NEUTROPHIL LYMPHOCYTE RATIO (NLR): AN EMERGING BIOMARKER IN MAINTENANCE HEMODIALYSIS PATIENTS

Neutrophil lymphocyte ratio (NLR) is increasingly considered as an important marker defining prognosis in maintenance hemodialysis patients. A high value has been associated with increasing rates of infections, sarcopenia, depressive symptoms, high parathormone levels, infections, and overall mortality. It has been also shown to be associated with the development of uremic symptoms and can be used as a marker for initiation of maintenance hemodialysis. This simple test if performed regularly can give us prognostic information in our regular dialysis patients.

A prospective observational cohort was studied between 1st February till 31st July 2025. All patients who were initiated on dialysis in our center were included in the study. Our center is a quartenary level dialysis institution offering the highest standard of dialysis delivery.

 Demographic variables, comorbidities, dialysis frequency, hospitalization, infections and mortality was noted during this study period. An initial NLR was noted for all patients.All continuous variables were noted as mean ±sd. A NLR value >3.5 was considered as the cut-off. Statistical analysis was done to look at the association of a high NLR with measured variables (comorbidities, dialysis details, out come measures etc).A p value of <0.05 was considered significant.

A total of 104 (63 males and 41 females) patients were followed up during the study period. The mean age of the cohort was 54.1±15.9 years. There were 41 diabetics. Of the 108 patients 49 patients were on twice weekly dialysis (rest were coming to the center three times a week). The mean (± sd) of creatinine, albumin, calcium, phosphorus, sodium, potassium and hemoglobin was 8.09(3.52) mg/dl,3.64(0.58) g/dl, 7.89(2.17) mg/dl, 5.23(2.40) mg/dl, 137.09(3.58) meq/L, 5.13(1.02) meq/L and 9.05(1.72) g/dl respectively. 61 patients (58.6%) had an NLR more than 3.5 in our cohort.59 out of 104 (56.7%) patients were on permanent dialysis catheter, rest were dialyzed through an AV fistula.

47 out of 49 patients(95.9%) on twice weekly dialysis had a high NLR compared to 14 (25.4%) on thrice weekly dialysis (p=0.001). 69.8% of the male patients had high NLR compared to 41.4% (17/41 patients) of females.(p<0.05). More than half of the diabetics (56.1% ) had a high NLR. A high NLR was seen in patients who were on AV fistula  for dialysis (64 % of the patients on AV fistula vs 54% on permanent catheter had a high NLR). There were 11 hospitalizations during the study, all but 1 happened in the group with high NLR. Blood stream infections were noted in 12 patients, except 2, all were in the high NLR group. All 4 mortalities were noted in the group with high NLR. The outcome events were small and did not merit statistical interpretation.

A high neutrophil lymphocyte ratio (NLR) is prevalent even in centers considered to be offering high quality dialysis. In our center, a high NLR was noted in males , those on twice weekly dialysis and diabetics. A poor outcome (hospitalizations, mortality) was predominantly noted in patients with high NLR.NLR is emerging as an important biomarker in maintenance hemodialysis patients. This marker can be obtained in majority of dialysis centers as a complete blood count is offered to patients world wide. Further studies are required to address the importance of this ratio not only in prognosis but its significance in its association in various aspect of hemodialysis delivery (timing of initiation, frequency of dialysis , infectious and non infectious outcomes etc).