• Users Online: 102
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 89-93

Study of absolute neutrophil count and neutrophil-lymphocyte ratio in patients with type 2 diabetes mellitus and its correlation with diabetic nephropathy


1 Department of General Medicine, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
2 Department of General Medicine, Dr B R Ambedkar Medical College, Bengaluru, Karnataka, India
3 Department of General Medicine, Gauhati Medical College, Guwahati, Assam, India

Date of Submission03-Oct-2020
Date of Decision03-Dec-2020
Date of Acceptance05-Dec-2020
Date of Web Publication21-Apr-2021

Correspondence Address:
Dr. G N Devamsh
No 500, 8th Main, 10th Cross, UPO, Sadashivanagar, Bengaluru - 560 080, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_75_20

Rights and Permissions
  Abstract 


Background and Objectives: Diagnostic markers to detect diabetic nephropathy at the early stage are important as early intervention can slow the loss of kidney function. Currently, there are very few diagnostic markers available. Micro-albuminuria is an accepted sign of early renal injury. Measurement of other markers such as neutrophil gelatinase-associated lipocalin and cystatin C, etc., is costly, and their utility is still under the research. Diabetic nephropathy in type 2 diabetes mellitus is thought to have elevated cytokines. However, their measurement is not easy. Absolute neutrophil count (ANC) and neutrophil-lymphocyte ratio (NLR) can act as a surrogate marker for the same. There is limited research concerning the correlation between ANC, NLR, and diabetic nephropathy. ANC is a very simple and inexpensive laboratory parameter. There are only a few studies done previously studying the association between ANC and albuminuria in the Indian population with type 2 diabetes mellitus. Subjects and Methods: This cross-sectional study was conducted in the hospitals attached to Bangalore Medical College and Research Institute. One hundred and forty-five Type II diabetes patients who gave consent for the study and satisfy the inclusion criteria were included in the study. Data were collected using semi-structured questionnaire, clinical examination, and relevant investigations. Statistical analysis was performed using the SPSS software. P < 0.05 was considered statistically significant. Results: Among the 145 individuals in the study, the mean age of the study population was 53.33 years (standard deviation: 11.90). The female-to-male ratio is 1.01: 1. The mean duration of disease was 5.88 years. The average ANC and NLR was higher in patients with proteinuria as compared to those without proteinuria. P value was statistically significant. It was noted that the NLR progressively increased from KDIGO stage G2 to G4, and the P value was statistically significant at 0.001. Interpretation and Conclusion: The NLR and ANC were significantly higher in patients with micro-albuminuria and macro-albuminuria compared to patients without proteinuria. They are simple, cost-effective parameters and can be considered as a surrogate marker for the detection and prognostic purposes of diabetic nephropathy. We hope this study adds to the existing data on NLR and ANC which are less studied parameters and paves way to future, well-matched, prospective studies which may define more in detail about the temporal correlation between ANC, NLR, and diabetic nephropathy.

Keywords: Absolute neutrophil count, diabetic nephropathy, neutrophil-lymphocyte ratio


How to cite this article:
Devamsh G N, Sheshan V, Chirag L U, Shetty A, Madhumathi R. Study of absolute neutrophil count and neutrophil-lymphocyte ratio in patients with type 2 diabetes mellitus and its correlation with diabetic nephropathy. APIK J Int Med 2021;9:89-93

How to cite this URL:
Devamsh G N, Sheshan V, Chirag L U, Shetty A, Madhumathi R. Study of absolute neutrophil count and neutrophil-lymphocyte ratio in patients with type 2 diabetes mellitus and its correlation with diabetic nephropathy. APIK J Int Med [serial online] 2021 [cited 2021 May 14];9:89-93. Available from: https://www.ajim.in/text.asp?2021/9/2/89/314200




  Introduction Top


Twenty-five to forty percent of patients with type 2 diabetes will eventually develop diabetic nephropathy.[1] Diabetic nephropathy is one of the most common causes of end-stage renal disease. The onset and course of diabetic nephropathy can be ameliorated to very significant degree by several interventions, but these interventions have their greatest impact if instituted at a point very early in the course of development of this complication. Once chronic kidney disease develops, therapy must be geared toward slowing the progression and prevention of complications and where that fails, preparation for renal replacement therapy.

