Introduction
Diabetes Mellitus (DM), chronic metabolic disease with increasing prevalence. In 2019, 463 million were affected with diabetes and this may be projected to increase 700 million by 2045 according to International Diabetes Federation (IDF). 1, 2 The micro-vascular complications of diabetes mellitus such as diabetic nephropathy, retinopathy, and neuropathy and macro-vascular diseases such as peripheral vascular diseases, stroke and cardiovascular diseases.3
The inflammatory mediators play a significant role in diabetes pathophysiology. These inflammatory mediators may inhibit β-cell function, promote apoptosis, and finally leads to insulin resistance.4 The inflammatory markers released from blood was found to be associated with diabetes mellitus.
Mean platelet volume (MPV), may indicate the prognosis of many inflammatory diseases.5 Red blood cell distribution width (RDW) is associated with CVDs, tumors and sepsis. Recently, a few studies documented that NLR and RLR may serve as a systemic marker in inflammatory conditions like cardiovascular disease, metabolic syndrome and malignancies. 6, 7 These are novel, available, and less expensive markers of Inflammation. White blood cell (WBC) count (Total and differential) is an indicator of inflammation and it is a cost-effective and routine investigation. NLR, emerged as a novel alternative marker for inflammation. 8 A study by Turkmen et al. reported that platelets may be involved in atherosclerosis by secreting proinflammatory cytokines and their bounding to endothelial cells.9 Platelets secretes thromboxanes, which may accelerate the inflammatory response in patients with increased platelets. 10, 11
The promising ratios NLR and PLR conveyed a systematic inflammatory response and has been evidenced as predictive and prognostic factors for DM and the related complications.12, 13 In this study, we evaluated NLR and PLR in T2DM patients.
Materials and Methods
This prospective case-control study was conducted in SRVS Government Medical College, Shivpuri, Madhya Pradesh, India. In this study, a total of 220 subjects were involved, among them 110 were T2DM patients were cases and 110 healthy subjects were controls. Among the 110 cases, 65 were males 45 were females. In controls, 70 were males and 40 were females. Institutional ethics committee approval is obtained for this study. Demographic details, physical and clinical examination were done for all the study subjects. Patients with cardiovascular diseases, thyroid diseases, liver disease, pregnant women were excluded from the study.
Under aseptic conditions, five ml of fasting venous blood samples were collected from each study participant and aliquoted into plain (3ml) and EDTA (2 ml) tubes and allowed to clot and centrifuged at 3000 rpm for 10 minutes. The obtained serum sample was used for the estimation of fasting and post-prandial glucose, renal profile [serum urea, creatinine and uric acid], lipid profile [serum total cholesterol, triglycerides, HDLC, LDLC (calculated) and VLDL (calculated)] using commercially available autoanalyzer kits. Whole blood sample was used for the Complete Blood Count (CBC) in EDTA vials. NLR and PLR were calculated. Whole blood sample was used for the estimation of HbA1c (Immunoturbidimetry). BMI was calculated.
Results
In this study, mean age 60.2±4.2 yrs, BMI 27.1±2.4 (kg/m2), Systolic blood pressure (SBP) 132.1±12.3 mmHg, Diastolic blood pressure (DBP) 90.2±10.5 mmHg, fasting blood sugar (FBS) 169.7±19.3 mg/dl, Post-Prandial blood sugar 238.1±39.5 mg/dl, HbA1c 7.9±0.8 %, Serum Urea 36.1±7.1 mg/dl, Creatinine 1.0±0.3 mg/dl, Serum uric acid (UA) 6.5±2.3 mg/dl, Serum Total Cholesterol 241.1±30.5 mg/dl, Serum Triglycerides 170.0±16.2 mg/dl, Serum LDLC 176.4±35.2 mg/dl, VLDL 34.1±3.2 mg/dl, Lymphocytes 17.2±4.1 %, NLR 6.7±2.3 and PLR 19.1±6.9 were significantly increased in T2DM cases whereas HDLC 30.7±3.9 mg/dl was significantly decreased in T2DM cases as indicated in Table 1.
Table 1
Comparison of Baseline, Biochemical and Haematological Parameters between T2DM cases and Healthy controls
Discussion
In this study, NLR and PLR were increased in patients of T2DM than the healthy controls. WBC count and its subtypes serves as inflammatory markers. NLR, a marker of inflammation that reflects a counterbalance between two complementary components of the immune system; Neutrophils, being the active, non-specific mediator of inflammation, forming the 1st line of defense, whereas lymphocytes acting as the protective or regulatory component of inflammation. 12 Platelets can interact with various cell types, including endothelial cells, T-lymphocytes, neutrophils, and mononuclear phagocytes. It has been reported that chronic inflammation may contribute to the development of atherosclerosis. Besides, PLR was found to be higher in some inflammatory conditions. 14
Studies have indicated that inflammatory markers, such as neutrophilia and lymphocytopenia, serves as independent markers of many diseases, especially complications of DM. 15, 16 Study by Rahar S et al. reported, NLR is a novel, inexpensive marker and may be used to measure inflammation in diabetes. 17 Study by Duman TT et al, reported that elevated NLR may be used as a marker of diabetic control in addition to HbA1c in T2DM subjects. 18 Yet, another study by Walaa H. Mohammad et al. reported that, NLR may serve an independent predictor of carotid artery intima media thickness (cIMT) and albuminuria in diabetic patients with micro and macrovascular complications. Therefore, NLR may serve as readily accessible marker of vascular complications of diabetes. 19
Similarly, Fawwad et al. also found NLR to be an important predictor of microvascular complications in subjects with T2DM.20 Study by A. Velayutharaj et al. reported WBC count is one of the markers of subclinical inflammation. In diabetes, due to the presence of low-grade inflammation, the white cell count, NLR and hsCRP were increased. Therefore, by assessing NLR will be useful in T2DM patients to control future vascular risk events. 21
PLR is also a novel inflammatory biomarker used as prognostic factor in various diseases. Abdelaziz et al. observed a higher PLR in subjects with T2DM with macroalbuminuria in comparison to those with microalbuminuria and normoalbuminuria.22 Akbas et al. and Alsayyad et al. also had similar observations. 23, 24
Conclusion
The present study results may conclude that increased NLR and PLR may be useful as a marker of inflammation in T2DM. These are easy to calculate from CBC, which is almost a routine investigation. These may serve as an alternative choice to other costly inflammatory markers. Further, studies are recommended with large sample size.
