determinants of C-reactive protein variation in hemodialysis patients: implications for patient survival.Am J Kidney Dis. 2009;53:1024–33. [DOI] [PubMed]
Navarro JF, Milena FJ, Mora C, León C, García J. Renal pro-inflammatory cytokine gene expression in diabetic nephropathy: effect of angiotensin-converting enzyme inhibition and pentoxifylline administration.Am J Nephrol. 2007;26:562–70. [DOI] [PubMed]
Fogo AB. Mechanisms of progression of chronic kidney disease.Pediatr Nephrol. 2007;22:2011–22. [DOI] [PubMed] [PMC]
Libby P. Inflammation in atherosclerosis.Arterioscler Thromb Vasc Biol. 2012;32:2045–51. [DOI] [PubMed] [PMC]
Núñez J, Núñez E, Bodí V, Sanchis J, Miñana G, Mainar L, et al. Usefulness of the neutrophil to lymphocyte ratio in predicting long-term mortality in ST segment elevation myocardial infarction.Am J Cardiol. 2008;101:747–52. [DOI] [PubMed]
Tamhane UU, Aneja S, Montgomery D, Rogers EK, Eagle KA, Gurm HS. Association between admission neutrophil to lymphocyte ratio and outcomes in patients with acute coronary syndrome.Am J Cardiol. 2008;102:653–7. [DOI] [PubMed]
Walsh SR, Cook EJ, Goulder F, Justin TA, Keeling NJ. Neutrophil-lymphocyte ratio as a prognostic factor in colorectal cancer.J Surg Oncol. 2005;91:181–4. [DOI] [PubMed]
Turkmen K, Guney I, Yerlikaya FH, Tonbul HZ. The relationship between neutrophil-to-lymphocyte ratio and inflammation in end-stage renal disease patients.Ren Fail. 2012;34:155–9. [DOI] [PubMed]
Okyay GU, Inal S, Oneç K, Er RE, Paşaoğlu O, Paşaoğlu H, et al. Neutrophil to lymphocyte ratio in evaluation of inflammation in patients with chronic kidney disease.Ren Fail. 2013;35:29–36. [DOI] [PubMed]
Demir NA, Sumer S, Celik G, Afsar RE, Demir LS, Ural O. How should procalcitonin and C-reactive protein levels be interpreted in haemodialysis patients?Intern Med J. 2018;48:1222–8. [DOI] [PubMed]
Jairam A, Das R, Aggarwal PK, Kohli HS, Gupta KL, Sakhuja V, et al. Iron status, inflammation and hepcidin in ESRD patients: the confounding role of intravenous iron therapy.Indian J Nephrol. 2010;20:125–31. [DOI] [PubMed] [PMC]
Wanner C, Drechsler C, Krane V. C-reactive protein and uremia.Semin Dial. 2009;22:438–41. [DOI] [PubMed]
Ahbap E, Sakaci T, Kara E, Sahutoglu T, Koc Y, Basturk T, et al. Neutrophil-to-lymphocyte ratio and platelet-tolymphocyte ratio in evaluation of inflammation in end-stage renal disease.Clin Nephrol. 2016;85:199–208. [DOI] [PubMed]
Guthrie GJ, Charles KA, Roxburgh CSD, Horgan PG, McMillan DC, Clarke SJ. The systemic inflammation-based neutrophil-lymphocyte ratio: experience in patients with cancer.Crit Rev Oncol Hematol. 2013;88:218–30. [DOI] [PubMed]
Chan C, Puckridge P, Ullah S, Delaney C, Spark JI. Neutrophil-lymphocyte ratio as a prognostic marker of outcome in infrapopliteal percutaneous interventions for critical limb ischemia.J Vasc Surg. 2014;60:661–8. [DOI] [PubMed]
Erturk M, Cakmak HA, Surgit O, Celik O, Aksu HU, Akgul O, et al. The predictive value of elevated neutrophil to lymphocyte ratio for long-term cardiovascular mortality in peripheral arterial occlusive disease.J Cardiol. 2014;64:371–6. [DOI] [PubMed]
Forget P, Khalifa C, Defour JP, Latinne D, Van Pel MC, De Kock M. What is the normal value of the neutrophil-to-lymphocyte ratio?BMC Res Notes. 2017;10:12. [DOI] [PubMed] [PMC]
World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.JAMA. 2013;310:2191–4. [DOI] [PubMed]
Jager-Wittenaar H, Ottery FD. Assessing nutritional status in cancer: role of the Patient-Generated Subjective Global Assessment.Curr Opin Clin Nutr Metab Care. 2017;20:322–9. [DOI] [PubMed]
