Association of neutrophil-lymphocyte ratio with all-cause and cardiovascular mortality in peritoneal dialysis patients: A systematic review and meta-analysis

doi:10.5662/wjm.v16.i1.106277

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World Journal of Methodology

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Meta-Analysis

World J Methodol. Mar 20, 2026; 16(1): 106277
Published online Mar 20, 2026. doi: 10.5662/wjm.v16.i1.106277

Association of neutrophil-lymphocyte ratio with all-cause and cardiovascular mortality in peritoneal dialysis patients: A systematic review and meta-analysis

Nanush Damarlapally, Roopeessh Vempati, Denise Mourad, Srivatsa Surya Vasudevan, Gaurav Mathur, Afrasayab Khan, Prathibha Banda, Harshavardhan Polamarasetty, Shaylika Chauhan, Nirmala Manjappachar, Talha Bhatti, Rupak Desai

Nanush Damarlapally, Department of Health Sciences, Houston Community College-Coleman Campus, Houston, TX 77030, United States

Roopeessh Vempati, Department of Internal Medicine, Trinity Health Oakland Hospital, Pontiac, MI 48341, United States

Denise Mourad, Afrasayab Khan, Department of Internal Medicine, Central Michigan University, Saginaw, MI 48602, United States

Srivatsa Surya Vasudevan, Department of Otolarngology, Louisiana State University Health Sciences Center, Shreveport, LA 70112, United States

Gaurav Mathur, Department of Internal Medicine, Connecticut Institute for Communities, Danbury, CT 06810, United States

Prathibha Banda, Department of Internal Medicine, Gandhi Medical College and Hospital, Secunderabad 500003, Telangāna, India

Harshavardhan Polamarasetty, Department of Biomedical Engineering, University of Houston, Houston, TX 77004, United States

Shaylika Chauhan, Department of Internal Medicine, Geisinger Health System, Wikes-Barre, PA 18707, United States

Nirmala Manjappachar, Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States

Talha Bhatti, Department of Cardiology, Lower Bucks Hospital, Bristol, PA 19007, United States

Rupak Desai, Department of Outcomes Research, Independent Researcher, Atlanta, GA 30079, United States

Author contributions: Damarlapally N and Vempati R contributed to methodology, performed screening and feasibility assessments, conducted data curation and data extraction, drafted the original manuscript, reviewed and edited the manuscript, and supervised the project; Mourad D and Bhatti T contributed to data extraction, writing the original draft, reviewing and editing the manuscript; Vasudevan SS performed statistical analysis and contributed to writing the original draft, reviewing and editing the manuscript; Mathur G and Khan A contributed to data extraction; Banda P and Polamarasetty H participated in data extraction and manuscript review and editing; Chauhan S and Manjappachar N reviewed and edited the manuscript, and managed project administration; Desai R conceptualized and designed the study, developed the methodology and software, performed formal analysis, provided resources, participated in writing and editing the manuscript, and managed project administration; all authors have read and approved the final manuscript.

Conflict-of-interest statement: The authors declare that they have no conflicts of interest to disclose related to this manuscript.

PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.

Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Corresponding author: Shaylika Chauhan, MD, FACP, Assistant Professor, Department of Internal Medicine, Geisinger Health System, 1000 E Mountain Blvd, Wikes-Barre, PA 18707, United States. drshaylikachauhan@gmail.com

Received: February 21, 2025
Revised: May 6, 2025
Accepted: July 4, 2025
Published online: March 20, 2026
Processing time: 354 Days and 9.2 Hours

Abstract

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) is a novel inflammatory marker predicting cardiovascular mortality (CVM) and all-cause mortality (ACM).

AIM

To investigate the association between the NLR and CVM and ACM in patients with peritoneal dialysis (PD).

METHODS

We reviewed articles from PubMed, Google Scholar, and Scopus until May 2024 for the association of ACM and CVM in patients with NLR following PD. We used a fixed effects model and I² statistics to pool hazard ratio (HR) and measure heterogeneity. Leave-one-out sensitivity analysis assessed the robustness of our study. Multivariate meta-regression (MMR) was utilized to identify influencing confounding factors. Joanna Briggs Institute (JBI) tool was used for quality assessment.

RESULTS

Out of 160 articles screened, seven studies from 2011 to 2024 with 4350 patients, a mean age of 49.9 years ± 15 years, and a median follow-up of 4 years were included. We found that higher NLR (> 3) was significantly associated with ACM [adjusted HR (aHR): 1.18, 95%CI: 1.03-1.36, P = 0.016]. However, there was no significant association of NLR (> 3) with CVM (aHR: 1.16, 95%CI: 0.68-1.98, P = 0.59) in patients following PD. Sensitivity analysis showed no variations. JBI tool revealed low bias among the studies. MMR revealed a significant relationship between age and ACM (coefficient: 0.14, P = 0.04).

CONCLUSION

Our meta-analysis identifies a significant association between NLR (> 3) and ACM outcome, which can help prevent deaths in the elderly and optimize resource use. Caution is needed when predicting mortality in this group as age significantly confounds ACM in patients undergoing PD.

Keywords: Neutrophil-to-lymphocyte ratio; Peritoneal dialysis; All-cause mortality; Cardiovascular mortality; End stage renal disease; Chronic renal failure; Mortality; Dialysis; Elderly; Cardiac arrest

Core Tip: Inflammation plays a silent but an important role in patients undergoing peritoneal dialysis (PD). This meta-analysis reveals that a simple, and inexpensive blood marker such as elevated neutrophil-to-lymphocyte ratio (NLR) (> 3) can significantly predict all-cause and cardiovascular mortality in this vulnerable group. With data from over 4300 patients, our study also identified age as a key confounder, urging clinicians to interpret NLR levels with caution in older adults. These findings position NLR as a powerful, accessible tool for early risk detection and tailored intervention in PD care.