Competing risks analysis for neutrophil to lymphocyte ratio as a predictor of diabetic retinopathy incidence in the Scottish population

Elevated blood glucose levels are associated with the progression of brain hypometabolism, and HDL-C and APOE4 add to this association

Background

Brain glucose hypometabolism has consistently been found in neurodegenerative disorders, including Alzheimer's disease (AD). High blood glucose and HDL cholesterol (HDL-C) levels have also been linked to neurodegeneration and AD. However, there is limited understanding of the relationships between dementia-related risk factors in the brain and blood.

Methods

A linear mixed model was used to examine the relationship between blood glucose and HDL-C levels and the progression of brain hypometabolism, adjusting for APOE4 and other clinical covariates. The hypometabolic convergence index (HCI) was measured by fluorodeoxyglucose-18 (FDG) positron emission tomography (PET) in participants from the Alzheimer's Disease Neuroimaging Initiative (ADNI). Data visualizations were generated to understand the joint effects of plasma glucose, HDL-C, and APOE4 on HCI.

Results

There were 336 individuals (781 observations), of whom 22.62% had AD. The majority were male (63.98%) and of white race, and 48.51% were carriers of APOE4. Over time, high blood glucose level was associated with the progression of brain glucose hypometabolism (β=0.33, 95% CI: 0.02, 0.64, p<0.05). A high plasma HDL-C level (β=1.22, 95% CI: 0.09, 2.35, p<0.05), more study visits (β=1.67, 95% CI: 1.37, 1.98, p<0.001), and being an APOE4 allele carrier (β=1.29, 95% CI: 0.15, 2.42, p<0.05) were also significant predictors of brain hypometabolism progression. APOE4 carrier status and number of visits account for the largest proportion of the variance from the fixed effects model. Random effects due to participant characteristics and fixed effects together accounted for 95.2% of the model variance. Subgroup analysis revealed that these effects were observed only in those without AD.

Conclusion

High plasma glucose levels facilitated the progression of brain hypometabolism. The effect was more prominent in the APOE4 double-carriers with elevated HDL-C. Elevated blood glucose may reflect systemic insulin resistance, which could impair brain glucose uptake, resulting in brain hypometabolism. Controlling blood glucose and HDL-C levels in APOE4 carriers may improve brain metabolism, potentially delaying the onset of dementia.

Neutrophil-to-lymphocyte ratio in type 2 diabetes patients combined with Lower Extremity Peripheral Artery Disease

Objective

This study explored the utility of NLR (neutrophil-to-lymphocyte ratio) as a marker to predict Lower Extremity Peripheral Artery Disease (PAD) in the Chinese population, as well as to assess its consistency and diagnostic value with digital subtraction angiography.

Methods

Patients were distributed into three groups according to the angiography in lower limb arterial: group L1, plaque with no stenosis; group L2, plaque with luminal stenosis and group L3, total vascular occlusion. Changes in the neutrophil-to-lymphocyte ratio were documented and compared among groups.

Results

Compared to group L1, NLR was significantly increased in L2 (1.76 vs 2.35, p=0.037) and L3 (1.76 vs 3.60, p<0.001), with a gradual decrease in ABI (Ankle-Brachial Index, 1.11 vs 1.02 vs 0.94, p<0.001). Those older patients with higher prevalence of hypertension (p=0.002), obesity (p=0.032), or reduced high-density lipoprotein cholesterol (p=0.020) were more likely to develop PAD; higher glycosylated hemoglobin (p=0.045), low-density lipoprotein cholesterol (p=0.006), and systolic blood pressure (p<0.001) levels led to a greater tendency to suffer stenosis or even occlusion; the probability of severe stenosis (>70%) increased to 2.075 times for every 1 increase in NLR, while it was 46.8% for every 0.1 increase in ABI. The optimal NLR cut-off value to predict severe stenosis in PAD was 2.73. Receiver operating characteristic curve analysis of the inflammatory biomarkers and severe stenosis prediction displayed an area under the curve of 0.81.

Conclusion

NLR could serve as a new noninvasive and accurate marker in predicting PAD.

