The Relationship of a Novel Marker of Inflammation (Neutrophil-to-Lymphocyte Ratio) to Nutritional Status, Diet and Clinical Outcomes in Hemodialysis Patients

Abstract

The aim of this dissertation was to examine prospectively the relationship of a novel marker of inflammation (neutrophil-to-lymphocyte ratio) with nutrition markers, diet and clinical outcomes in a cohort study that included 77 patients from one hemodialysis (HD) center located in South Florida. Demographics and clinical parameters were obtained from patients’ medical charts. Nutritional status was determined at baseline, six and 12 months using the Malnutrition-Inflammation Score (MIS) and the 7-point Subjective Global Assessment (SGA) scale consisting of two categories: medical history and physical examination. Dietary assessments were performed, and 24-hour diet recalls were collected at each assessment visit. Neutrophil-to-Lymphocyte Ratio (NLR) at baseline was associated with nutritional markers (albumin and body mass index) and was a predictor of hospitalizations only for diabetics (HR=0.27, 95% CI 0.07-0.96, P=0.044). Participants with moderate-to-severe malnutrition based on SGA had a 2.67 higher risk for hospitalization events. MIS >5 was associated with hospitalization (HR=2.11, 95% CI:1.12-3.97, P=0.019) and with mortality (HR=13.87, 95% CI:1.56-123.045, P= 0.018) even after adjustments. Meeting energy recommendations reduced the chances of hospitalization by 59% (HR=0.41 95% CI:0.21-0.79, P=0.008), and mortality was reduced by 81% (H R=0.19, 95% CI:0.03-0.98, P=0.049). The intake of two or more fruit servings per day was associated with lowering mortality risk by 75% (HR=0.246, 95%CI: 0.069- 0.880, P=0.031); and intake of at least 7 grams of cereal fiber per day lowered mortality risk by 81% (HR= 0.187; 95.0% CI:0.05-0.693, P=0.012). Our findings support the use of NLR, an inexpensive and convenient inflammation marker, as a strong predictor of outcomes in hemodialysis patients, and provide preliminary data on the protective effect that a low NLR might have on the risk of hospitalizations in HD patients. Our study also provided observational evidence for nutrition interventions that aim at improving the nutrition-inflammation status and promoting adequate energy, protein and fiber intakes in patients living with hemodialysis.