|Year : 2021 | Volume
| Issue : 2 | Page : 82-87
Neutrophil lymphocyte ratio (NLR) in type 2 diabetes mellitus and its correlation with renal function: An institutional experience
Seema Rahar1, Sadhna Marwah1, Bindu Kulshreshtha2
1 Department of Pathology, PGIMER & Dr. RML Hospital, New Delhi, India
2 Department of Endocrinology, PGIMER & Dr. RML Hospital, New Delhi, India
|Date of Submission||27-Jun-2021|
|Date of Decision||09-Aug-2021|
|Date of Acceptance||10-Aug-2021|
|Date of Web Publication||20-Dec-2021|
Dr. Seema Rahar
Department of Pathology, PGIMER & Dr. RML Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Introduction: Patients with diabetes mellitus commonly develop chronic vascular complications including diabetic nephropathy (DN). Chronic inflammation plays an important role in pathogenesis of diabetes and its complications. Neutrophil-Lymphocyte Ratio (NLR) is a novel potential marker for determining inflammation.
Objective: To study NLR in type 2 diabetes mellitus and its correlation with renal function.
Method: This study is a cross-sectional observational study conducted at a tertiary care hospital. This study included 200 patients diagnosed with type 2 diabetes mellitus, 100 of whom had deranged renal functions and 100 patients had normal renal function. The control group was composed of 100 healthy age and sex-matched subjects. NLR was calculated and statistical analysis was made using student's t-test, post HOC test, and ANOVA. A value of P < 0.05 was considered significant.
Results: When NLR was compared among three groups, NLR was significantly higher in diabetic patients as compared to controls and NLR was significantly higher in diabetic nephropathy group as compared to the diabetic with normal renal function group and control group.
Conclusions: NLR is a novel, simple and inexpensive marker that can be used as a measure of systemic inflammation in diabetes and correlates with severity of diabetic nephropathy.
Keywords: Diabetes mellitus, diabetic nephropathy, inflammation, neutrophil- lymphocyte ratio
|How to cite this article:|
Rahar S, Marwah S, Kulshreshtha B. Neutrophil lymphocyte ratio (NLR) in type 2 diabetes mellitus and its correlation with renal function: An institutional experience. J NTR Univ Health Sci 2021;10:82-7
|How to cite this URL:|
Rahar S, Marwah S, Kulshreshtha B. Neutrophil lymphocyte ratio (NLR) in type 2 diabetes mellitus and its correlation with renal function: An institutional experience. J NTR Univ Health Sci [serial online] 2021 [cited 2022 Jan 24];10:82-7. Available from: https://www.jdrntruhs.org/text.asp?2021/10/2/82/332856
| Introduction|| |
Diabetes mellitus (DM) is a serious, chronic disease that occurs due to relative insulin deficiency and poses a tremendous burden to the health care systems worldwide. Persistent hyperglycemia and long duration of the metabolic disturbances can cause vascular damage and ultimately seems to be responsible for the long-term complications of diabetes which are divided into macrovascular complications and microvascular complications (Nephropathy, Retinopathy, Neuropathy).
Chronic inflammation plays an important role in pathogenesis of diabetes mellitus and its complications. White blood count (WBC) is a conventional, crude but inexpensive, and sensitive marker of inflammatory status. Several other inflammatory markers such as interleukin (IL)-1, IL6, IL8, transforming growth factor β1, tumor necrosis factor α have been identified but most of them are time-consuming, expensive, and difficult to standardize in routine clinical practice. Neutrophil- to lymphocyte ratio (NLR) is defined as a novel potential marker to analyze inflammation in cardiac and non-cardiac disorders.
NLR represents a combination of two markers- neutrophils represent the active non-specific inflammatory mediators that initiate the first-line defense while lymphocytes represent the regulatory or protective component of inflammation. NLR can be used as a cheap and reliable predictor of the occurrence of diabetic nephropathy, which has been evaluated in this study in an Indian population.
