Published online May 16, 2024. doi: 10.12998/wjcc.v12.i14.2308
Revised: February 14, 2024
Accepted: April 2, 2024
Published online: May 16, 2024
Processing time: 128 Days and 19.9 Hours
Type 2 diabetes mellitus (T2DM) is a leading risk factor for the development and progression of chronic kidney disease (CKD). However, an accurate and con
To investigate the relationship between NLR and renal function in T2DM patients.
This study included 1040 adults aged 65 or older with T2DM from Shanghai's Community Health Service Center. The total number of neutrophils and lym
Significant differences were found in terms of sex, serum creatinine, blood urea nitrogen, total cholesterol, and low-density lipoprotein cholesterol among patients with T2DM in different NLR groups (P < 0.0007). T2DM patients in the highest NLR quartile had a higher prevalence of CKD (P for trend = 0.0011). Multivariate logistic regression analysis indicated that a high NLR was an independent risk factor for CKD in T2DM patients even after adjustment for important clinical and pathological parameters (P = 0.0001, odds ratio = 1.41, 95% confidence intervals: 1.18-1.68).
An elevated NLR in patients with T2DM is associated with higher prevalence of CKD, suggesting that it could be a marker for the detection and evaluation of diabetic kidney disease.
Core Tip: In elderly type 2 diabetes mellitus (T2DM) patients, elevated neutrophil-to-lymphocyte ratio (NLR) is strongly linked to an increased risk of chronic kidney disease (CKD), uncovering NLR as a potential independent biomarker for early detection of renal damage. This finding holds significant promise for addressing the current challenge of delayed CKD diagnosis in T2DM, signifying the potential utility of NLR as a convenient and sensitive detection method for identifying CKD in diabetic patients.
- Citation: Gao JL, Shen J, Yang LP, Liu L, Zhao K, Pan XR, Li L, Xu JJ. Neutrophil-to-lymphocyte ratio associated with renal function in type 2 diabetic patients. World J Clin Cases 2024; 12(14): 2308-2315
- URL: https://www.wjgnet.com/2307-8960/full/v12/i14/2308.htm
- DOI: https://dx.doi.org/10.12998/wjcc.v12.i14.2308
Diabetes is a prevalent metabolic disease with significant implications for global health, and type 2 diabetes mellitus (T2DM) represents the predominant form of diabetes in China, accounting for over 90% of cases[1]. T2DM is one of the leading risk factors for the development and progression of chronic kidney disease (CKD)[2]. In Asia, it is estimated that > 60% of patients with diabetes will develop kidney complications, compared with 30%-40% in Europeans despite having a similar duration of diabetes[3,4]. Furthermore, CKD in diabetic individuals is associated with increased morbidity and premature mortality, which impose a substantial economic burden on healthcare systems[5,6]. Given the continuous in
Recent studies have shown that the neutrophil-to-lymphocyte ratio (NLR), an inflammatory marker, strongly correlates with acute ischemic stroke, tumors, sepsis, and CKD[7-10]. However, prior research has mostly examined hospitalized patients with more severe conditions, overlooking diabetic patients in the general population. This article mainly ex
This study involved 1040 adults aged 65 years old or above diagnosed with T2DM from the health examination platform of the Community Health Service Center in Songnan Town, Baoshan District, Shanghai, China from June to August 2021. The investigation focused on three medical service stations located in the community health service center and affiliated institutes of Songnan Town. The diagnosis of T2DM was in accordance with Chinese guidelines for the prevention and treatment of T2DM (2020 edition)[11], namely, a fasting plasma glucose (FPG) level ≥ 7.0 mmol/L or a previous diagnosis of T2DM and currently receiving oral medication. Participants were excluded if they had incomplete or uncertain basic information, type 1 DM, a history of hormone therapy within a year, any type of malignancy, a current acute infection, or an established hematologic disease. Oral consent was obtained from all participants, and the study was approved by the central ethics committee.
Demographics (sex and age) and disease history, such as hypertension, were self-reported by all participants through comprehensive questionnaires completed by trained general practitioners and volunteers. Height and weight were mea
For laboratory testing, the participants’ whole blood was drawn into an EDTA vacuum anticoagulant tube and mixed by inversion several times. Additionally, 6 mL of fasting venous blood was obtained in the early morning, and the su
The estimated glomerular filtration rate (eGFR), expressed in ml/min/1.73 m2, was calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation on the basis of Scr[12]. The formula was as follows: (1) if female: Scr ≤ 0.7 mg/dL, eGFR = 144 × (Scr/0.7)-0.329 × (0.993)age; Scr > 0.7 mg/dL, eGFR = 144 × (Scr/0.7)-1.209 × (0.993)age; and (2) if male: Scr ≤ 0.9 mg/dL, eGFR = 141 × (Scr/0.9)-0.411 × (0.993)age; Scr > 0.9 mg/dL, eGFR = 141 × (Scr/0.9)-1.209 × (0.993)age. CKD was defined as an eGFR of 60 mL/min/1.73 m2 or less[13].
