The neutrophil-to-lymphocyte ratio as a predictor of all-cause mortality in individuals with anemia: A population-based study

BACKGROUND: This study investigates the association between the neutrophil-to-lymphocyte ratio (NLR) and all-cause mortality in individuals with anemia using the National Health and Nutrition Examination Survey (NHANES) 1999-2018 dataset. METHODS: We included 3,212 participants with anemia, categorized into three groups by NLR values. Baseline characteristics, comorbidities, and demographics were analyzed. We performed univariate logistic regression, multivariable Cox regression, non-linear regression, and breakpoint analysis to examine NLR-mortality relationships. Subgroup analysis assessed effect modification by clinical factors. RESULTS: The mean age of the cohort was 56.0 ± 18.3 years. Participants in the highest NLR tertile (T3) had significantly higher mortality risk, with an HR of 1.25 (95% CI:1.07-1.48, p = 0.007) in the fully adjusted model. Univariate logistic regression showed that NLR was independently associated with mortality (odds ratio [OR] = 1.44, 95% confidence interval [CI]: 1.35-1.52, p < 0.001), with higher mortality risk in the highest NLR tertile (OR = 2.9, 95% CI: 2.39-3.53, p < 0.001). Multivariable Cox regression analysis confirmed NLR as a significant predictor (hazard ratio [HR] = 1.11, 95% CI: 1.07-1.15, p < 0.001). A non-linear regression analysis identified a data-derived threshold at NLR = 1.475, with the risk of mortality increasing significantly above this threshold (HR = 1.134, 95% CI: 1.073-1.2, p < 0.001). CONCLUSION: NLR is a significant predictor of all-cause mortality in individuals with anemia. Elevated NLR, particularly above 1.475, is associated with a 25.0% higher mortality risk, suggesting its potential utility as a prognostic biomarker in this context.