The aim of the present study was to evaluate NLR levels and comparing them between diabetics, diabetics with deranged renal function, and healthy controls. We also aimed to find out possible correlation between NLR, HbA1c, and micro-vascular complication (nephropathy) in type 2 diabetes mellitus.
| Methods|| |
The study was a cross-sectional observational study conducted at a tertiary care hospital during a period of 4 months. Patients who were already diagnosed with type 2 diabetes mellitus according to the American Diabetes Association (ADA) diagnostic criteria were randomly selected in the study. ADA criteria included any these- fasting plasma glucose ≥126 mg/dl or random plasma glucose ≥200 mg/dl (in a patient with classic hyperglycemic signs) or 2-hour plasma glucose ≥200 mg/dl during an oral glucose tolerance test (OGTT) with a loading dose of 75 gm glucose or glycated hemoglobin (HbA1c) level ≥6.5%.
Patients were excluded if they had Coronary Artery Disease, Heart Failure, fever, pyrexia of unknown origin (PUO), acute Poisoning, HIV positive patient, viral infection, skin infection, parasitic infestation, patients on anti-inflammatory drugs, any known malignancy and any hematological disorder that affect neutrophil and lymphocytes. Patients with diseases that can affect urinary protein excretion like nephrotic syndrome, urolithiasis, urinary tract infection, dehydration state and other non-diabetic causes of CKD were also excluded.
The study protocol was explained to the patients and informed consent was taken. The Institutional Ethics committee of the hospital approved the study. Information was collected from the patients on their duration of type 2 diabetes, treatment history, age, sex and blood pressure. Blood sample of 5 ml each was collected in plain and EDTA vacutainers and urine was collected in sterile plastic containers. Samples were processed within 2 hours for routine biochemical and hematological analysis. Blood Urea, Serum Creatinine, urine albumin creatinine ratio (UACR), Urine microalbumin, HbA1c, fasting blood glucose and complete blood counts (CBC) were measured. Albuminuria was tested by dipstick method using MICRAL-II TEST strips. Urine albumin excretion of 30-300 mg/g of creatinine was defined as microalbuminuria and >300 mg/g was overt albuminuria. Estimated Glomerular filtration rate (eGFR) were assessed for the patients to determine the renal function. GFR was calculated by MDRD 4 variable formula (Modification of Diet in Renal Disease). A patient was defined to have diabetic kidney disease if GFR was <60 ml/min/1.73 mm2 and or presence of albuminuria >30 mg/g. Hemoglobin (Hb), total leucocyte count (TLC), absolute counts of neutrophil and lymphocyte were assessed among the CBC parameters. Anaemia was defined as Hb <13 g/dL in males and <12 g/dL in females. Neutrophil- lymphocyte ratio (NLR) was calculated by dividing the absolute neutrophil count by absolute lymphocyte count on a peripheral blood smear.
A total of 258 patients of diabetes mellitus were assessed during the study period however 58 patients were excluded after applying the exclusion criteria. Finally, 200 patients with type 2 diabetes mellitus were included, who were divided into two groups- 100 patients (DM group) having diabetes with no albuminuria, Urine microalbumin <30 mg/g and eGFR ≥90 mL/min/1.73 m2 and 100 patients (DN group) having deranged renal functions with Urine microalbuminuria of 30-300 mg/g or overt proteinuria and eGFR <90 mL/min/1.73 m2. The control group composed of 100 healthy age and sex-matched subjects who came for routine health check-ups.
Normality of distribution of variables was checked using Kolmogorov–Smirnov Test. Descriptive tables were drawn. Quantitative data was expressed as mean ± SD while qualitative data was expressed as percentage. The comparison between cases and controls was done using the t-test and post HOC test. The ANOVA test was used for the intergroup comparison between the three groups. The Pearson correlation test was used to analyze the correlation of NLR with other parameters. A P value < 0.05 was considered significant. Data was analyzed using SPSS software, Chicago, USA, version 20.0. A written informed consent was obtained from each patient.
| RESULTs|| |
A total of 300 subjects had been enrolled in this study, 200 type 2 DM patients which were divided into Group 1- DM Group (diabetes mellitus without deranged renal functions) Group 2-DN Group (diabetes mellitus with diabetic nephropathy) and Group 3 included 100 age and sex-matched control subjects.