Diabetic nephropathy in Type 2 diabetes mellitus has an inflammatory pathology. Many inflammatory markers have been found to be related to diabetic nephropathy such as interleukin (IL)-1, IL-6, IL-8, transforming growth factor ß, and many other cytokines. However, their measurement is not routinely used. In this respect, neutrophil-lymphocyte ratio (NLR) has emerged as a novel surrogate marker.[2]

NLR is an easily available parameter to assess the inflammatory status of a subject. It has proven its usefulness in the stratification of mortality in major cardiac events. Many cross-sectional studies have supported NLR to be a cost-effective marker for diabetic nephropathy in early stages and can be a predictor of severity of albuminuria. Similarly, absolute neutrophil count (ANC) is a very simple and inexpensive laboratory parameter. It has not been reported previously in association with albuminuria in the Indian population with Type 2 diabetes mellitus.

Owing to the paucity of data on neutrophil-lymphocyte ratio and ANC in patients with type 2 diabetes in the South Indian population, the present study aims to estimate the levels of both ANC and NLR in type 2 diabetes patients in southeren India. An attempt is also made to study the correlation with diabetic nephropathy as suggested by previous studies.

Aims and objectives

The primary objective was to estimate the levels of ANC and NLR in patients with type 2 diabetes mellitus.

The secondary objective was to identify a correlation between ANC, NLR, and diabetic nephropathy.


  Subjects and Methods Top


This cross-sectional study was conducted on 145 patients with type 2 diabetes mellitus attending outpatient department/admitted in the department of medicine of hospitals attached to Bangalore Medical College and Research Institute (BMCRI) from November 2017 to May 2019.

The inclusion criteria were age more than 18 years, patients with type 2 diabetes mellitus according to American Diabetes Association criteria, and patients with type 2 diabetes mellitus who are willing to participate in the study and give informed written consent. The exclusion criteria were active infection, leukocytosis (white blood cell [WBC] >10,000/mm3) or leukocytopenia (WBC <4000/mm3), known case of malignancy/hematological proliferative disorder, patients who have received steroids/immunosuppressive therapy/chemotherapy, and diabetic ketoacidosis.

After obtaining approval from the Institutional Ethics Committee of BMCRI, written informed consent was obtained from the patients. Data were collected by semi-structured questionnaire, clinical examination, and investigations. ANC was calculated using impedance with hydrofocus cytometry. NLR was taken as the ratio of neutrophil-to-lymphocyte count. Urine albumin estimation was done using immunoturbidimetry. Statistical analysis was performed using the IBM® SPSS (Statistical Product and Service Solutions)® Statistics Version 20. Data were analyzed by descriptive statistics. Student's t-test was used for significant difference between two means. Pearson correlational analysis/Spearman's rank correlation was used to assess the correlation between ANC, NLR, and diabetic nephropathy.


  Results Top


The present study was conducted in the Department of Medicine, BMCRI. A total of 145 cases of diabetes mellitus were taken, and the data obtained thereby are presented and analyzed below.

The maximum number of patients in our study was more than 60 years of age (31.03%) with a mean age of 53.33 years (SD – 11.90). The lowest age encountered was 32 years, whereas the oldest patient was 76 years in our present study series.

In the present study, 73 (50.3%) patients of the study population were female and 72 (49.6%) were male. The female-to-male (F: M) ratio is 1.01: 1.

It is observed that 62 patients (42.6%) had the disease for 2–5 years, 50 patients (34.5%) had the disease for 6–10 years, 15 (10.3%) patients had the disease for more than 10 years, and 18 (12.4%) patients had the disease for <2 years. The mean duration of the disease was 5.88 years with standard deviation (SD) of 4.69. It is observed that 82 patients in the study (56.5%) were not hypertensive and 63 (43.4%) were hypertensive.

