International Journal of Advances in Medicine

Varma S et al. Int J Adv Med. 2021 Jul;8(7):952-956

http://www.ijmedicine.com pISSN2349-3925 | eISSN2349-3933

DOI: https://dx.doi.org/10.18203/2349-3933.ijam20212407
Original Research Article

Correlation of neutrophil lymphocyte ratio with HbA1c

in patients of type 2 diabetes mellitus
Sanjay Varma*, Manisha Khande, Preeti Gupta, Archana,
Rajeev Lochan Khare, Yogendra Malhotra, Devpriya Lakra

Department of Medicine, Pt. Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India

Received: 04 May 2021

Accepted: 01 June 2021

*Correspondence:
Dr. Sanjay Varma,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Neutrophil lymphocyte is an indicator of subclinical inflammation. Type 2 diabetes mellitus is

associated with chronic low-grade inflammation. One of the novel inflammatory markers is hemogram derived
neutrophil to lymphocyte ratio. There are very few studies which are directly accessing the relation between NLR and
HbA1c, so in the present study our aim to correlate neutrophil lymphocyte ratio with glycemic control in patients
having type 2 diabetes.
Methods: Hospital based observational cross section study was carried out at department of medicine, Pt JNMMC
and Dr BRAM Hospital, Raipur, between September 2018 to August 2019. 105 patients with type 2 diabetes mellitus
according to ADA criteria who were aged more than 18 years were included in the study. Relevant investigation and
complete blood count were performed. Microsoft excel and SPSS version 25 were used for collection and analysis of
the data, p<0.05 was considered as significant.
Results: Out of 105 patients who were given the consent for the study, the ration of male is to female was 1:0.98,
mean age of all the patients was 51.77±10.56 years, mean neutrophil lymphocyte ratio among the patients was
6.30±2.646, HbA1c count more than ≥9 was 54 (51.27%). NLR had a positive correlation with HbA1c and was found
to be an independent predictor of poor glycemic control in patients with type 2 diabetes mellitus.
Conclusions: Increased NLR is associated with elevated HbA1c and poor glycemic control. Type NLR should be
used as a marker of diabetic control level in addition to HbA1c in type 2 diabetic subjects.

Keywords: NLR, American heart association, HbA1c, Glycemic control

INTRODUCTION obese adolescents.1 It is predominant form of diabetes

worldwide. The incidence of diabetes is increasing day
Diabetes mellitus describes a metabolic disorder having by day. The epidemic of diabetes is under way in both
multiple etiology. It is characterized by chronic developing and developed countries. According to IDF,
hyperglycemia resulting from defects in insulin secretion, some 425 million people worldwide, or 8.8% of adults
insulin action, or both. Symptoms are polyuria, aged 20-79, are estimated to have diabetes. About 75%
polydipsia, polyphagia. If left untreated, diabetes can live in low and middle income countries. If these trends
cause many complications.1 Type 2 diabetes mellitus is continue, by 2040 some 642 million people, or one adult
heterogeneous group of disorders characterized by in ten, will have diabetes.
variable degree of insulin resistance, impaired insulin
secretion and increased hepatic gluconeogenesis, In Type 2 diabetes mellitus sub-acute chronic
typically develop with increasing age and particularly in inflammation is a common and at least two major
inflammatory pathways, stress-activated Jun N-terminal

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 Varma S et al. Int J Adv Med. 2021 Jul;8(7):952-956

