Hindawi

Journal of Diabetes Research

Volume 2020, Article ID 6219545, 9 pages
https://doi.org/10.1155/2020/6219545

Research Article
Associations between the Neutrophil-to-Lymphocyte
Ratio and Diabetic Complications in Adults with Diabetes: A
Cross-Sectional Study

Heng Wan,1 Yuying Wang,1 Sijie Fang,2 Yi Chen ,1 Wen Zhang,1 Fangzhen Xia,1
Ningjian Wang ,1 and Yingli Lu 1
1
Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University
School of Medicine, Shanghai, China
2
Department of Ophthalmology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine,
Shanghai, China

Correspondence should be addressed to Yingli Lu; luyingli2008@126.com

Received 18 December 2019; Revised 7 April 2020; Accepted 15 April 2020; Published 29 April 2020

Academic Editor: Ilaria Campesi

Copyright © 2020 Heng Wan et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective. The neutrophil-to-lymphocyte ratio (NLR) is an inexpensive and easily measurable laboratory index indicating systemic
inflammation, while the application of many other inflammatory markers has been limited in daily clinical practice. However, large
population studies about investigating the associations of the NLR level with diabetic complications including cardiovascular and
cerebrovascular diseases (CVD), diabetic kidney disease (DKD), and diabetic retinopathy (DR) in the same population were
limited. The aim of our study is to evaluate the associations between the NLR level and the prevalence of CVD, DKD, and DR
in adults with diabetes simultaneously. Methods. A cross-sectional survey of 4,813 diabetic adults was conducted in seven
communities in China. Persons underwent several medical examinations, including the measurement of anthropometric factors,
blood pressure, routinely analyzed leukocyte characteristics, glucose, lipid profiles, urine albumin/creatinine ratio, and fundus
photographs. Results. Compared with the first quartile of the NLR level, the odds of having CVD was significantly increased by
21% for participants in the highest quartile (OR 1.21; 95% CI 1.00, 1.47) (P for trend < 0:05). Similarly, the prevalence of DKD
among participants in the highest quartile of the NLR level was significantly increased by 150% (OR 2.50; 95% CI 1.95, 3.19) (P
for trend < 0:05). However, no association was found between the NLR level and the prevalence of DR (P for trend > 0:05).
These associations were all fully adjusted. Conclusions. A higher NLR level was associated with an increased prevalence of CVD
and DKD, other than DR, in diabetic adults.

1. Introduction towards early diagnosis and effective surveillance of diabetic

complications.
Type 2 diabetes mellitus (T2DM) has become a serious threat Chronic inflammation has been considered the potential
to global human health because of its vascular complications pathogenesis responsible for the development of diabetic
which are associated with increased disability, frailty, and complications [5–7]. However, the application of many
reduced life expectancy, including cardiovascular and cere- inflammatory markers has been limited in daily clinical prac-
brovascular diseases (CVD), diabetic kidney disease (DKD), tice because of their costs and technical difficulties in measur-
and diabetic retinopathy (DR) [1–3]. A recent review reports ing. It is noteworthy that the neutrophil-to-lymphocyte ratio
that half of diabetic adults present with diabetic microvascu- (NLR), an easily measurable and inexpensive laboratory index
lar complications and 27% with macrovascular complica- calculated by routinely analyzed leukocyte characteristics,
tions [4]. Thus, considerable attention has been directed combines the negative effects of neutrophils on endothelial
2 Journal of Diabetes Research

Subjects in METAL study (𝜇 = 4813)

Exclusion
missing routinely analyzed
leukocyte characteristics data
(n = 16)

Basal subjects analyzed in this study (n = 4797)

Exclusion
Exclusion 1.Missing ACR data (n = 233)
Missing vascular Exclusion
2.Subjects with kidney cancer, Missing DR information
measurement information chronic nephritis, ≥1 RBC/high- (n =1531)
(n = 109) power field or ≥ 1 WBC/high-
power field in urine sample
(n = 637)

Subjects analyzed for associations Subjects analyzed for associations Subjects analyzed for associations
between white cell count and CVD between white cell count and DKD between white cell count and DR
(n = 4688) (n = 3927) (n= 3266)

Figure 1: Flowchart of sampling frame and participants selected from the METAL study.

damage with the antiatherosclerotic role of lymphocytes [8]. had lived in the current area for ≥6 months. 4,813 subjects
Therefore, the NLR has been considered a convenient indica- with diabetes received examination in 2018. Participants
tor for systemic inflammation [9, 10]. who missed routinely analyzed leukocyte characteristics
Studies have shown that low NLR may be considered a results were excluded (n = 16). We then excluded the partic-
novel surrogate marker of DN in early stages and a predictor ipants missing vascular measurement information (n = 109);
of lower risk for hospitalizations in hemodialysis patients missing ACR data (n = 233) or subjects with kidney cancer,
with diabetes [11, 12]. Some other studies have implicated chronic nephritis, ≥1 RBC/high-power field, or ≥1 WBC/-
NLR as a risk factor of diabetes and its complications [13, high-power field in urine sample (n = 637); and missing DR
14]. However, the studies with large sample participants were information (n = 1531), respectively. Finally, the number of
still limited and conclusions were conflicting. For example, participants who were involved in the analyses for associa-
Ciray et al. suggested that NLR was not associated with the tions of the NLR level with CVD, DKD, and DR was, respec-
pathogenesis of DR [15] and Gijsberts et al. considered that tively, 4688, 3927, and 3266 (Figure 1).
NLR was of a limited predictive value in prediction of cardio- The study protocol conformed to the ethical guidelines of
vascular mortality [16]. In addition, to the best of our the 1975 Declaration of Helsinki as reflected in a priori
knowledge, no studies have evaluated the associations of approval by the Ethics Committee of Shanghai Ninth Peo-
NLR with macro- and microvascular complications in the ple’s Hospital, Shanghai Jiao Tong University School of Med-
same diabetic population. Thus, in this large community- icine. Written consent was obtained from all the participants
based sample study, we aimed at investigating the associa- in our study.
tions between the NLR level and the prevalence of CVD,
DKD, and DR simultaneously in adults with diabetes. 2.2. Measurements. The questionnaire about demographics,
medical history, family history, and lifestyle factors was filled
2. Materials and Methods out by the same trained personnel in the SPECT-China study
[18, 19] during the interview. Clinical examinations, includ-
2.1. Study Design and Participants. Participants who have ing height, weight, and blood pressure, were measured
been previously diagnosed with T2DM according to the diag- according to a standard protocol as before [20, 21]. Body
nostic criteria for diabetes proposed by the Chinese Diabetes mass index (BMI) was calculated as the weight in kilograms
Society [17] and registered in the platform in the commu- divided by the height in meters squared. We defined current
nity healthcare center were enrolled in METAL study smoking as having smoked at least 100 cigarettes in the life-
(Environmental Pollutant Exposure and Metabolic Dis- time and smoking cigarettes currently [22].
eases in Shanghai, Trial registration: ChiCTR1800017573, Overnight fasting blood (at least 8 h of fasting) was
http://www.chictr.org.cn. Registered 04 August 2018) from obtained between 6:00 and 9:00 am, which was refrigerated
seven communities in Pudong and Huangpu District, Shang- immediately and sent to a central laboratory for measuring
hai, China. The age of the citizens was ≥18 years old and in two hours. Routinely analyzed leukocyte characteristics
Journal of Diabetes Research 3

