The neutrophil–lymphocyte ratio as a risk factor for all-cause and cardiovascular mortality among individuals with diabetes: evidence from the National Health and Nutrition Examination Survey (NHANES) 2003–2016
Authors' conclusion
An elevated NLR is independently associated with increased all-cause and cardiovascular mortality in diabetes patients.
Study context
- Population
- Patients with diabetes from seven NHANES cycles (2003–2016); mortality from National Death Index records
- Participants
- 3,251 patients
- Exposure
- