Prognostic Value of the Platelet to Lymphocyte Ratio on Cardiovascular Complications in Chronic Hemodialysis Patients
Conditions: Cardiovascular Complications in Hemodialysis
Sponsor: Minia University

Prognostic Value of the Platelet-to Lymphocyte 
Ratio on Cardiovascular Complications in 
Chronic Hemodialysis Patients 
 
    
  Submitted for partial fulfillment of the Master degree 
    In Internal Medicine  
By    
 
Hana Mohamed Ali  
M.B.,B.Ch.  
   
    
 Under Supervision Of  
   
   
Prof. Dr. Hasan Mohamed Mohee El-Deen   
Professor of Internal Medicine   
Faculty of Medicine    
 El-Minia University   
   
Dr. Shaima Hassaan Hamdy   
Lecturer of Internal Medicine   
Faculty of Medicine    
El-Minia University   
   
Dr. Amr Mostafa Abdel Hafez   
Lecturer of Cardiology   
Faculty of Medicine    
El-Minia University   
   
   
   
   
 Minia University   
2023   
   
   
   

   
   
INTRODUCTION   
Chronic kidney disease (CKD) is a global public health problem. With the decline in renal 
function, patients with end-stage kidney disease (ESKD) can choose hemodialysis (HD), peritoneal 
dialysis (PD) or kidney transplantation as renal replacement therapy to improve their quality of 
life. Globally, HD is still the most important renal replacement therapy. With the continuous 
development and optimization of dialysis technology, the survival time of maintenance 
hemodialysis (MHD) patients is gradually prolonged. However, even in developed countries, the 
mortality rate of MHD patients remains high (Saran et al., 2020).    
   
Many studies have shown that 30-50 percent (%) of MHD patients have chronic 
inflammation state (Chavez Valencia et al., 2017). Persistent inflammation can lead to a variety of 
complications, especially cardiovascular disease, malnutrition and anemia, thereby increasing the 
mortality of MHD patients (Liao et al., 2022). Although less than 5% of MHD patients die directly 
from inflammation, inflammation can interact with a variety of risk factors and has an important 
impact on the prognosis of MHD patients. Studies have found that inflammation is closely related 
to high-risk factors of death such as myocardial hypertrophy, ventricular dysfunction, 
atherosclerosis, protein energy consumption, anemia and renal bone disease (Akchurin and 
Kaskel, 2015). Therefore, the development of inflammation-related indicators has important 
clinical value for judging the prognosis of MHD patients and guiding early intervention. Recent 
studies have found that the ratios of different blood cell components are new inflammatory 
markers, which have good predictive value in the outcome of CKD, cardiovascular disease, 
rheumatic disease, etc., including platelet-to-lymphocyte ratio (PLR) (Kurtul and Ornek, 2019).    
   
Previous studies have inconsistent conclusions about the predictive value of PLR on 
mortality of HD patients. Xiang et al., (2108) suggested that higher PLR is a strong and 
independent predictor of all-cause and cardiovascular mortality among HD patients. Another study 
found that PLR could independently predict all-cause mortality in these populations (Yaprak et al., 
2016).    
   
   

AIM OF THE STUDY   
We hypothesized that the combination of PLR could form a new indicator for predicting the 
mortality of HD patients. Therefore, we incorporated PLR into an inflammation scoring system 
and investigated the value of inflammation score in predicting all-cause and cardiovascular 
mortality in HD patients.   
   
SUBJECTS AND METHODS   
This current retrospective controlled hospital based study will recruiting 60 ESKD patients 
who underwent MHD sessions at the HD unit of Nephrology Department of Minia University 
Hospital in the period from January 2024 to June 2024. In addition, the study included 20 
unrelated adult healthy nonsmoker subjects matched for age, gender, ethnicity and body mass index 
(BMI) with the HD patients to serve as control group. These subjects were carefully screened for 
any previous history, symptoms and signs indicative of cardiac, renal or liver diseases, neither of 
which were be found on both clinical examination and standard laboratory tests. Additionally, all 
of them were be on a regular diet without drugs or vitamin supplements at the time of the study.  
They were selected from the medical and paramedical staff member team of the same hospital.   
Ethical approval and written informed consent:   
An approval of the study will be obtained from Mina University Academic and Ethical Committee.  
Every patient signed an informed written consent for acceptance of the operation.   
Inclusion criteria:   
Patients undergoing HD for more than three months who will agree to be included in this study.   
Exclusion criteria:    
We are going to exclude patients who have:   
➢ Younger than 18 year- old or Older than 75 year-old,   
➢ Patients with positive serum marker of anti-hepatitis C virus (anti-HCV), hepatitis B surface  
antigen (HBsAg) and human immunodeficiency virus (HIV).    
➢ Alcohol or illicit drug abusers.    
➢ Inflammatory state due to infection,   