The association of inflammatory biomarkers with clinical outcomes in diabetic retinopathy participants: data from NHANES 2009-2018

OBJECTIVE

The aim of this study was to assess the association of neutrophil lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), and system inflammation response index (SIRI) with the all-cause mortality and diabetes-cardiovascular mortality in participants with diabetic retinopathy (DR).

METHODS

A total of 572 participants with DR from NHANES were included, and divided into survival group (n = 440) and all-cause death group (n = 132). NLR = neutrophil count/lymphocyte count, MLR = monocyte count/lymphocyte count, SIRI = (neutrophil count × monocyte count)/lymphocyte count. We utilized the NHANES Public-Use Linked Mortality File through April 26, 2022, to determine mortality status. Diabetes-cardiovascular death was defined as death resulting from heart disease, cerebrovascular disease, or diabetes mellitus. The Spearson Correlation Analysis, Kaplan-Meier curves, Cox proportional hazards regression models, Restricted cubic spline plots and Decision Curve Analysis were used.

RESULTS

The all-cause mortality and diabetes-cardiovascular mortality were significantly higher in NLR ≥ 1.516, MLR ≥ 0.309, SIRI ≥ 0.756, and NLR + MLR + SIRI subgroups than NLR < 1.516, MLR < 0.309, SIRI < 0.756 subgroups, and other participants except NLR + MLR + SIRI (all P < 0.05). The HR of NLR, MLR, SIRI, NLR + MLR + SIRI for all-cause mortality were 1.979(1.13-3.468), 1.850(1.279-2.676), 1.821(1.096-3.025), 1.871(1.296-2.703), respectively. The hazard ratio of NLR, MLR, SIRI, NLR + MLR + SIRI for diabetes-cardiovascular mortality were 2.602(1.028-6.591), 2.673(1.483-4.818), 2.001(0.898-4.459), 2.554(1.426-4.575), respectively. In the restricted cubic spline plots, the relationship between NLR, MLR, SIRI and HR of all-cause mortality and diabetes-cardiovascular mortality was overall as "J" shaped. In both age < 60 and age > 60 years participants, the all-cause mortality and diabetes-cardiovascular mortality were significantly higher in NLR ≥ 1.516, MLR ≥ 0.309, SIRI ≥ 0.756, and NLR + MLR + SIRI subgroups than NLR < 1.516, MLR < 0.309, SIRI < 0.756 subgroups, and other participants except NLR + MLR + SIRI (all P < 0.05).

CONCLUSION

NLR, MLR, and SIRI may be three independent prognostic predictors for all-cause mortality and diabetes-cardiovascular mortality among individuals with DR. In practical clinical applications, combining NLR, MLR, and SIRI may enhance the prediction of all-cause mortality and diabetes-cardiovascular mortality in DR.

Advances in Structural and Functional Retinal Imaging and Biomarkers for Early Detection of Diabetic Retinopathy

Diabetic retinopathy (DR), a vision-threatening microvascular complication of diabetes mellitus (DM), is a leading cause of blindness worldwide that requires early detection and intervention. However, diagnosing DR early remains challenging due to the subtle nature of initial pathological changes. This review explores developments in multimodal imaging and functional tests for early DR detection. Where conventional color fundus photography is limited in the field of view and resolution, advanced quantitative analysis of retinal vessel traits such as retinal microvascular caliber, tortuosity, and fractal dimension (FD) can provide additional prognostic value. Optical coherence tomography (OCT) has also emerged as a reliable structural imaging tool for assessing retinal and choroidal neurodegenerative changes, which show potential as early DR biomarkers. Optical coherence tomography angiography (OCTA) enables the evaluation of vascular perfusion and the contours of the foveal avascular zone (FAZ), providing valuable insights into early retinal and choroidal vascular changes. Functional tests, including multifocal electroretinography (mfERG), visual evoked potential (VEP), multifocal pupillographic objective perimetry (mfPOP), microperimetry, and contrast sensitivity (CS), offer complementary data on early functional deficits in DR. More importantly, combining structural and functional imaging data may facilitate earlier detection of DR and targeted management strategies based on disease progression. Artificial intelligence (AI) techniques show promise for automated lesion detection, risk stratification, and biomarker discovery from various imaging data. Additionally, hematological parameters, such as neutrophil-lymphocyte ratio (NLR) and neutrophil extracellular traps (NETs), may be useful in predicting DR risk and progression. Although current methods can detect early DR, there is still a need for further research and development of reliable, cost-effective methods for large-scale screening and monitoring of individuals with DM.