kinases (JNK) and the transcription factor NF-kappa B.2 confidence level 99% (0.99), power of test=(1-β)=0.01
This inflammatory state produces various pro- and correlation (r)=0.45.
inflammatory cytokines, which amplified by adipokines
like TNF-alpha, IL-1, IL-6, IL-10, leptin, adiponectin, Investigation
monocyte chemoattractant protein, angiotensinogen,
resistin, chemokines, serum amyloid protein.2,3 Adipose After overnight fast and after complete aseptic
tissue infiltrate by macrophages and immune cells (B precautions venous blood samples (10ml) were collected
cells and T cells) which trigger local and systemic in hemogram tubes containing EDTA and biochemistry
chronic low-grade inflammation, by producing more tubes, samples were maintained at room temperature and
cytokines and chemokines which create a pathologic link tested within 1 hour of collection to minimize variations
between obesity, insulin resistance and diabetes.3-6 In due to sample ageingand neutrophil and lymphocyte
patients with diabetes to measure the long-term glycemic count were measured by automated hematology analyzer.
control HbA1c is used. It plays important role in Neutrophil lymphocyte ratios (NLR) were estimated by
assessing the adequacy of therapy and need for dividing the absolute neutrophil count to absolute
intervention in patients with poorly controlled diabetes lymphocyte count. HbA1c was estimated by HPLC on
mellitus. However, HbA1c usually does not predict Bio-Rad HPLC analyzer using manufacturer’s protocol.
ongoing inflammation and diabetes associated The fully automated HPLC variant II (Bio-Rad
complications accurately. Neutrophil lymphocyte ratio laboratories, Munich, Germany) was used.
(NLR) is sign of balance between neutrophil lymphocyte
level in body and is an indication of subclinical Statistical analysis
inflammation. NLR is a simple ratio of absolute
neutrophil count and absolute lymphocyte count.7 It is Collected data were expressed as percentage and
also a potential marker to determine inflammation in mean±standard deviation (SD). SPSS software was used
various cardiac and non-cardiac disorders. It is used to for statistical analysis. Chi square test was used for
predict the prognosis of diseases such as acute categorical variables. Pearson correlation coefficient (r)
myocardial infarction (MI), stroke, and heart failure. was calculated to know the relation between HbA1c and
There are very less studies which shows the direct NLR, p<0.05 was considered statistically significant.
correlation between HbA1c and NLR in patients with
type 2 diabetes, so in this study we are going to access RESULTS
the relation betweenHbA1c and NLR in patients with
type 2 diabetes. The present study was conducted in the department of
medicine, Dr. B. R. A. M. hospital Raipur on 105 patients
Aim and objectives of Type 2 Diabetes Mellitus and baseline demographic
characteristic of population of study shown in (Table 1).
Aim and objectives of current studies were to correlate The study comprises of 105 patients. Out of 105 cases
NLR (neutrophil-lymphocyte ratio) with HbA1c in having mean age 51.77±10.56, out of 53 were males
patients of type 2 diabetes mellitus and to estimate NLR having mean age was 51.32±10.05 years and rest 52
(neutrophil-lymphocyte ratio). were females having mean age was 52.37±11.34. Mean
BMI of all participant was 24.76±2.40. 30(28.57%) of
METHODS the participants had systolic blood pressure more than
140mmhg while 71.43% of the patient had SBP lower
Hospital based observational cross-section study was than 140mmhg, whereas Diastolic Blood Pressure in 48
carried out at department of medicine, Pt JNMMC and Dr (45.71%) of the participants had more than 90mmhg as
BRAM hospital, Raipur, between September 2018- shown in above (Table 1). For all 105 participants had
August 2019. The study was conducted after getting the mean absolute Neutrophil count was 8.31±4.19910³/µl,
institutional ethical committee clearance. All the patients among 105 study subjects 63 patients (60%) their
gave informed written consent for the study. 105 patients absolute Neutrophil count was more than 7.0 and 42
with type 2 diabetes mellitus according to ADA criteria patients (40%) their absolute neutrophil count was within
who were aged more than 18 years were included in the normal limit. 81 patients (77.14%) had normal absolute
study. Patients were included in the study by simple lymphocyte count, 20 patients had absolute lymphocyte
random sampling. Patients of type 1 diabetes mellitus, count less than 0.9, remaining 4 patients (3.82%) had
age <18 years, patients having active infection, known absolute lymphocyte count more than 2.9. Mean
cases of inflammatory disorders, acute and chronic renal neutrophil lymphocyte ratio count was 6.30±2.646, in
failure, chronic liver disease, acute MI, malignancy i.e. which 79 patients (75.23%) had NLR more than 3.53, and
Leukaemia were excluded from the study. remaining 26 patients (24.77%) had NLR within normal
limit. In our study 54 patients (51.42%) had HbA1C
Sample size more than 9%, 39 patients (37.14%) had HbA1C in
between 7.1-9%, rest 12 patients (11.44%) had HbA1c
Sample size was calculated to be 105 by correlation less than 7.0%. Among 105 patients, 72 patients (68.6%)
calculator, considering significance level (α)=0.01, were not fulfilling the ADA treatment goal of FBS. Out