including leukocyte, neutrophil, lymphocyte, and monocyte were logarithmically transformed to achieve a normal distri-
level were measured with SYSMEX XS-800i. NLR and MLR bution. The associations of the NLR level quartiles with the
levels were calculated. Fasting plasma glucose (FPG), serum prevalence of CCA plaque, CVD, DKD, and DR were tested
creatinine, total cholesterol, triglycerides and high- (HDL) by binary logistic regression analyses. Linear regression anal-
and low-density lipoprotein (LDL) were detected with Beck- ysis was used to test the associations of the NLR level quar-
man Coulter AU 680 (Brea, USA). Glycated hemoglobin tiles with Ln ACR and eGFR. The associations of the NLR
(HbA1c) was tested using high-performance liquid chroma- level quartiles with NPDR and PDR were analyzed by multi-
tography with MQ-2000PT, (Shanghai, China). Morning nomial logistic regression. Receiver operating characteristic
urine samples were collected in the refrigerator immediately (ROC) curve analysis was used to compare the prognostic
to measure the levels of urine albumin and creatinine with powers of the neutrophil, lymphocyte, and the NLR level
Beckman Coulter AU 680 (Brea, USA); then, the urine albu- for DKD.
min to creatinine ratio (ACR) was calculated. Common Sensitivity analyses were performed. We evaluated the
carotid artery (CCA) plaque was assessed by a Mindray M7 associations between the leukocyte, neutrophil, and lympho-
ultrasound system (MINDRAY, Shenzhen, China) with a cyte level quartiles and the prevalence of CCA plaque and
10 MHz probe. Participants were diagnosed with DR by CVD in Supplementary Table 1, the associations between
remote reading form ophthalmologists, using retinal fundus the leukocyte, neutrophil, and lymphocyte level quartiles
photography, Topcon TRC-NW400 Non-Mydriatic Retinal and the prevalence of DKD in Supplementary Table 2,
Camera (Oakland, USA) as before [21, 23]. and the associations between the leukocyte, neutrophil,
and lymphocyte level quartiles and the prevalence of DR in
2.3. Outcome Definition. The definition of dyslipidemia Supplementary Table 3. We also calculated the associations
was that total cholesterol ≥ 6:22 mmol/L (240 mg/dL), tri- between the NLR level quartiles and the prevalence of dia-
glycerides ≥2:26 mmol/L (200 mg/dL), LDL ≥ 4:14 mmol/L betic complications in the same group of the participants in
(160 mg/dL), and HDL < 1:04 mmol/L (40 mg/dL) or self- Supplementary Table 4. To take into account the ongoing
reported previous diagnosis of hyperlipidemia, according to treatment among the patients, we have reanalyzed the associ-
the modified National Cholesterol Education Program- ations between NLR and the prevalence of CVD, DKD, and
Adult Treatment Panel III [24]. DR adjusting the further model including age, sex, education
The outcome CVD was defined as previously diagnosed status, duration of diabetes, current smoking, BMI, HbA1c,
with coronary heart disease, stroke, or peripheral arterial dis- dyslipidemia, systolic blood pressure, and the usage of anti-
ease, which were recorded in the registration platform. The platelet medications in Supplementary Table 5.
definition of present CCA plaque was subjectively causing a
relative diameter narrowing ≥25% according to the Framing- 3. Results
ham Heart Study [25].
The estimated glomerular filtration rate (eGFR) was cal- 3.1. Characteristics of the Participants by the NLR Level
culated by the Chronic Kidney Disease Epidemiology Collab- Quartiles. Table 1 shows the general and sociodemographic
oration equation for “Asian origin”. The definition of DKD characteristics of the study population. A total of 4,797 dia-
was that ACR ≥ 30 mg/g and/or eGFR < 60 mL/min per betic participants, with a mean age of 67 years old (SD 9,
1.73 m2, suggested by the American Diabetes Association max 99, min 23), were enrolled in this study. Participants
statement [26]. in the highest NLR level quartile, compared with those in
The DR classification was DR stage 0 (no abnormalities), the lowest quartile, were more likely to be men, have an older
DR stages 1 to 3 (nonproliferative DR, intraretinal microa- age and longer duration of diabetes, be a current smoker, and
neurysms, hemorrhages, venous beading, and prominent have lower education and eGFR, greater FPG, HbA1c, and
microvascular abnormalities), and DR stage 4 (proliferative urine ACR and higher prevalence of CCA plaque, CVD,
DR, neovascularization or vitreous/preretinal hemorrhages) DKD, and hypertension (all P for trend < 0:05).
in accordance with the “Global Diabetic Retinopathy Project
Group” [27]. 3.2. Associations between the NLR Level and the Prevalence of
CCA Plaque and CVD. The association between an elevated
2.4. Statistical Analysis. IBM SPSS Statistics, Version 22 (IBM NLR level and an increased prevalence of CVD and CCA
Corporation, Armonk, NY, USA), was used in the current plaque is found in Table 2. In the unadjusted model, com-
analysis. P value (two sided) <0.05 indicated significance. pared with the first quartile of the NLR level, the odds of
Continuous variables were expressed as the mean ± SD, and having CCA plaque and CVD was significantly increased
categorical variables as percentages (%) or median (inter- by 72% and 44% for participants in the highest quartile
quartile range). The NLR level was divided into quartiles. (both P for trend < 0:05). After adjusting for age, sex, educa-
Logistic or linear regression analysis was performed for mea- tion status, duration of diabetes, current smoking, BMI,
surement of the trend of variable changes across the NLR HbA1c, dyslipidemia, and systolic blood pressure, the asso-
level quartiles, providing unadjusted P values. ciations still remained.
A regression test was used to detect the associations
between the NLR level quartiles and diabetic complications. 3.3. Associations between the NLR Level and the Prevalence of
Data were summarized as odds ratios or regression coeffi- DKD. The associations between a higher NLR level and
cients (95% CI). In the analyses, the levels of urinary ACR increased Ln ACR, decreased eGFR, and greater prevalence
4 Journal of Diabetes Research

Table 1: Characteristics of the participants by the NLR level quartiles.