The L-shape relationship between hemoglobin, albumin, lymphocyte, platelet score and the risk of diabetic retinopathy in the US population

Background

The primary aim of this study was to investigate the correlation between diabetic retinopathy (DR) and the HALP score (hemoglobin, albumin, lymphocyte, and platelet) in individuals with diabetes within the United States population.

Methods

This cross-sectional investigation was based on the National Health and Nutrition Examination Survey (NHANES) database from 2003-2018. The following module calculated the HALP score: HALP score = [lymphocytes (/L) × hemoglobin (g/L) × albumin (g/L)]/platelets (/L). By performing the receiver operating characteristic (ROC) analysis, the optimal cutoff value of HALP was ascertained. Restricted cubic splines (RCS), multivariable logistic regression analysis, sensitivity analysis, and subgroup analysis were conducted to evaluate the effect of the HALP score on DR patients. Finally, the decision curve analysis (DCA) and clinical impact curve (CIC) were conducted to estimate the predictive power and clinical utility of the HALP score with clinical indicators.

Results

According to the cutoff value (42.9) determined by the ROC curve, the participants were stratified into a lower HALP group (HALPlow) and a higher HALP group (HALPhigh). An L-shaped relationship between HALP score and DR risk was presented in the RCS model (P for nonlinearity <0.001). The DR risk sharply decreased with the increase of HALP, and the decline reached a plateau when HALP was more than 42.9. After fully adjustment, the multivariate logistic regression analysis found that HALPlow was an independent risk factor for DR (OR = 1.363, 95% CI: 1.111-1.671, P < 0.001). Besides, sensitivity analysis showed consistent results. Furthermore, the combination of HALP score and clinical indicators demonstrated predictive power and clinical utility, as shown by the ROC curve, DCA, and CIC.

Conclusion

The HALP score has an L-shaped correlation with the risk of DR, and thus, the HALP score may contribute to the timely intervention of diabetes patients.

Association of neutrophil-lymphocyte ratio with all-cause and cardiovascular mortality in US adults with diabetes and prediabetes: a prospective cohort study

BACKGROUND

The neutrophil-lymphocyte ratio (NLR) is a novel hematological parameter to assess systemic inflammation. Prior investigations have indicated that an increased NLR may serve as a potential marker for pathological states such as cancer and atherosclerosis. However, there exists a dearth of research investigating the correlation between NLR levels and mortality in individuals with diabetes and prediabetes. Consequently, this study aims to examine the connection between NLR and all-cause as well as cardiovascular mortality in the population of the United States (US) with hyperglycemia status.

METHODS

Data were collected from a total of 20,270 eligible individuals enrolled for analysis, spanning ten cycles of the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018. The subjects were categorized into three groups based on tertiles of NLR levels. The association of NLR with both all-cause and cardiovascular mortality was evaluated using Kaplan-Meier curves and Cox proportional hazards regression models. Restricted cubic splines were used to visualize the nonlinear relationship between NLR levels and all-cause and cardiovascular mortality in subjects with diabetes after accounting for all relevant factors.

RESULTS

Over a median follow-up period of 8.6 years, a total of 1909 subjects with diabetes died, with 671 deaths attributed to cardiovascular disease (CVD). And over a period of 8.46 years, 1974 subjects with prediabetes died, with 616 cases due to CVD. The multivariable-adjusted hazard ratios (HRs) comparing high to low tertile of NLR in diabetes subjects were found to be 1.37 (95% CI, 1.19-1.58) for all-cause mortality and 1.63 (95% CI, 1.29-2.05) for CVD mortality. And the correlation between high to low NLR tertile and heightened susceptibility to mortality from any cause (HR, 1.21; 95% CI, 1.03-1.43) and CVD mortality (HR, 1.49; 95% CI, 1.08-2.04) remained statistically significant (both p-values for trend < 0.05) in prediabetes subjects. The 10-year cumulative survival probability was determined to be 70.34%, 84.65% for all-cause events, and 86.21%, 94.54% for cardiovascular events in top NLR tertile of diabetes and prediabetes individuals, respectively. Furthermore, each incremental unit in the absolute value of NLR was associated with a 16%, 12% increase in all-cause mortality and a 25%, 24% increase in cardiovascular mortality among diabetes and prediabetes individuals, respectively.