The age of cases ranged from 40 to 76 years with a mean of 53.31 years and among control group age ranged from 40 to 78 years with a mean of 50.6 years. Ratio of males to females in this study was 1:1.1 among the patients. Duration of diabetes in the patients ranged from 6 months to 11 years with a mean duration of 4.47 years. Baseline characteristics and laboratory data of the three studied groups are outlined in [Table 1].
|Table 1: Baseline Characterstics and Laboratory Data of the Three Studied Groups|
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Anemia was found in 56 (56%) patients out of 100 among Group 1 and 82 (82%) patients were found to be anemic in Group 2. The mean hemoglobin in diabetes mellitus without deranged renal function (Group 1) was 11.74 ± 2.11 g/dL and in diabetic nephropathy group (Group 2) was 10.46 ± 1.86 g/dL whereas in controls (Group 3) mean was 13.21 ± 1.04 g/dL.
Mean total leucocyte count (TLC) in Group 1 was 7508 ± 1731/mm3 and in Group 2 was 9444 ± 2348/mm3 while in control group mean was 7172 ± 1697/mm3. TLC was found to be higher in diabetic nephropathy group as compared to both diabetes mellitus without deranged renal function and the control group which was found to be statistically significant using post hoc test (P < 0.001). However, among the diabetes mellitus (Group 1) and controls (Group 3), a statistically significant difference was not found (P = 0.665).
Among the three groups, Absolute neutrophil count (ANC), Absolute lymphocyte count (ALC) was calculated and finally Neutrophil-Lymphocyte ratio (NLR) was derived by dividing ANC and ALC. NLR in Group 1 varied from 1.57 to 2.91 with a mean of 2.11 ± 0.37 and in Group 2 it varied from 2.2 to 8.8 with a mean of 3.91 ± 1.68 while in Group 3 NLR ranged from 1.3 to 2.02 with a mean of 1.60 ± 0.18 [Figure 1].
NLR was compared among three groups using the ANOVA test and NLR value was significantly higher in DN Group (Group 2) as compared to control group (Group 3) (P < 0.001) and DM Group (Group 1) (P < 0.001). Also NLR value was higher in DM Group than the Control Group (P = 0.034) [Table 2].
Among the Group 2 patients (with deranged renal functions) maximum patients, 62% were found to be in stage 2 Chronic Kidney Disease (CKD) (eGFR 60-80 ml/min/1.73 m2) and 28% patients were found to be in stage 3 CKD (eGFR 30-59 ml/min/1.73 m2) according to the eGFR values.
A logistic regression analysis was conducted with NLR and other variables between the two groups. [Table 3] Pearson correlation of NLR with other variables in DN group (Group 2) showed a significant relationship between NLR and TLC, HbA1c, serum creatinine, urine ACR, urine microalbumin and eGFR. However, in the DM group (Group 1), significant relationship of NLR was found to be with blood sugar levels and HbA1c only and not with other variables.
|Table 3: Correlation of NLR With Other Studied Variables in DN Group and DM Group. (Logistic Regression Analysis)|
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| Discussion|| |
Diabetes mellitus is a systemic disease characterized by vascular and renal complications. Several studies have indicated that inflammatory molecules and endothelial dysfunction play an important role in the developing insulin resistance and macro and microvascular complications in patients of diabetes mellitus.,,,,, Neutrophils and lymphocytes are one of the major mediators of inflammation. Neutrophil-lymphocyte ratio (NLR) is a novel marker that can be used as a marker of subclinical inflammation. Several epidemiological studies have highlighted that chronic low-grade inflammation is associated with diabetes mellitus, hypertension, obesity, smoking, other lifestyle habits, and even cancers.