(1) Hypertension was defined according to the Chinese guidelines for the prevention and treatment of hypertension (2018 Revision)[14], with systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg, or with a previous diagnosis of hypertension and currently being treated with oral antihypertensive drugs; (2) Smoking referred to those who smoked ≥ 1 cigarette per day on average, continuously or cumulatively for the past 6 months; (3) Drinking was defined as consuming alcohol at least once a week at a dose of ≥ 50 g of ethanol per occasion, continuously or cu
Continuous variables were expressed as the mean ± SD or median with interquartile range and were analyzed by an in
All statistical analyses were performed using SAS software (version 9.4). A two-tailed P value < 0.05 was considered statistically significant.
Table 1 shows the general characteristics of the study population. A total of 1040 participants diagnosed with T2DM were included in the analysis and divided into four groups according to their NLR: quartile 1 (NLR < 1.38, 261 patients), quartile 2 (1.38 ≤ NLR < 1.76, 258 patients), quartile 3 (1.76 ≤ NLR < 2.30, 262 patients), and quartile 4 (NLR ≥ 2.30, 259 patients). No significant difference was observed among the groups concerning age, BMI, SBP, DBP, FPG, TG, platelet counts, smoking, drinking, regular exercise, and hypertension (Table 1). However, significant differences were found in terms of sex, BUN, Scr, eGFR, TC, LDL-C, HDL-C, neutrophil, lymphocyte and white blood cell (WBC) counts among the four groups (P < 0.05).
Variables | Total | Quartile 1 (NLR < 1.38) | Quartile 2 (1.38 ≤ NLR < 1.76) | Quartile 3 (1.76 ≤ NLR < 2.30) | Quartile 4 (NLR ≥ 2.30) |
N | 1040 | 261 | 258 | 262 | 259 |
Male1, n (%) | 490 (47.1) | 99 (37.9) | 119 (46.1) | 130 (49.6) | 142 (54.8) |
Age (yr) | 71.9 ± 5.5 | 71.5 ± 5.5 | 72.0 ± 5.7 | 71.9 ± 5.4 | 72.3 ± 5.5 |
BMI (kg/m2) | 25.0 ± 4.0 | 25.1 ± 3.6 | 25.3 ± 4.6 | 25.1 ± 3.7 | 24.7 ± 4.2 |
SBP (mmHg) | 145.3 ± 20.3 | 144.8 ± 19.7 | 144.4 ± 19.4 | 146.5 ± 20.2 | 145.3 ± 22.0 |
DBP (mmHg) | 78.7 ± 11.7 | 77.8 ± 11.5 | 79.0 ± 10.8 | 78.9 ± 11.0 | 79.2 ± 13.5 |
FPG (mmol/L) | 7.8 ± 2.4 | 7.6 ± 1.8 | 8.0 ± 2.8 | 7.8 ± 2.4 | 8.0 ± 2.3 |
BUN1 (mmol/L) | 6.8 ± 2.1 | 6.4 ± 1.6 | 6.9 ± 2.2 | 6.6 ± 2.0 | 7.1 ± 2.3 |
Scr1 (mmol/L) | 74.1 ± 21.8 | 68.2 ± 16.1 | 73.1 ± 19.4 | 75.3 ± 22.1 | 79.8 ± 26.8 |
eGFR1 (mL/min/1.73 m2) | 80.2 ± 15.7 | 83.6 ± 12.9 | 80.7 ± 15.0 | 79.3 ± 16.0 | 77.7 ± 17.0 |
TC1 (mmol/L) | 4.7 ± 1.2 | 5.0 ± 1.2 | 4.8 ± 1.3 | 4.7 ± 1.1 | 4.6 ± 1.1 |
TG (mmol/L) | 1.7 ± 1.5 | 1.6 ± 1.2 | 1.8 ± 2.0 | 1.7 ± 1.5 | 1.5 ± 1.1 |
LDL-C1 (mmol/L) | 3.0 ± 0.9 | 3.2 ± 1.0 | 3.0 ± 1.0 | 2.9 ± 0.9 | 2.9 ± 0.9 |
HDL-C1 (mmol/L) | 1.5 ± 0.4 | 1.5 ± 0.3 | 1.4 ± 0.3 | 1.5 ± 0.4 | 1.5 ± 0.4 |
Neutrophil1 | 3.7 ± 1.0 | 2.9 ± 0.7 | 3.5 ± 0.8 | 3.9 ± 0.9 | 4.5 ± 1.0 |
Lymphocyte1 | 2.1 ± 0.6 | 2.6 ± 0.7 | 2.2 ± 0.5 | 1.9 ± 0.4 | 1.5 ± 0.4 |
WBC1 | 6.3 ± 1.4 | 6.1 ± 1.3 | 6.3 ± 1.4 | 6.3 ± 1.4 | 6.5 ± 1.4 |
Platelet | 189.1 ± 48.5 | 187.6 ± 46.3 | 191.7 ± 46.2 | 191.2 ± 52.0 | 185.8 ± 49.4 |
Smoking, n (%) | 174 (16.7) | 36 (13.8) | 48 (18.6) | 47 (17.9) | 43 (16.6) |
Drinking, n (%) | 179 (17.2) | 36 (13.8) | 54 (20.9) | 48 (18.3) | 41 (15.8) |
Regular exercise, n (%) | 197 (18.9) | 53 (20.3) | 52 (20.2) | 51 (19.5) | 41 (15.8) |
Hypertension, n (%) | 714 (68.7) | 171 (65.5) | 182 (70.5) | 187 (71.4) | 174 (67.2) |
Using the definition of CKD, there were 132 cases in total. As shown in Figure 1, patients in the higher NLR quartile group had a greater prevalence of CKD (P for trend = 0.0011).