Majority of the patients had normal body mass index (BMI) according to the Asian pacific criteria. Eighty-four (57.9%) patients had normal BMI. Twenty (13.8%) patients had a BMI <17.5. Thirty-one (21.4%) patients had BMI between 23 and 28 and 10 (6.9%) patients had BMI more than 28. The mean BMI was 21.2 with SD of 3.67.

According to [Figure 1], there were 26 (17.9%), 46 (31.7%), and 73 (50.3%) patients who had HbA1c of <7, 7–9, and >9%, respectively. The mean HbA1c was 9.56% with SD of 2.95
Figure 1: Distribution of HbA1c among the study population

Click here to view


The mean fasting blood sugar (FBS) of patients with HbA1c <7 was 134.6 ± 38.7. Similarly, mean FBS for patients with HbA1c 7-9 and >9 was 146.5 ± 49.7 and 225.8 ± 82.6, respectively. The lowest FBS among the study population was 41 mg/dl and highest was 486 mg/dl. The FBS was higher in patients with HbA1c >9.

The mean PPBS of patients with HbA1c <7 was 215.4 ± 59.3.7. Similarly, mean PPBS for patients with HbA1c 7-9 and >9 was 253.07 ± 79.7 and 326.5 ± 110.6, respectively. The lowest PPBS among the study population was 108 mg/dl and highest was 658 mg/dl. The PPBS was higher in patients with HbA1c >9 as compared to those with HbA1c <9.

It is observed that 64 (44.14%), 37 (28.27%), and 40 (27.58%) of the patients were in group with no proteinuria, microalbuminuria, and macroalbuminuria, respectively.

It is also observed that 71.2% of the study population with HbA1c >9 have proteinuria and 28.8% do not have proteinuria. On the other hand, 65.2% of the study population with HbA1c between 7 and 9 and 50% of population with HbA1c <7 do not have proteinuria. Hence, patients with good glycemic control have less proteinuria as compared to patients with poor glycemic control.

It is observed from [Figure 2] that the average ANC in patients without proteinuria, with microalbuminuria and macroalbuminuria was 4874.6 ± 1084.2, 5740.5 ± 1403.3, and 6220.05 ± 1323.3, respectively. The mean ANC in our study population was 5611.7 with SD of 1270.3. The P value was statistically significant (<0.05)
Figure 2: Average absolute neutrophil count ratio in proteinuria groups

Click here to view


It is observed from [Figure 3] that the average NLR in patients without proteinuria, microalbuminuria, and macroalbuminuria was 2.27 ± 1.53, 3.25 ± 1.66, and 4.78 ± 2.66, respectively. The mean NLR in our study population was 3.43 with SD of 1.95. The P value was statistically significant (<0.05). To identify the best cutoff value of NLR in our study, receiver operating characteristic (ROC) analysis was performed. The ROC analysis revealed that the best cutoff value for NLR in our study was 2.5 with a sensitivity of 83.12%, specificity of 89.71%, and Younden index J value of 0.7282 [Figure 4].
Figure 3: Average neutrophil-lymphocyte ratio in proteinuria groups

Click here to view
Figure 4: Receiver-operating characteristic analysis of neutrophillymphocyte ratio in the study population

Click here to view


From [Table 1], it is seen that there is a significant correlation between NLR and proteinuria. The P value was significant at <0.05 when comparing NLR between the groups without proteinuria and microalbuminuria, between microalbuminuria and macroalbuminuria group, without proteinuria and macroalbuminuria group.
Table 1: Correlation between mean neutrophil-lymphocyte ratio and proteinuria groups

Click here to view


From the data in [Table 2], it was observed that the ANC was 5121.6 ± 1122.5 in G1 stage as compared to 5282.09 ± 1555.3 in G5 stage. There was no linear correlation between ANC and KDIGO staging.
Table 2: Comparison of absolute-neutrophil count and KDIGO staging

Click here to view


The P value was not statistically significant.