WBC (white blood cell) count and its subtypes are inexpensive and readily available classic inflammatory markers. NLR represents the balance between neutrophil and lymphocyte level in the body which can act as an indicator of systemic inflammation. In NLR, two different immune pathways are responsible for inflammatory response. Neutrophils are related to ongoing inflammation in the body while the lymphocytes reflect the immune regulatory pathway., NLR is superior to other leucocyte parameter like neutrophil count, lymphocyte count or total leucocyte count (TLC) since it is more stable and less influenced by physiological, pathological and physical factors., Although many novel disease-specific biomarkers have been identified, but calculating NLR is simple and cheaper than measuring other inflammatory cytokines like IL-6, IL-1b, TNF alpha.
This study analyses the independent relationship between NLR and Diabetes mellitus (DM) and Diabetic Nephropathy (DN) in Indian population. Results showed that NLR was significantly higher in diabetic patients as compared to controls and NLR was significantly higher in diabetic nephropathy group as compared to the diabetic with normal renal function group (P < 0.001). TLC was found to be significantly elevated in patients with diabetic nephropathy group as compared to diabetic patients with normal renal function and controls; however, no significant difference was found between diabetic group and control group.
The present study along with some of the other studies showed that NLR is significantly elevated in patients with diabetes mellitus and diabetic nephropathy when compared to controls and that these markers have a high diagnostic value in differentiating patients with DN from healthy individuals.
Our results were in concordance with Huang et al. who found that NLR was significantly higher in diabetic patients with early-stage diabetic nephropathy as compared to diabetics without DN and controls. Moursy et al. also have shown that NLR was higher among patients with overt nephropathy as compared to patients with incipient nephropathy, but it did not reach a statistical significance. Asfar B, et al. studied that NLR was discretely associated with both 24-hour urinary protein and urinary albumin excretion in newly diagnosed type 2 diabetes patients in Turkey and NLR could be related to diabetic nephropathy and is also correlated as a predictor of end-stage renal disease. Likewise, in another study, Akbas et al. also showed that NLR was significantly raised in patients with higher albuminuria indicating an association between inflammation and endothelial dysfunction in diabetes with nephropathy. Chittawar et al. also found that NLR was higher in diabetic nephropathy patients as compared to patients without nephropathy.
Duman et al. compared NLR levels of patients with HbA1c and found a positive correlation between them, similar to our result which showed that NLR has positive correlation with HbA1c in both groups i.e., diabetes with normal and deranged renal function.
| Conclusion|| |
NLR is an emerging marker of systemic inflammation which is simple, affordable, universally available and can be easily calculated from a complete haemogram report without any complex calculations. The current study demonstrated that NLR was elevated in diabetes mellitus patients with deranged renal function and hence can be used as a predictive marker to assess the presence of diabetic nephropathy timely.
The limitations in our study were the relatively small sample size, more studies with a larger sample size needs to be undertaken. Many common infections and inflammatory conditions alter the NLR and it may not be possible to completely exclude them. Normal cut off values of NLR have not been defined in any of the studies and thus further studies are required to address these limitations.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Duman TT, Aktas G, Atak BM, Kocak MZ, Erkus E, Savli H. Neutrophil to lymphocyte ratio as an indicative of diabetic control level in type 2 diabetes mellitus. Afr Health Sci 2019;19:1602-6.
Asfar B. The relationship between neutrophil lymphocyte ratio with urinary protein and albumin excretion in newly diagnosed patients with type 2 diabetes. Am J Med Sci 2013;347:217-20.
Huang W, Huang J, Liu Q, Lin F, He Z, Zeng Z, et al
. NLR is a reliable predictor marker for early stage diabetic nephropathy. Clin Endocrinol 2015;82:229-33.
Chittawar S, Dutta D, Qureshi Z, Surana V, Khandare S, Dubey TN. Neutrophil- lymphocyte Ratio is a novel predictor of nephropathy, retinopathy and coronary artery disease in Indians with type 2 diabetes. Indian J Endocrinol Metab 2017;21:864-70.
Bhutta H, Agha R, Wong J, Tang TY, Wilson YG, Walsh SR. Neutrophil lymphocyte ratio predicts medium term survival following elective major vascular surgery: A cross sectional study. Vasc Endovascular Surg 2011;45:227-31.