As shown in Table 2, we found that high NLR was associated with a higher prevalence of CKD in T2DM patients in multivariate regression models even after adjustment for important clinical parameters, including age, sex, smoking, drinking, regular exercise, BMI, SBP, FPG, TG and LDL-C (P value < 0.0001). With an SD increase in the NLR, the prevalence of CKD increased by 44%. Furthermore, when NLR was categorized into quartiles, the association between NLR and CKD remained, and there was a 3.3-fold increased prevalence of CKD in T2DM patients in the highest quartile of NLR (OR 3.30, 95%CI: 1.78-6.12, P = 0.0001) compared to those in the lowest quartile. AUROC was analyzed to de
Exposure | Age-and-sex adjusted model | Multivariate model | ||
OR (95%CI) | P value | OR (95%CI) | P value | |
NLR (per SD) | 1.39 (1.17-1.65) | 0.0002 | 1.44 (1.21-1.72) | < 0.0001 |
Quartile 1 (< 1.38) | Reference | Reference | ||
Quartile 2 (1.38–1.76) | 1.69 (0.89-3.22) | 0.1100 | 1.57 (0.81-3.04) | 0.1785 |
Quartile 3 (1.76–2.30) | 2.42 (1.30-4.50) | 0.0052 | 2.52 (1.35-4.73) | 0.0039 |
Quartile 4 (≥ 2.30) | 3.07 (1.68-5.62) | 0.0003 | 3.30 (1.78-6.12) | 0.0001 |
P for trend | 0.0001 | < 0.0001 |
In this cross-sectional study comprising 1040 patients diagnosed with T2DM, we observed that higher NLR was sig
CKD is a common and severe complication in individuals with diabetes, although its precise pathogenesis remains poorly understood. It is recognized that a sequence of pathological events, including parenchymal cell loss, chronic in
NLR has recently emerged as a discerning inflammatory indicator that provides insights into the equilibrium between neutrophils and lymphocytes, two critical constituents of the immune system. While neutrophils function as nonspecific instigators of inflammation, lymphocytes play regulatory and protective roles in the context of inflammatory responses[18]. NLR has garnered recognition as a reliable metric for gauging the extent of systemic inflammation[19,20]. Previous studies have shown a positive association between NLR and well-established inflammation markers, such as interleukin-6 and C-reactive protein[21,22]. Notably, in comparison to other inflammatory markers, the NLR exhibits advantages in terms of stability, cost-effectiveness, and accessibility[23].
Growing evidence substantiates the connection between elevated NLR and progression and prognosis of CKD[24-28]. Although DKD is the most common cause of CKD, the relationship between NLR and CKD in T2DM patients is still relatively understudied[29]. Notably, a previous study showed a positive correlation between neutrophil levels and uri
Our study adds to the literature by providing compelling evidence of a significant association between NLR and CKD prevalence in patients with T2DM. However, it should be noted that this study had some limitations. First, as a cross-sectional study, a causal relationship between NLR and CKD could not be established. Second, the small sample might have introduced selection bias. Third, due to data constraints, our study population was not assessed for urine albumin and CRP, consequently relying on eGFR to evaluate kidney function and WBC counts to assess inflammatory markers as a control for NLR. Last, as this study was conducted at a single center and only included patients aged 65 years and older, the generalizability of our findings to other settings may be limited. Therefore, future investigations should consider lar
Our findings revealed a significant association between elevated NLR levels and reduced eGFR, as well as a higher prevalence of CKD in Chinese adults with T2DM. These results suggest that NLR has potential as a valuable biomarker for early detection of kidney damage in diabetes patients. However, it is crucial to emphasize the need for further re
The authors thank all team members and participants in the Community Health Service Center of Songnan Town, Baoshan District, Shanghai, China.
Provenance and peer review: Unsolicited article; Externally peer reviewed.
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Specialty type: Endocrinology and metabolism
Country/Territory of origin: China
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P-Reviewer: Kurasawa S, Japan; Ohashi N, Japan S-Editor: Liu JH L-Editor: A P-Editor: Xu ZH
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