Neutrophil percentage-to-albumin ratio (NPAR) as a biomarker for asthma: a cross-sectional analysis of NHANES data

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OBJECTIVE: This study aimed to access the neutrophil percentage-to-albumin ratio (NPAR) as a potential biomarker for asthma risk and to explore its association with asthma incidence in a nationally representative adult population. METHODS: We analyzed cross-sectional data from 17,800 adults in the National Health and Nutrition Examination Survey (NHANES 2009-2018). NPAR was calculated as the ratio of neutrophil percentage to serum albumin concentration. Multivariable logistic regression models adjusted for demographic, socioeconomic, clinical, and laboratory covariates were employed to assess NPAR-asthma associations. Missing data were addressed via multiple imputations, and model performance was evaluated using receiver operating characteristic (ROC) curves with bootstrap validation. Restricted cubic splines analyzed non-linear relationships, while subgroup analyses tested effect heterogeneity across demographic and clinical strata. Sensitivity analyses compared complete-case and imputed datasets. RESULTS: Elevated NPAR levels were strongly associated with increased asthma risk. In fully adjusted models, each one-unit increase in NPAR corresponded to a 2.6% rise in asthma prevalence (adjusted OR = 1.026, 95% CI: 1.008-1.045, P = 0.0046). ROC curve analysis demonstrated an AUC of 0.699 for NPAR in predicting asthma. Subgroup analyses revealed effect modification by sex, race, and cardiovascular disease history, though interaction terms did not meet Bonferroni-adjusted significance thresholds. Restricted cubic spline analyses indicated a U-shaped dose-response relationship, with minimal risk observed at NPAR values of 12-15, suggesting dual pathological mechanisms: oxidative stress susceptibility at lower NPAR values and neutrophilic inflammation dominance at higher values. CONCLUSION: This study provides the first epidemiological evidence supporting NPAR as an independent biomarker for asthma risk. The U-shaped association highlights the complex interplay between systemic inflammation and oxidative stress in asthma pathogenesis. While NPAR offers a cost-effective and accessible tool for risk stratification, its moderate predictive performance underscores the need for complementary biomarkers to enhance clinical utility. Future research should integrate serial NPAR measurements and multi-omics profiling to validate its role in asthma management.

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