➢ Autoimmune diseases,   
➢ Current malignancy or history of malignancy, ➢ Immunosuppressive therapy.   
All the study subjects will be submitted to the following:   
I) Thorough clinical history:   
It will be taken with special emphasis on age, gender, residence, cigarette smoking, 
hypertension, diabetes mellitus, stroke history, peripheral vascular disease (PVD) history,  
dialysis duration and prescribed medications.   
II) Careful examination:   
All body systems were carefully examined with special emphasis on the cardiovascular system 
examination. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) measurements 
were taken in the supine position before and after HD session using a sphygmomanometer. In 
addition, body weight, height and body mass index (BMI) were carefully evaluated and 
calculated based on dry weight. The BMI equals body weight in kilogram (Kg) ÷ height in 
square meter (m²) (Keys et al., 1972).   
III) Dialytic session data   
As the dialysis prescriptions may act as potential confounding factors, intradialytic data were 
be evaluated for each patient with special emphasis on haemodialysis access, ultrafiltration (UF) 
volume, Kt/V (K – dialyzer clearance of urea; t – dialysis time; V – volume of distribution of urea)  
and urea reduction ratio (URR). 
 IV) Laboratory Investigations:   
A peripheral overnight fasting period venous blood sample will be withdrawn from each subject 
after they will be rested in a supine position for 5 min and prior to heparinization in HD patients. 
The blood sample will be divided into three blood collection tubes, one containing 
ethylenediamine-tetra acetic acid (EDTA), one tube containing tri-sodium citrate and lastly a 
plane tube.    
➢ On an EDTA containing tube, 3 ml blood will be used for determination of hemoglobinA1c 
(HbA1c), parathyroid hormone related protein (PTHrP) and complete blood count (CBC). 
The white blood cell differentiation will be detected as part of CBC, and then we will  
calculate platelet-to-lymphocyte ratio   

➢ On a trisodium citrate containing tube, 1.8 ml blood will be used for determination of 
prothrombin time (PT) and prothrombin concentration (PC).   
➢ On a plane tube, 4 ml blood will be left to be clotted then centrifuged. Expressed serum will 
be used for determination of fasting serum glucose (FSG) level, fasting serum insulin level, 
liver function tests (LFTs), creatinine, urea, uric acid, electrolytes [including sodium, 
potassium, magnesium, phosphorus and calcium], viral markers [including anti-HCV, 
HBsAg and HIV], iron profile [including Serum iron and total iron binding capacity (TIBC) 
and transferrin saturation (TSAT)], serum ferritin and high sensitive C -reactive protein (Hs 
CRP).    
After asking the subjects to be fasting for another 4 hours or till the end of HD session, another 
4 ml of peripheral venous blood sample will be taken from each subject after they adopted a 
supine position for 5 min. The blood sample will be collected in a new plane tube and left to be  
clotted then centrifuged. Expressed serum will be used to assess lipid profile.    
V)Imaging studies    
1. Lateral abdominal radiography: It will be used to detect abdominal aortic  
calcifications that are defined as the presence of a longitudinal linear or strip-shaped 
high-density shadow at the level of the first to fourth lumbar vertebrae (Wang et al., 
2022).   
2. Bilateral carotid duplex: The intimal medial thickness (IMT), bilateral peak systolic 
velocities (PSV) and blood flow volumes will be measured for the common carotid arteries 
(CCA) and vertebral arteries. At the CCA, hemodynamic variables will be measured at a 
segment located 2 cm proximal to the bifurcation of the CCA; at the vertebral arteries, 
variables will be measured at the arterial segment between the transverse processes of the 
4th and 5th cervical vertebrae in the sagittal plane. The diameter of the vessels at each location 
will be measured at each evaluation. Total cerebral blood flow will be calculated as the sum 
of the bilateral blood flow volumes in the CCAs and vertebral arteries (Chung et al., 2015).   
3. Electrocardiogram (ECG) assessment: It will be used for detection of arrhythmias  
and axis deviation   
4. Transthoracic Echocardiogram (TTE) assessment: It will be used to evaluate the 
following echocardiographic parameters including: interventricular septum thickness at 
end-diastole (IVSd), interventricular septum thickness at end-systole (IVSs), left ventricular 

internal dimension at end-diastole (LVIDd), left ventricular internal dimension at end-
systole (LVIDs), left ventricular posterior wall thickness at enddiastole (LVPWd), left 
ventricular posterior wall thickness at end-systole (LVPWs), left ventricular fractional 
shortening (LVFS), left atrium diameter (LAD), aortic root (AO) diameter and the ratio of 
the left atrial dimension to the aortic annulus dimension (LA/Ao), end-diastolic volume 
(EDV), end-systolic volume (ESV), left ventricular ejection fraction (LVEF), stroke volume 
(SV), left ventricular hypertrophy (LVH) and pulmonary arterial systolic pressure (PASP). 
Furthermore, the valvular structure, function and presence of calcifications will be also 
evaluated. Valvular calcifications were defined as a brilliant echo of >1 mm in one or more 
cusps of the aortic or mitral valve or mitral ring. In addition, the presence of aortic 
atherosclerotic changes will be evaluated (Ellouali. et al., 2015).   
VI) Outcomes   
Cardiovascular events including non-fatal myocardial infarction, unstable angina, 
cerebrovascular events (intraparenchymal hemorrhage, subarachnoid hemorrhage, cerebral 
infarction), hospitalization for congestive heart failure, serious cardiac arrhythmia 
(resuscitated cardiac arrest, ventricular fibrillation, sustained ventricular tachycardia, 
paroxysmal ventricular tachycardia, an initial episode of atrial fibrillation or flutter, severe 
bradycardia or heart block) and peripheral arterial diseases will be evaluated after 6 months  
and confirmed by medical records.   
 Statistical analysis:   
Data were analyzed using Statistical Package for Social Science (SPSS) version 25.0. Quantitative 
data were expressed as mean ± standard deviation (SD). Qualitative data were expressed as 
frequency and percentage.    
For all analyses, statistical significance will be defined as p-values ≤0.05.   
   
   
  
   
 
 
 
 

 
 
 
 
 
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