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 Varma S et al. Int J Adv Med. 2021 Jul;8(7):952-956

of which 33(31.4%) were female patients and 39(68.6%) Table 2: Hematological distribution of study
were male patients. That of for PPBS, 72 patients population.
(68.6%) were not fulfilling the ADA treatment goal of
PPBS. Out of which 32 (61.5%) were female patients and Parameters Mean±SD/N (%) Max. Min.
40 (75.5%) were male patients as shown in above (Table Absolute neutrophil
8.31±4.199
2). count 10³/µl
<1.7 0 (0) 24.73 1.76
Table 1: Demographic data of study population. 1.7-7.0 42 (40)
>7.0 63 (60)
Parameters Mean±SD/N (%) Absolute lymphocyte count (103/ul)
Age 51.77±10.56 <0.9 20 (19.04)
Gender 0.9-2.9 81 (77.14)
Male 53 (50.47) >2.9 4 (3.82)
Female 52 (49.53) Neutrophil
BMI (Kg/m2) 24.76 ± 2.40 6.30±2.646
lymhocyte ratio
SBP (mmHg) <0.78 0 (0) 11.28 1.36
<140 75 (71.43) 0.78-3.53 26 (24.77)
≥140 30 (28.57) > 3.53 79 (75.23)
DBP (mmHg) HbA1c
<90 57 (54.28) <7.0 12 (11.44)
≥90 48 (45.71) 7.0-9.0 39 (37.14)
>9.0 54 (51.42)
The association of NLR with HbA1c which was FBS (mg/dl)
significant association (p<0.001) noted between two <130 33 (31.40)
parameters indicating higher frequency of NLR with
≥130 72 (68.80)
higher HbA1c% is shown in table, also NLR and HbA1c
was positive moderately correlated was observed. PPBS (mg/dl)
Association of HbA1c with absolute neutrophil count was <180 33 (31.40)
assessed and found significant association between two ≥180 72 (68.80)
parameters indicating higher frequency of increased WBC 10³/µl
neutrophil count in subjects with High HbA1c levels. <04 1 (0.95)
Association of HbA1c with absolute lymphocyte count 04-11 77 (73.33)
was assessed and found significant association between >11 27 (25.72)
two parameters indicating higher frequency of increased
lymphocyte count in subjects with High HbA1c levels.

Table 3: Association and correlation of NLR with HbA1c among study subjects.

HbA1c N (%)
NLR Total Chi-square P value R value
<7 7-9 >9
0.78-3.53 10 (9.52) 14 (13.33) 2 (1.90) 26 (24.76)
>3.53 2 (1.90) 25 (49.52) 52 (49.52) 79 (75.24) 37.54 <0.001 0.57
Total 12 (11.43) 39 (37.14) 54 (51.43) 105 (100)

Figure 1: Association of HbA1c with absolute Figure 2: Association of HbA1c with absolute
neutrophil count. lymphocyte count.

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 Varma S et al. Int J Adv Med. 2021 Jul;8(7):952-956

DISCUSSION diabetic patients. In our study we found a significant

positive correlation between NLR and glycemic control.
Current study depicts moderately positive correlation Increased NLR is associated with elevated HbA1c and
between NLR and HbA1c. Several studies have observed poor glycemic control. Type 2 DM patients with raised
a link between NLR and insulin resistance, metabolic NLR should be evaluated for cardiovascular, renal and
syndrome and atherosclerosis. To our knowledge, there ocular complications of diabetes.NLR may be useful as
are only few studies directly correlating NLR and an easily measurable, noninvasive, widely available and
glycemic control. Gender comparison in current study cost-effective parameter for the disease monitoring tool
showed that males are more prevalent than females. In
ICMR Indian study conducted by Vishwanathan et al the
prevalence of type 2 diabetes mellitus was higher in during follow up of diabetic patients. Moreover, NLR can
males (46.7%) as compared to females.8 But in study be used as a population screening, disease and drug
conducted by Singh et al found that prevalence of type 2 monitoring tool on large scale basis. NLR can be used as
diabetes mellitus were higher in females (9.91%) as marker of diabetic control in addition to HbA1C in type 2
compared to males (6.79%), which is contrary to our diabetic subjects.
study.9
Funding: No funding sources
In order to determine inflammation in various cardiac and Conflict of interest: None declared
non-cardiac disorders, neutrophil lymphocyte ratio NLR Ethical approval: The study was approved by the
is a potential marker because of its superior predictive, Institutional Ethics Committee
diagnostic and differentiating ability compared to total
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patients. Pak J Med Sci. 2017;33(6):1366-70. neutrophil lymphocyte ratio with HbA1c in patients
of type 2 diabetes mellitus. Int J Adv Med
2021;8:952-6.

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