NLR level
Quartile 1 Quartile 2 Quartile 3 Quartile 4
Characteristic P for trend
(≤1.382) (>1.382, ≤1.777) (>1.777, ≤2.319) (>2.319)
N 1194 1211 1198 1194 /
Age (yr) 66:16 ± 8:38 67:06 ± 8:61 66:69 ± 8:40 68:73 ± 9:04 <0.001
Men (%) 38.9 43.8 48.2 53.6 <0.001
Duration of diabetes (yr) 8 (3-15) 8 (3-15) 8 (3-15) 10 (5-18) <0.001
Current smoking (%) 14.3 18.4 19.7 19.9 <0.001
Beyond high school education (%) 53.7 52.6 52.2 48.6 0.016
BMI (kg/m2) 24:67 ± 3:51 25:07 ± 3:60 25:26 ± 3:58 24:84 ± 3:67 0.134
FPG (mmol/L) 7:46 ± 2:13 7:66 ± 2:40 7:90 ± 2:45 8:06 ± 2:77 <0.001
HbA1c (%) 7:40 ± 1:34 7:47 ± 1:36 7:54 ± 1:40 7:55 ± 1:41 0.005
Total cholesterol (mmol/L) 5:38 ± 1:19 5:13 ± 1:18 5:05 ± 1:19 4:90 ± 1:19 <0.001
Triglycerides (mmol/L) 1.60 (1.11-2.32) 1.53 (1.11-2.25) 1.57 (1.13-2.17) 1.46 (1.06-2.10) 0.215
HDL (mmol/L) 1:25 ± 0:30 1:21 ± 0:28 1:19 ± 0:29 1:17 ± 0:30 <0.001
LDL (mmol/L) 3:33 ± 0:85 3:17 ± 0:84 3:12 ± 0:83 3:01 ± 0:84 <0.001
Hypertension (%) 74.3 78.1 79.3 82.8 <0.001
Dyslipidemia (%) 60.1 62.4 63.8 62.6 0.169
CCA plaque (%) 27.9 34.3 34.7 39.2 <0.001
CVD (%) 34.4 34.7 37.2 41.9 <0.001
ACR (mg/g) 11 (7-21) 12 (7-27) 14 (8-34) 17 (9-44) <0.001
eGFR (mL/min per 1.73 m2) 94:17 ± 14:70 92:82 ± 15:57 92:35 ± 16:51 87:30 ± 20:12 <0.001
DKD (%) 16.6 23.4 28.1 33.8 <0.001
DR (%) 15.3 17.2 18.7 16.9 0.296
NPDR (%) 14.8 17.0 18.0 16.4 0.327
PDR (%) 0.5 0.2 0.7 0.5 0.601
Leukocyte (×10 9/L) 6:02 ± 1:51 6:26 ± 1:53 6:57 ± 1:54 7:02 ± 1:88 <0.001
Lymphocytes (×10 9/L) 2:60 ± 0:76 2:21 ± 0:55 1:99 ± 0:48 1:61 ± 0:44 <0.001
Neutrophils (×10 9/L) 2:88 ± 0:76 3:48 ± 0:87 4:00 ± 0:96 4:81 ± 1:45 <0.001
NLR 1:13 ± 0:19 1:58 ± 0:12 2:02 ± 0:15 3:08 ± 0:89 <0.001
The data are summarized as the mean ± SD or median (interquartile range) for continuous variables or as a numerical proportion for categorical variables. P for
trend was calculated by regression tests. NLR: neutrophil-to-lymphocyte ratio; BMI: body mass index; FPG: fasting plasma glucose; HbA1c: glycated
hemoglobin; HDL: high-density lipoprotein; LDL: low-density lipoprotein; CCA: common carotid artery; CVD: cardiovascular and cerebrovascular diseases;
ACR: albumin to creatinine ratio; eGFR: estimated glomerular infiltration rate; DKD: diabetic kidney disease; DR: diabetic retinopathy; NPDR:
nonproliferative diabetic retinopathy; PDR: proliferative diabetic retinopathy.

Table 2: Associations between the NLR level quartiles and the prevalence of CCA plaque and CVD.

NLR level quartiles

P for trend 1SD increment of NLR
Q1 (≤1.38) Q2 (>1.38, ≤1.78) Q3 (>1.78, ≤2.32) Q4 (>2.32)
CCA plaque Ref. 1.37 (1.15, 1.64) 1.39 (1.17, 1.66) 1.72 (1.44, 2.04) <0.001 1.20 (1.13, 1.27)
CVD Ref. 1.05 (0.88, 1.24) 1.15 (0.98, 1.37) 1.44 (1.22, 1.71) <0.001 1.22 (1.14, 1.29)
CCA plaque1 Ref. 1.23 (1.00, 1.50) 1.24 (1.01, 1.51) 1.25 (1.02, 1.53) 0.041 1.08 (1.01, 1.16)
CVD1 Ref. 0.94 (0.77, 1.13) 1.10 (0.92, 1.34) 1.21 (1.00, 1.47) 0.025 1.16 (1.09, 1.24)
The participants missing vascular measurement information (n = 109) were excluded. Finally, 4688 participants were involved in the analyses. Data are
expressed as regression coefficients (95% CI). Logistic regression analyses were used for the associations of the NLR level with the prevalence of CVD and
CCA plaque with and without adjusting the model. 1The model was adjusted for age, sex, education status, duration of diabetes, current smoking, BMI,
HbA1c, dyslipidemia, and systolic blood pressure. CVD: cardiovascular and cerebrovascular diseases; CCA: common carotid artery; BMI: body mass index;
HbA1c: glycated hemoglobin; NLR: neutrophil-to-lymphocyte ratio.
Journal of Diabetes Research 5

Table 3: Associations between the NLR level quartiles and the prevalence of DKD.