Dutta D, Mondal SA, Kumar M, Hasanoor Reza AH, Biswas D, Singh P, et al
. Serum fetuin-A concentration predicts glycaemic outcomes in people with prediabetes: A prospective study from Eastern India. Diabet Med 2014;31:1594-9.
Mahmoodzadeh S, Moazenzadeh M, Rashidinejad H, Sheikhvatan M. Diagnostic performance of electrocardiography in the assessment of significant coronary artery disease and its anatomical size in comparison with coronary angiography. J Res Med Sci 2011;16:750-5.
Rivero A, Mora C, Muros M, García J, Herrera H, Navarro-González JF. Pathogenic perspectives for the role of inflammation in diabetic nephropathy. Clin Sci (Lond) 2009;116:479-92.
Astrup AS, Tarnow L, Pietraszek L, Schalkwijk CG, Stehouwer CD, Parving HH, et al
. Markers of endothelial dysfunction and inflammation in type 1 diabetic patients with or without diabetic nephropathy followed for 10 years: Association with mortality and decline of glomerular filtration rate. Diabetes Care 2008;31:1170-6.
Pitsavos C, Tampourlou M, Panagiotakos DB, Skoumas Y, Chrysohoou C, Nomikos T, et al
. Association between low-grade systemic inflammation and type 2 diabetes mellitus among men and women from the ATTICA study. Rev Diabet Stud 2007;4:98-104.
Nakanishi N, Sato M, Shirai K, Suzuki K, Tatara K. White blood cell count as a risk factor for hypertension: A study of Japanese male office workers. J Hypertens 2002;20:851-7.
Brooks GC, Blaha MJ, Blumenthal RS. Relation of C reactive protein to abdominal adiposity. Am J Cardiol 2010;106:56-61.
Yasue H, Hirai N, Mizuno Y, Harada E, Itoh T, Yoshimura M, et al
. Low grade inflammation, thrombogenicity and atherogenic lipid profile in cigarette smokers. Circ J 2006;70:8-13.
Pirkola J, Vaarasmaki M, Ala-Korpela M, Bloigu A, Canoy D, Hartikainen AL, et al
. Low grade systemic inflammation in adolescents: Association with early life factors, gender and lifestyle. Am J Epidemiol 2010;171:72-82.
Rajakariar R, Lawrence T, Bystrom J, Hilliard M, Colville-Nash P, Bellingan G, et al
. Novel biphasic role for lymphocytes revealed during resolving inflammation. Blood 2008;111:4184-92.
El Kebir D, Filep JG. Targeting neutrophil apoptosis for enhancing the resolution of inflammation. Cells 2013;2:330-48.
Nunez J, Nunez E, Bodi V, Sanchis J, Minana G, Mainar L, et al
. Usefulness of the neutrophil to lymphocyte ratio in predicting long term mortality in ST segment elevation myocardial infarction. Am J Cardiol 2008;101:747-52.
Gibson PH, Croal BL, Cuthbertson BH, Small GR, Ifezulike AI, Gibson G, et al
. Preoperative neutrophil to lymphocyte ratio and outcome from coronary artery bypass grafting. Am Heart J 2007;154:995-1002.
Turkmen K, Guney I, Yerlikaya FH, Tonbul HZ. The relationship between neutrophil to lymphocyte ratio and inflammation in end stage renal disease patients. Ren Fail 2012;34:155-9.
Moursy EY, Megallaa MH, Mouftah RF, Ahmed SM. Relationship between neutrophil lymphocyte ratio and microvascular complication in Egyptian patients with type 2 diabetes. Am J Int Med 2015;3:250-5.
Akbas EM, Demirtas L, Ozcicek A, Timuroglu A, Bakirci EM, Hamur H, et al
. Association of epicardial adipose tissue, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio with diabetic nephropathy. Int J Clin Exp Med 2014;7:1794-801.
[Table 1], [Table 2], [Table 3]