Predictive role of neutrophil-percentage-to-albumin, neutrophil-to-lymphocyte and eosinophil-to-lymphocyte ratios for mortality in patients with COPD: Evidence from NHANES 2011-2018

Respirology. 2023 Dec;28(12):1136-1146. doi: 10.1111/resp.14589. Epub 2023 Sep 1.


Background and objective: This study evaluated the predictive roles of hematologic inflammatory biomarkers including neutrophil-percentage-to-albumin ratio (NPAR), neutrophil-to-lymphocyte ratio (NLR) and eosinophil-to-lymphocyte ratio (ELR) for mortality in community-dwelling individuals with chronic obstructive pulmonary disease (COPD).

Methods: This longitudinal study extracted data of adults 40-79 years who had physician-diagnosed COPD from the United States (US) National Health and Nutrition Examination Survey (NHANES) 1999-2018. Cox regressions determined the associations between NPAR, NLR, ELR and their components, with all-cause mortality, cardiovascular disease (CVD) mortality and mortality from chronic lower respiratory disease (CLRD). Receiver operating characteristic (ROC) curve analysis estimated the predictive performances of these biomarkers for 5-year all-cause mortality.

Results: Data of 1158 subjects were analysed. After adjustment, higher NPAR was significantly associated with increased all-cause and CVD mortality, and mortality from CLRD (adjusted hazard ratio [aHR] = 1.14, 1.15 and 1.16). Higher NLR was associated with an increased all-cause and CVD mortality (aHR = 1.16 and 1.29). Higher neutrophil was associated with increased all-cause mortality and mortality from CLRD (aHR = 1.13 and 1.34). Albumin was associated with decreased all-cause and CVD mortality (aHR = 0.91 and 0.86). ELR, eosinophil or lymphocyte was not significantly associated with either mortality outcomes. Adjusted AUC of NPAR and NLR in predicting 5-year all-cause mortality were 0.808 (95% CI: 0.722-0.845) and 0.799 (95% CI: 0.763-0.835), respectively.

Conclusion: In community-dwelling US adults with COPD, increased NPAR and NLR are associated with mortality risks. NPAR outperforms the other hematologic inflammatory biomarkers in predicting 5-year all-cause mortality.

Keywords: COPD; National Health and Nutrition Examination Survey (NHANES); chronic obstructive pulmonary disease; eosinophil-to-lymphocyte ratio; mortality; neutrophil-percentage-to-albumin ratio; neutrophil-to-lymphocyte ratio.

MeSH terms

  • Adult
  • Aged
  • Albumins
  • Biomarkers
  • Cardiovascular Diseases*
  • Eosinophils
  • Humans
  • Longitudinal Studies
  • Lymphocytes
  • Middle Aged
  • Neutrophils
  • Nutrition Surveys
  • Prognosis
  • Pulmonary Disease, Chronic Obstructive* / diagnosis
  • Retrospective Studies
  • United States / epidemiology


  • Albumins
  • Biomarkers