NLR level quartiles

P for trend 1SD increment of NLR
Q 1 (≤1.38) Q 2 (>1.38, ≤1.78) Q 3 (>1.78, ≤2.32) Q 4 (>2.32)
In total individuals
Ln ACR Ref. 0.18 (0.07, 0.29) 0.36 (0.25, 0.47) 0.59 (0.48, 0.70) <0.001 0.23 (0.19, 0.27)
eGFR Ref. -1.07 (-2.52, 0.38) -1.69 (-3.15, -0.24) -6.19 (-7.65, -4.73) <0.001 -2.35 (-2.87, -1.84)
DKD Ref 1.60 (1.27, 2.02) 1.98 (1.58, 2.48) 2.60 (2.08, 3.24) <0.001 1.35 (1.26, 1.45)
Ln ACR1 Ref. 0.12(0.01, 0.23) 0.28(0.17, 0.39) 0.43(0.32, 0.54) <0.001 0.18(0.14, 0.22)
eGFR2 Ref. -1.24 (-2.75, 0.27) -1.81 (-3.33, -0.29) -5.14 (-6.66, -3.63) <0.001 -1.85 (-2.39, -1.30)
DKD1 Ref. 1.54 (1.20, 1.99) 2.06 (1.61, 2.65) 2.50 (1.95, 3.19) <0.001 1.36 (1.25, 1.47)
In individuals with normal eGFR (eGFR ≥ 90 mL/min per 1.73 m2)
Ln ACR1 Ref. 0.11 (-0.01, 0.22) 0.27 (0.15, 0.39) 0.29 (0.17, 0.41) <0.001 0.12 (0.07, 0.16)
DKD1 Ref. 1.65 (1.18, 2.30) 2.11 (1.52, 2.93) 2.19 (1.58, 3.03) <0.001 1.20 (1.08, 1.33)
Participants missing ACR data (n = 233) or subjects with kidney cancer, chronic nephritis, ≥1 RBC/high-power field or ≥1 WBC/high-power field in urine
sample (n = 637) were excluded. Finally, 3927 participants were involved in the analyses. Data are expressed as regression coefficients or odds ratios (95%
CI). Linear regression analysis was used for the associations of the NLR level with Ln ACR and eGFR, respectively, with and without adjusting the model.
Logistic regression analyses were used for the association between the NLR level and the prevalence of DKD with and without adjusting the model. 1The
model was adjusted for age, sex, education status, duration of diabetes, current smoking, BMI, HbA1c, dyslipidemia, and systolic blood pressure. 2The
model was adjusted for education status, duration of diabetes, current smoking, BMI, HbA1c, dyslipidemia, and systolic blood pressure. Ln ACR:
logarithmically transformed albumin to creatinine ratio; eGFR: estimated glomerular infiltration rate; DKD: diabetic kidney disease; BMI: body mass index;
HbA1c: glycated hemoglobin; NLR: neutrophil-to-lymphocyte ratio.

Table 4: Associations between the NLR level quartiles and the prevalence of DR.

NLR level quartiles

P for tend 1SD increment of NLR
Q 1 (≤1.38) Q2 (>1.38, ≤1.77) Q3 (>1.77, ≤2.30) Q4 (>2.30)
DR Ref. 1.15 (0.88, 1.50) 1.27 (0.98, 1.65) 1.12 (0.86, 1.45) 0.314 1.01 (0.92, 1.10)
NPDR Ref. 1.17 (0.90, 1.53) 1.26 (0.97, 1.64) 1.12 (0.86, 1.46) 0.343 1.00 (0.90, 1.12)
PDR Ref. 0.51 (0.09, 2.77) 1.56 (0.44, 5.56) 1.02 (0.25, 4.09) 0.630 1.13 (0.70, 1.83)
DR1 Ref. 1.18 (0.89, 1.57) 1.36 (1.03, 1.80) 1.09 (0.82, 1.45) 0.402 1.00 (0.91, 1.11)
NPDR1 Ref. 1.19 (0.90, 1.58) 1.34 (1.01, 1.77) 1.06 (0.80, 1.42) 0.530 1.00 (0.90, 1.10)
PDR1 Ref. 0.52 (0.09, 2.87) 1.56 (0.43, 5.59) 0.94 (0.23, 3.86) 0.712 1.08 (0.69, 1. 67)
Participants missing DR information (n = 1531) were excluded. Finally, 3266 participants were involved in the analyses. Data are expressed as odds ratios (95%
CI). Binary logistic regression was used for analyzing the association between the NLR level and the prevalence of DR with and without adjusting the model. The
associations of the NLR level with NPDR and PDR were analyzed by multinomial logistic regression with and without adjusting the model. 1The model was
adjusted for age, sex, education status, duration of diabetes, current smoking, BMI, HbA1c, dyslipidemia, and systolic blood pressure. DR: diabetic
retinopathy; NPDR: nonproliferative diabetic retinopathy; PDR: proliferative diabetic retinopathy; NLR: neutrophil-to-lymphocyte ratio.