From [Table 3], it is observed that the mean NLR was 2.48 ± 1.46 in G1 stage as compared to 3.31 ± 2.14 in G5 stage. It was noted that the NLR progressively increased from stage G2 to G4 and the P value was statistically significant at 0.001.
Table 3: Comparison of neutrophil-lymphocyte ratio and KDIGO staging

Click here to view


It is observed that the Spearman's correlation shows statistically significant correlation between HbA1c, ANC, NLR, and diabetic nephropathy [Table 4]. ANC and NLR have a statistically significant correlation with urine PCR in the study population [Table 5].
Table 4: Spearman's correlation with diabetic nephropathy

Click here to view
Table 5: Spearman's correlation with urine polymerase chain reaction

Click here to view



  Discussion Top


Out of the 145 patients in our study, the maximum number of patients in our study were more than 60 years of age (31.03%) with a mean age of 53.33 years (SD 11.90). The age distribution in our study is comparable to the study of Akbas et al. with a mean age of 57.28 years (SD ± 10.64).[3] It is also comparable to Chittawar et al. study on the Indian population in Madhya Pradesh and Bhopal (52.29 ± 10.64).[4]

The female-to-male ratio is 1.01: 1 with no sex-related variability which is comparable to Chittawar et al. (2017) with an female-to-male ratio of 1.05:1. There was no significant sex-related variability in our study.

The mean duration of disease was 5.88 years with SD of 4.69.

Chittawar et al. (2017) study had mean disease duration of 3 years (1–8 years) and Kahraman et al.[5] study on correlation of NLR ratio in diabetic nephropathy had mean duration of 5 years comparable to our study population.

In our present study, the majority of the patients were having normal BMI according to Asia pacific criteria. The mean BMI was 21.2 with SD of 3.67 which is comparable to the study by Chittawar et al. (26.25 ± 3.2). As these studies were conducted in different parts of India, it may indicate that the differences might be due to different population groups, which have different genetic background and different social, cultural, lifestyle, and dietary habits.

The mean HbA1c in proteinuria groups were 8.7%, 9.75%, and 10.36%, respectively. This is comparable to Akbas et al. (2014) whose similar design study on NLR ratio in diabetic nephropathy had mean HbA1c in proteinuria groups as 8.42%, 9.5%, and 9.82%, respectively. The majority of the study population had poor glycemic control.

In the present study, 64 (44.14%), 37 (28.27%), and 40 (27.58%) of the patients were in group with no proteinuria, microalbuminuria, and macro-albuminuria, respectively. In Akbas et al.'s (2014) study, there were 132 patients in no proteinuria group which is significantly higher than in our study, 34 patients in microalbuminuria group, and 34 patients in macroalbuminuria groups, which is comparable to our study.

In our study population, the average ANC in patients without proteinuria, with microalbuminuria and macroalbuminuria was 4874.6 ± 1084.2, 5740.5 ± 1403.3, and 6220.05 ± 1323.3, respectively. The mean ANC in our study population was 5611.7 with SD of 1270.3. In the study conducted by Chittawar et al., the ANC in patients without and with proteinuria was 4653.51 ± 1185.93 and 5293.91 ± 1479, respectively. Similarly, in Chung et al., the average ANC in patients without proteinuria, with microalbuminuria and macroalbuminuria was 3.730 ± 1.283, 4.101 ± 1.432, and 4.742 ± 1.590, respectively.[6] It is observed that ANC is higher in patients with proteinuria as compared to those without proteinuria.

