ORIGINAL RESEARCH article
Front. Nutr.
Sec. Clinical Nutrition
Volume 12 - 2025 | doi: 10.3389/fnut.2025.1595119
Altered albumin/neutrophil to lymphocyte ratio are associated with all-cause and cardiovascular mortality for advanced cardiovascular-kidney-metabolic syndrome
Provisionally accepted
- Department of Immunology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
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Background:Advanced cardiovascular-kidney-metabolic (CKM) syndrome, comprising stages 3–4, is associated with elevated all-cause mortality (ACM) and cardiovascular mortality (CVM). The albumin-to-neutrophil/lymphocyte ratio (ANLR), integrating nutritional and inflammatory status, is a novel biomarker, but its prognostic value in advanced CKM remains unclear.Methods:Data were drawn from the 1999–2018 National Health and Nutrition Examination Survey (NHANES), linked with mortality outcomes from the National Death Index. ANLR was calculated as ALB × NLR. CKM stages were defined based on American Heart Association criteria, adapted to NHANES. Outcomes included ACM and CVM. Propensity score matching (PSM) was used to balance confounders. The optimal ANLR cutoff was identified using maximally selected rank statistics. Survival differences were analyzed via Kaplan-Meier curves and multivariate Cox proportional hazards models. Restricted cubic spline (RCS) analysis assessed potential non-linear associations. Stratified and interaction analyses explored effect modifiers.Results:A total of 3,266 individuals with advanced CKM syndrome (median age 73 years, 41.12% male) were analyzed. Before PSM, those in the lowest ANLR tertile had significantly higher risks of ACM (HR: 1.58, 95% CI: 1.39–1.78) and CVM (HR: 1.65, 95% CI: 1.34–2.04). Post-PSM and full adjustment, an ANLR <1.04 was independently associated with elevated ACM (HR: 1.52, 95% CI: 1.27–1.81) and CVM (HR: 2.02, 95% CI: 1.49–2.75). Interaction tests for CVM showed no significance, while ACM associations varied by age, gender, and CKM stage (all P_interaction < 0.05). RCS analysis revealed L-shaped associations between ANLR and both mortality outcomes (all P_non-linearity < 0.001). ANLR and NLR showed comparable and superior predictive value to ALB, particularly for ACM.Conclusion:Lower ANLR levels, reflecting heightened inflammation and malnutrition, are independently linked to increased ACM and CVM in advanced CKM syndrome. As accessible, low-cost biomarkers, ANLR and NLR may help identify high-risk individuals. Further studies are warranted to elucidate their prognostic role in this population.
Keywords: ANLR, Malnutrition, Inflammation, Mortality, Advanced CKM syndrome, NHANES
Received: 14 May 2025; Accepted: 07 Jul 2025.
Copyright: © 2025 Yin, Zou and Yang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence:
Jinmei Zou, Department of Immunology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
Jing Yang, Department of Immunology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
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