of DKD are found in Table 3. In the total participants, com- cated. The NLR level was still associated with Ln ACR and
pared with the lowest quartile, individuals in the highest DKD positively (both P for trend < 0:05), indicating that
quartile had the highest β for Ln ACR [0.59 (0.48, 0.70)] the systemic inflammation indicated by the NLR level may
and the lowest β [-6.19 (-7.65, -4.73)] for eGFR in the unad- have negative effects on nephrotic changes in the very early
justed model. Furthermore, the prevalence of DKD among stage of diabetes.
the participants in the highest quartile increased by 160%
(OR 2.60; 95% CI 2.08, 3.24) compared with the participants 3.4. Associations between the NLR Level and the Prevalence of
in the first quartile significantly (P for trend < 0:001). After DR. No association was found between the NLR level and the
adjusting for age, sex, education status, duration of diabetes, prevalence of DR in Table 4. In the unadjusted model, the
current smoking, BMI, HbA1c, dyslipidemia, and systolic associations of the NLR level quartiles with the prevalence
blood pressure, the associations of the NLR level with Ln of DR, NPDR, and PDR were not found. After adjusting for
ACR and the prevalence of DKD still remained (both P age, sex, education status, duration of diabetes history, cur-
for trend < 0:01). After adjusting for education status, dura- rent smoking, BMI, HbA1c, dyslipidemia, and systolic blood
tion of diabetes, current smoking, BMI, HbA1c, dyslipid- pressure, there were also no associations between the NLR
emia, and systolic blood pressure, 1SD increment of the level and the prevalence of DR, NPDR, and PDR (all P for
NLR level was still significantly related to eGFR (β -1.85, trend > 0:05).
95% CI -2.39, -1.30).
Interestingly, in participants with normal eGFR 3.5. Receiver Operating Characteristics (ROC) Curve Analysis.
(eGFR ≥ 90 mL/min per 1.73 m2), these results were repli- Figure 2(a) shows the diagnostic ability of NLR, neutrophil,
6 Journal of Diabetes Research

1.0 1.0

0.8 0.8

0.6 0.6
Sensitivity

Sensitivity
0.4 0.4

0.2 0.2

0.0 0.0
0.0 0.2 0.4 0.6 0.8 1.0 0.0 0.2 0.4 0.6 0.8 1.0
1-specificity 1-specificity

NLR Lymphocytes NLR Lymphocytes

Neutrophils Line of equality Neutrophils Line of equality
(a) (b)

Figure 2: ROC curve of NLR, neutrophil, and lymphocyte levels for diagnosing CVD and DKD. (a) The ROC curve of NLR, neutrophil,
and lymphocyte levels for diagnosing CVD. (b) The ROC curve of NLR, neutrophil, and lymphocyte levels for diagnosing DKD. ROC:
receiver operating characteristic; NLR: neutrophil-to-lymphocyte ratio; CVD: cardiovascular and cerebrovascular diseases; DKD: diabetic
kidney disease.

and lymphocyte levels for CVD analyzed by the ROC curve. with the first quartile of the lymphocyte level, the individuals
The area under ROC curve of NLR, neutrophil, and lympho- in the fourth quartile had a lower prevalence of DKD (OR
cyte levels for CVD was 0.545, 0.524, and 0.463, respectively 0.61; 95% CI 0.48, 0.77) after adjusting for the same model.
(all P < 0:05). The cutoff with the biggest Youden index of In Supplementary Table 3, after adjusting for potential con-
NLR was 2.1 with the sensitivity of 37.2% and specificity founders, leukocyte, neutrophil, and lymphocyte levels were
70.5%. all not associated with the prevalence of DR (all P for trend
The diagnostic ability of NLR, neutrophil, lymphocyte, > 0:05). The different associations between the NLR level
and leukocyte levels for DKD was analyzed by the ROC curve and the prevalence of CVD, DKD, and DR were also evalu-
(Figure 2(b)). The area under ROC curve of NLR, neutrophil, ated in the same population (Supplementary Table 4). A
and lymphocyte levels for DKD was 0.607, 0.600, and 0.468, higher NLR level was still associated with an increased prev-
respectively (all P < 0:01). The cutoff with the biggest Youden alence of CVD and DKD (both P for trend < 0:05), other
index of NLR was 1.7 (sensitivity of 68.0% and specificity than DR (P for trend > 0:05). After fully adjusting the further
47.8%). model including age, sex, education status, duration of diabe-
tes, current smoking, BMI, HbA1c, dyslipidemia, systolic
3.6. Sensitivity Analyses. In Supplementary Table 1, although blood pressure, and the usage of antiplatelet medications,
leukocyte and neutrophil levels were positively associated the associations of the NLR level with the prevalence of
with the prevalence of CCA plaque (both P for trend < 0:05), CVD and DKD still remained (Supplementary Table 5).
no associations were found between them and the prevalence
of CVD (both P for trend > 0:05) after adjusting for age, sex, 4. Discussion
education status, duration of diabetes history, current smok-
ing, BMI, HbA1c, dyslipidemia, and systolic blood pressure. The present study provides evidence about the associations
Lymphocytes were associated with neither the prevalence of between the NLR level and diabetic complications including
CVD nor CCA plaque after adjusting for the same model CVD, DKD, and DR. The main finding was that the NLR
(both P for trend > 0:05). In Supplementary Table 2, com- level was positively associated with CVD and DKD, other
pared with the first quartile of leukocyte and neutrophil than DR, after correction for the potential confounders. To
levels, individuals in the fourth quartile had higher preva- the best of our knowledge, it is the first large-scale population
lence of DKD, respectively [(OR 1.52; 95% CI 1.19, 1.93) study that evaluated the association between the NLR level
and (OR 2.15; 95% CI 1.68, 2.75)] after adjusting for potential and three chronic vascular complications in the same popu-
confounders (both P for trend < 0:05). However, compared lation simultaneously.
Journal of Diabetes Research 7

