Emerging research from Kordofan State reveals how NLR and PLR ratios from routine blood work could transform CKD management in resource-limited settings.
In the vast, sun-scorched landscapes of Kordofan State, Sudan, a silent epidemic steadily advances. Chronic Kidney Disease (CKD) affects millions worldwide, with a particularly devastating impact in regions where healthcare resources are limited. In Sudan, studies have shown that CKD patients often present with significant hematological abnormalities, including deranged red blood cell parameters that worsen as the disease progresses 3 .
CKD affects over 850 million people worldwide, with disproportionate impact in developing regions.
Traditional inflammatory markers like CRP require specialized tests often unavailable in resource-limited settings.
NLR and PLR ratios offer a simple, cost-effective alternative derived from routine blood tests.
To appreciate the significance of these new findings, we must first understand the role of inflammation in chronic kidney disease. Unlike the acute inflammation that occurs when you cut your finger—localized, obvious, and temporary—the inflammation in CKD is systemic, subtle, and persistent. This "slow-burning fire" within the body gradually damages blood vessels and tissues, accelerating the decline of kidney function.
In healthy individuals, the kidneys efficiently filter toxins from the blood. But as kidney function declines, waste products accumulate, triggering a constant state of immune activation. This chronic inflammatory state is characterized by elevated levels of proteins like C-reactive protein (CRP) and inflammatory cytokines such as interleukin-6 (IL-6) 2 .
These inflammatory substances not only directly damage the delicate filtering structures of the kidneys but also contribute to the cardiovascular complications that make CKD so deadly. Patients with CKD are 10-30 times more likely to die from cardiovascular causes than the general population.
Sudan, like many African nations, bears a significant burden of kidney disease. Recent Sudanese studies have documented that CKD patients consistently show abnormal hematological parameters, with reduced hemoglobin concentration, red blood cell counts, and hematocrit percentage compared to healthy individuals 3 . These abnormalities become more pronounced as the disease progresses, highlighting the interrelationship between kidney function and blood health.
The global relevance of this local research cannot be overstated. Studies from Brazil, Sri Lanka, and China have all demonstrated the value of NLR and PLR in monitoring CKD progression 1 4 . What makes the Kordofan research unique is its focus on validating these markers specifically within Sudanese populations, where genetic factors, prevalent infections, and environmental influences may alter their predictive value.
Imagine you're a researcher in Kordofan State, determined to find better ways to monitor CKD patients. Your mission: determine whether NLR and PLR can serve as reliable indicators of the inflammatory state in Sudanese CKD patients.
Enroll CKD patients at different stages of the disease—from early stages (II and III) to advanced stages (IV and V)—along with a control group of healthy individuals for comparison. This allows you to track how inflammatory markers change as kidney function declines.
Draw blood samples from each participant. This simple procedure requires nothing more sophisticated than a needle, syringe, and standard blood collection tubes—equipment available even in basic clinical settings.
The blood samples are analyzed using an automated hematology analyzer—a device increasingly available in regional hospitals across Sudan. From this routine test, extract the absolute numbers of neutrophils, lymphocytes, and platelets.
Using these numbers, calculate:
NLR = Absolute Neutrophil Count ÷ Absolute Lymphocyte Count
PLR = Absolute Platelet Count ÷ Absolute Lymphocyte Count
To validate findings, compare the NLR and PLR values with standard inflammatory markers like high-sensitivity C-reactive protein (hs-CRP) 1 , using established laboratory methods.
Use statistical methods to determine whether significant differences exist between the CKD patients and healthy controls, and whether these ratios correlate with disease severity.
The results emerging from such studies—both in Sudan and globally—paint a compelling picture of the clinical value of NLR and PLR in CKD management.
| Group | Average NLR | Average PLR | hs-CRP (mg/dL) |
|---|---|---|---|
| CKD with Inflammation | >1.98 | >116.07 | >0.5 |
| CKD without Inflammation | <1.98 | <116.07 | <0.5 |
| Healthy Controls | 1.0-1.5 | 80-100 | <0.3 |
| CKD Stage | eGFR Range | Average NLR | Average PLR |
|---|---|---|---|
| Stage II | 60-89 | 1.8-2.2 | 100-115 |
| Stage IIIA | 45-59 | 2.3-2.7 | 116-130 |
| Stage IIIB | 30-44 | 2.8-3.4 | 131-150 |
| Stage IV | 15-29 | 3.5-4.5 | 151-170 |
Higher cardiac risk with elevated NLR 5
Sensitivity of NLR for detecting inflammation
Sensitivity of PLR for detecting inflammation
For Sudanese researchers investigating inflammatory markers in CKD, certain laboratory tools and reagents form the foundation of their work:
| Item | Function | Application in NLR/PLR Studies |
|---|---|---|
| EDTA Blood Collection Tubes | Prevents blood clotting by binding calcium | Standard for hematological analysis; preserves cell morphology |
| Automated Hematology Analyzer | Counts and characterizes blood cells | Provides absolute neutrophil, lymphocyte, and platelet counts |
| Manual Hemocytometer | Manual cell counting method | Verification of automated counts; use when automated analyzers unavailable |
| Leishman's Stain | Stains blood cell components | Differentiation of white blood cell types in manual counts |
| Statistical Software (SPSS, Stata) | Data organization and statistical analysis | Determines significance of findings and calculates diagnostic accuracy |
| ROC Curve Analysis | Evaluates diagnostic test performance | Determines optimal cut-off values for NLR and PLR |
The value of detecting inflammation lies in our ability to intervene. Fortunately, research suggests that simple, affordable interventions may help reduce the inflammatory burden in CKD patients.
Dietary fiber supplementation has emerged as a particularly promising approach. A recent meta-analysis of 21 randomized controlled trials found that supplementing with 6-50 grams of dietary fiber daily significantly reduced key inflammatory markers, including interleukin-6 and tumor necrosis factor-alpha .
The mechanisms are fascinating: fiber shifts gut microbial activity from protein fermentation (which produces toxic metabolites) to carbohydrate fermentation (which produces beneficial short-chain fatty acids).
The potential applications of NLR and PLR extend throughout the CKD journey:
The story unfolding in Kordofan State's research laboratories represents more than just a scientific curiosity—it embodies a paradigm shift in how we approach complex diseases in resource-limited settings. In the Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio, we find an elegant solution to a pressing problem: how to provide sophisticated care when resources are constrained.