Deo SV, Deo V, Sundaram V. Survival analysis-part 2: Cox proportional hazards model.Indian J Thorac Cardiovasc Surg. 2021;37:229–33. [DOI] [PubMed] [PMC]
Abramowitz M, Muntner P, Coco M, Southern W, Lotwin I, Hostetter TH, et al. Serum alkaline phosphatase and phosphate and risk of mortality and hospitalization.Clin J Am Soc Nephrol. 2010;5:1064–71. [DOI] [PubMed] [PMC]
Xie Y, Wei ZB, Duan XW. Prognostic value of pretreatment serum alkaline phosphatase in nasopharyngeal carcinoma.Asian Pac J Cancer Prev. 2014;15:3547–53. [DOI] [PubMed]
Webber M, Krishnan A, Thomas NG, Cheung BM. Association between serum alkaline phosphatase and C-reactive protein in the United States National Health and Nutrition Examination Survey 2005–2006.Clin Chem Lab Med. 2010;48:167–73. [DOI] [PubMed]
Kerner A, Avizohar O, Sella R, Bartha P, Zinder O, Markiewicz W, et al. Association between elevated liver enzymes and C-reactive protein: possible hepatic contribution to systemic inflammation in the metabolic syndrome.Arterioscler Thromb Vasc Biol. 2005;25:193–7. [DOI] [PubMed]
Gupta J, Mitra N, Kanetsky PA, Devaney J, Wing MR, Reilly M, et al.; CRIC Study Investigators. Association between albuminuria, kidney function, and inflammatory biomarker profile in CKD in CRIC.Clin J Am Soc Nephrol. 2012;7:1938–46. [DOI] [PubMed] [PMC]
Prakash J, Raja R, Mishra RN, Vohra R, Sharma N, Wani IA, et al. High prevalence of malnutrition and inflammation in undialyzed patients with chronic renal failure in developing countries: a single center experience from eastern India.Ren Fail. 2007;29:811–6. [DOI] [PubMed]
Singbartl K, Formeck CL, Kellum JA. Kidney-immune system crosstalk in AKI.Semin Nephrol. 2019;39:96–106. [DOI] [PubMed]
Zhao WM, Tao SM, Liu GL. 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.Ren Fail. 2020;42:1059–66. [DOI] [PubMed] [PMC]
Behairy MAEM, Shawky SM, Bawady SAEh, El Kezza GAEH, Ahmed FA. Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in evaluation of inflammation and nutritional status in chronic kidney disease patients.Egypt J Hosp Med. 2022;89:5814–23. [DOI]
Diaz-Martinez J, Campa A, Delgado-Enciso I, Hain D, George F, Huffman F, et al. The relationship of blood neutrophil-to-lymphocyte ratio with nutrition markers and health outcomes in hemodialysis patients.Int Urol Nephrol. 2019;51:1239–47. [DOI] [PubMed]
Neuen BL, Leather N, Greenwood AM, Gunnarsson R, Cho Y, Mantha ML. Neutrophil-lymphocyte ratio predicts cardiovascular and all-cause mortality in hemodialysis patients.Ren Fail. 2016;38:70–6. [DOI] [PubMed]
Johnson DW, Dent H, Hawley CM, McDonald SP, Rosman JB, Brown FG, et al. Association of dialysis modality and cardiovascular mortality in incident dialysis patients.Clin J Am Soc Nephrol. 2009;4:1620–8. [DOI] [PubMed] [PMC]
An X, Mao HP, Wei X, Chen JH, Yang X, Li ZB, et al. Elevated neutrophil to lymphocyte ratio predicts overall and cardiovascular mortality in maintenance peritoneal dialysis patients.Int Urol Nephrol. 2012;44:1521–8. [DOI] [PubMed]
Yoshitomi R, Nakayama M, Sakoh T, Fukui A, Katafuchi E, Seki M, et al. High neutrophil/lymphocyte ratio is associated with poor renal outcomes in Japanese patients with chronic kidney disease.Ren Fail. 2019;41:238–43. [DOI] [PubMed] [PMC]
Bernelot Moens SJ, Verweij SL, van der Valk FM, van Capelleveen JC, Kroon J, Versloot M, et al. Arterial and cellular inflammation in patients with CKD.J Am Soc Nephrol. 2017;28:1278–85. [DOI] [PubMed] [PMC]
Solak Y, Yilmaz MI, Sonmez A, Saglam M, Cakir E, Unal HU, et al. Neutrophil to lymphocyte ratio independently predicts cardiovascular events in patients with chronic kidney disease.Clin Exp Nephrol. 2013;17:532–40. [DOI] [PubMed]