Accumulated evidences have implicated that chronic [15], which our result is consistent with. The controversial
inflammation plays a dominant role in the development of results may be resulted on account of different conditions
diabetic complications [6, 28]. NLR, a readily available among the participants. To evaluate the different associations
and inexpensive index calculated by blood routine examina- between the NLR level and diabetic complications, we further
tion, has been considered a novel inflammatory biomarker analyzed the associations in the same group of the partici-
reflecting both adaptive immune response (mediated by pants (Supplementary Table 4). The results showed that a
lymphocytes) and innate immune response (mediated by higher NLR level was still associated with an increased prev-
neutrophils) [29, 30]. Thus, evaluating the associations alence of CVD and DKD, other than DR, which suggested
between the NLR level and different diabetic complications that the systemic inflammation indicated by the NLR level
is important. was more harmful to CVD and DKD than DR. Our result
Most of the previous studies have indicated NLR as a risk may partly explain the different incidence of CVD, DKD,
factor of CVD [31–33]. However, the results are not consis- and DR and may have certain enlightening effect on investi-
tent. For example, Gijsberts et al. considered that NLR was gating the pathophysiological mechanisms of different diabe-
of a limited predictive value in prediction of cardiovascular tes complications.
mortality [16]. Studies have suggested that presence of CCA There were some limitations in the present study,
plaque could predict CVD events [34, 35]; thus, we used it although it is an investigation of large sample community
to assess early CVD risk. In our study, although the leukocyte dwelling participants with strong quality control. First, this
and neutrophil levels were associated with the prevalence is a cross-sectional study; thus, causal relationships between
of CCA plaque, no association between leukocyte and NLR and diabetic complications cannot be confirmed. Sec-
the neutrophil level and the prevalence of CVD was found ond, our study participants were all Han Chinese, which
(Supplementary Table 1). Only the NLR level was positively restricted the extrapolation of current results to other ethnic-
associated with both CVD and CCA plaque, which suggests ities. Third, we were not able to account for all factors which
that the elevated NLR level may be a more proper predictor might have limited the multivariate approach.
of CVD events than leukocyte and neutrophil levels. In addi-
tion, the reason for the different results regarding the associ- 5. Conclusions
ations of leukocyte and neutrophil levels between the CCA
plaque and CVD may be that abnormalities of leukocytes We found that a higher NLR level was associated with an
or neutrophils have been reported in conjunction with ath- increased prevalence of CVD and DKD, other than DR, after
erosclerotic vascular diseases [36], just a predicting factor of adjusting for the potential confounders in Chinese adult with
CVD, which cannot represent the total incidence of CVD. diabetes, which suggests measuring routinely analyzed leuko-
In the present study, we found that the NLR level was asso- cyte characteristics timely may be critical for the prevention
ciated with the ACR level and the prevalence of DKD posi- of diabetic vascular complications. Further studies are still
tively, with eGFR negatively. Similarly, our results showed, needed to confirm present results.
in participants with normal eGFR (eGFR ≥ 90 mL/min per
1.73 m2), the positive association of the NLR level with Abbreviations
increased ACR and a higher prevalence of DKD sustained.
This indicates that the change of the NLR level may start in T2DM: Type 2 diabetes mellitus
diabetic adults with pure proteinuria. Our findings were CVD: Cardiovascular and cerebrovascular diseases
inconsistent with the previous studies [15, 37]; both of which DKD: Diabetic kidney disease
reported that increased NLR was significantly associated with DR: Diabetic retinopathy
DKD. Interestingly, we found that the neutrophil level was NLR: Neutrophil-to-lymphocyte ratio
positively associated with the ACR level and the prevalence BMI: Body mass index
of CVD, whereas the lymphocyte level was associated with FPG: Fasting plasma glucose
the ACR level and the prevalence of DKD negatively (Supple- HbA1c: Glycated hemoglobin
mentary Table 2), which may be resulted from the harmful HDL: High-density lipoprotein
effects of neutrophils on endothelial damage and the anti- LDL: Low-density lipoprotein
atherosclerotic role of lymphocytes [8]. Thus, an index CCA: Common carotid artery
including both neutrophil and lymphocyte levels, like NLR, ACR: Albumin to creatinine ratio
was needed vitally. We suggested that the NLR level may Ln ACR: Logarithmically transformed albumin to creati-
have better stability than independent neutrophil, lympho- nine ratio
cyte, and leukocyte levels, since it indicates the balance eGFR: Estimated glomerular infiltration rate
between the neutrophil and lymphocyte levels, which is less OR: Odds ratios
affected by various pathological and physiological status. CIs: Confidence intervals.
At present, the association between the NLR level and the
prevalence of DR is controversial. A hospital-based cross- Data Availability
sectional study indicated that NLR could be recommended
as an inexpensive diagnostic biomarker for DR [38]; how- The raw data supporting the conclusions of this manuscript
ever, the result of the study conducted by Ciray et al. showed will be made available by the authors, without undue reserva-
there was no independent association between NLR and DR tion, to any qualified researcher.
8 Journal of Diabetes Research