In our present study, average NLR in patients without proteinuria, microalbuminuria, and macroalbuminuria was 2.27 ± 1.53, 3.25 ± 1.66, and 4.78 ± 2.66, respectively. The mean NLR in our study population was 3.43 with SD of 1.95. In a study by Akbas et al. (2014), the mean NLR in a similar grouping was 1.56±0.9, 1.96 ± 1.2, and 2.03±0.89. In Chittawar et al.'s (2017) study, the mean NLR in diabetic nephropathy group was 2.85 ± 0.85 and 1.85 ± 0.65 in patients without nephropathy. In a study by Moursy et al. in Egypt, NLR ratio was 1.4 ± 0.3, 2.29 ± 1.07, and 2.52 ± 1.21 in patients without nephropathy, with microalbuminuria, and macroalbuminuria, respectively.[7]

From the above studies, it is clearly seen that there is an increasing trend in NLR values between the proteinuria groups, which is a similar trend in our study.

In the present study, a significant positive correlation was seen between NLR and proteinuria groups. The mean NLR increased between the groups with P < 0.05. A significant positive Spearman Rho correlation with the proteinuria groups was in agreement with the other studies as mentioned. This was a similar trend in the study by Chittawar et al., Akbas et al., and Kahrman et al. where higher NLR was associated with microalbuminuria and macroalbuminuria compared to patients with no proteinuria.

In our study, there was no linear correlation between ANC and KDIGO staging. The P value was not statistically significant. However, it was noted that the NLR progressively increased from stage G2 to G4, and the P value was statistically significant at 0.001. There are hardly any studies correlating ANC, NLR, and KDIGO staging in diabetic nephropathy.

The limitations of the study include small sample size, cross-sectional study, and effect of oral hypoglycemic agents and insulin therapy on ANC and NLR was not assessed in our study.


  Conclusion Top


Diabetes mellitus is a major health problem throughout India, mainly because of the morbidity and mortality associated with its complications. The present study highlighted that diabetic nephropathy is seen in elderly patients with the longer duration of disease at increased frequency. Increasing age at the diagnosis of disease and poor glycemic control are associated with increased prevalence of nephropathy in the patients.

The neutrophil–lymphocyte ratio and ANC were significantly higher in patients with microalbuminuria and macroalbuminuria as compared to patients without proteinuria. They are simple, cost-effective parameters, and can be considered as a surrogate marker for the detection and prognostic purposes of diabetic nephropathy in resource-limited setup.

We hope this study adds to the existing data on neutrophil-lymphocyte ratio and ANC which are a less studied parameters and paves way to future, well-matched, prospective studies which may define more in detail about the temporal correlation between ANC, NLR, and diabetic nephropathy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, et al., editors. Harrison's principles of internal medicine. 19th ed.. Vol 2, Part 16., New York: McGraw-Hill; 2015. p. 3178-209.  Back to cited text no. 1
    
2.
Navarro-González J, Mora-Fernández C, de Fuentes M, García-Pérez J. Inflammatory molecules and pathways in the pathogenesis of diabetic nephropathy. Nature Reviews Nephrology 2011;7:327-40.  Back to cited text no. 2
    
3.
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. International J Clin Exp Med 2014;7:1794-801.  Back to cited text no. 3
    
4.
Chittawar S, Khandare S, Nahar N, Dubey T, Qureshi Z. Study of neutrophil-lymphocyte ratio as novel marker for diabetic nephropathy in type 2 diabetes. Indian J Endocr Metab 2017;21:387-92.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Kahraman C, Kahraman NK, Aras B, Coşgun S, Gülcan E. The relationship between neutrophil-to-lymphocyte ratio and albuminuria in type 2 diabetic patients: a pilot study. Arch Med Sci 2016;12:571-5.  Back to cited text no. 5
    
6.
Chung F, Tsai J, Chang D, Shin S, Lee Y. Peripheral Total and differential leukocyte count in diabetic nephropathy: The relationship of plasma leptin to leukocytosis. Diabetes Care 2005;28:1710-7.  Back to cited text no. 6
    
7.
Moursy EY, Megallaa MH, Mouftah RF, Ahmed SM. Relationship between neutrophil-lymphocyte ratio and microvascular complications in Egyptian patients with type 2 diabetes. Am J Int Med 2015;3:250-5.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Subjects and Methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed67    
    Printed2    
    Emailed0    
    PDF Downloaded16    
    Comments [Add]    

Recommend this journal