CONCLUSIONS

The findings of this prospective cohort study conducted in the US indicate a positive association of elevated NLR levels with heightened risks of overall and cardiovascular mortality among adults with diabetes and prediabetes. However, potential confounding factors for NLR and the challenge of monitoring NLR's fluctuations over time should be further focused.

Diabetic retinopathy related homeostatic dysregulation and its association with mortality among diabetes patients: A cohort study from NHANES

AIMS

To develop a metric termed the diabetic retinopathy-related homeostatic dysregulation (DRHD) value, and estimate its association with future risk of mortality in individuals with type 2 diabetes.

METHODS

With the data of the NHANES, the biomarkers associated with DR were identified from 40 clinical parameters using LASSO regression. Subsequently, the DRHD value was constructed utilizing the Mahalanobis distance approach. In the retrospective cohortof 6420 type 2 diabetes patients, we estimated the associations between DRHD values and mortality related to all-cause, cardiovascular disease (CVD) and diabetes-specific causes using Cox proportional hazards regression models.

RESULTS

A set of 14 biomarkers associated with DR was identified for the construction of DRHD value. During an average of 8 years of follow-up, the multivariable-adjusted HRs and corresponding 95 % CIs for the highest quartiles of DRHD values were 2.04 (1.76, 2.37), 2.32 (1.78, 3.01), and 2.29 (1.72, 3.04) for all-cause, CVD and diabetes-specific mortality, respectively. Furthermore, we developed a web-based calculator for the DRHD value to enhance its accessibility and usability (https://dzwxl-drhd.streamlit.app/).

CONCLUSIONS

Our study constructed the DRHD value as a measure to assess homeostatic dysregulation among individuals with type 2 diabetes. The DRHD values exhibited potential as a prognostic indicator for retinopathy and for mortality in patients affected by type 2 diabetes.

Relationship between neutrophil to lymphocyte ratio and diabetic peripheral neuropathy: a systematic review and meta-analysis

BACKGROUND

The present study aims to review the existing scientific literature on the role of neutrophil to lymphocyte ratio (NLR) in diabetic peripheral neuropathy (DPN) to perform a meta-analysis on the available data.

METHODS

The electronic repositories Web of Science, PubMed, and Scopus were systematically explored starting from their establishment up until June 9, 2022.

RESULTS

Fifteen articles were included in the meta-analysis after multiple screening according to the PRISMA guidelines. The combined findings indicated that individuals with DPN had higher levels of NLR in comparison to those without DPN (SMD = 0.61; CI 95% = 0.40-0.81, p < 0.001). In the subgroup assessment based on ethnicity, it was observed that diabetic patients with DPN exhibited increased NLR levels in contrast to those without DPN in studies conducted in India (SMD = 1.30; CI 95% = 0.37-2.24, p = 0.006) and East Asia (SMD = 0.53; CI 95% = 0.34-0.73, p < 0.001) but not in studies conducted in Turkey (SMD = 0.30; CI 95% = - 0.06-0.67, p = 0.104) and Egypt (SMD = 0.34; CI 95% = -0.14-0.82, p = 0.165). The pooled sensitivity of NLR was 0.67 (95% CI = 0.49-0.81), and the pooled specificity was 0.70 (95% CI, 0.56-0.81). The pooled positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio (DOR) of NLR were 2.30 (95% CI = 1.71-3.09), 0.45 (95%CI = 0.30-0.67), and 5.06 (95% CI = 3.16-8.12), respectively.

CONCLUSION

NLR serves as a distinct marker of inflammation, and its rise in cases of DPN suggests an immune system imbalance playing a role in the development of the disease.