Disclosure [3] A. J. Garber, M. J. Abrahamson, J. I. Barzilay et al., “Consensus

statement by the American Association of Clinical Endocri-
The funders played no role in the design or conduct of the nologists and American College of Endocrinology on the com-
study, collection, management, analysis, or interpretation of prehensive type 2 diabetes management algorithm - 2019
data or in the preparation, review, or approval of the article. executive summary,” Endocrine Practice, vol. 25, no. 1,
pp. 69–100, 2019.
Conflicts of Interest [4] Y. Zheng, S. H. Ley, and F. B. Hu, “Global aetiology and epide-
miology of type 2 diabetes mellitus and its complications,”
The authors declare that they have no competing or financial Nature Reviews. Endocrinology, vol. 14, no. 2, pp. 88–98, 2018.
interests regarding to the submitted work. [5] L. Ferrucci and E. Fabbri, “Inflammageing: chronic inflamma-
tion in ageing, cardiovascular disease, and frailty,” Nature
Reviews. Cardiology, vol. 15, no. 9, article 64, pp. 505–522,
Authors’ Contributions 2018.
Y.L. and N.W. designed the research; H.W., Y.W., S.F., C.Y., [6] T. Fujita, S. Hemmi, M. Kajiwara et al., “Complement-medi-
F.X., and W.Z. conducted the research; H.W. and Y.W. ana- ated chronic inflammation is associated with diabetic micro-
vascular complication,” Diabetes/Metabolism Research and
lyzed the data, and H.W. wrote the manuscript. Y.L. had pri-
Reviews, vol. 29, no. 3, pp. 220–226, 2013.
mary responsibility for the final content. All authors read and
[7] E. Cebeci, C. Cakan, M. Gursu et al., “The main determinants
approved the final manuscript. Heng Wan and Yuying Wang
of serum resistin level in type 2 diabetic patients are renal func-
contributed equally to this work. tion and inflammation not presence of microvascular compli-
cation, obesity and insulin resistance,” Experimental and
Acknowledgments Clinical Endocrinology & Diabetes, vol. 127, no. 4, pp. 189–
194, 2019.
The authors thank all team members and participants in [8] H. Cantor and E. Simpson, “Regulation of the immune
the METAL study. This study was supported by the National response by subclasses of T lymphocytes. I. Interactions
Natural Science Foundation of China (91857117, 81600614); between pre-killer T cells and regulatory T cells obtained from
Science and Technology Commission of Shanghai Munici- peripheral lymphoid tissues of mice,” European Journal of
pality (19140902400, 18410722300); the Major Science and Immunology, vol. 5, no. 5, pp. 330–336, 1975.
Technology Innovation Program of Shanghai Municipal [9] A. Shiny, Y. S. Bibin, C. S. Shanthirani et al., “Association of
Education Commission (2019-01-07-00-01-E00059); Com- neutrophil-lymphocyte ratio with glucose intolerance: an indi-
mission of Health and Family Planning of Pudong District cator of systemic inflammation in patients with type 2 diabe-
(PWZxq2017-17); Municipal Human Resources Develop- tes,” Diabetes Technology & Therapeutics, vol. 16, no. 8,
ment Program for Outstanding Young Talents in Medical pp. 524–530, 2014.
and Health Sciences in Shanghai (2017YQ053); Shanghai [10] P. H. Gibson, B. H. Cuthbertson, B. L. Croal et al., “Usefulness
Jiao Tong University School of Medicine (19XJ11007). of neutrophil/lymphocyte ratio as predictor of new-onset
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Supplementary Materials 2010.
[11] J. Diaz-Martinez, A. Campa, I. Delgado-Enciso et al., “The
Supplementary Table 1: associations between the leukocyte,
relationship of blood neutrophil-to-lymphocyte ratio with
neutrophil, and lymphocyte level quartiles and the preva- nutrition markers and health outcomes in hemodialysis
lence of CCA plaque and CVD. Supplementary Table 2: asso- patients,” International Urology and Nephrology, vol. 51,
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level quartiles and the prevalence of DKD. Supplementary [12] S. A. Khandare, S. Chittawar, N. Nahar, T. N. Dubey, and
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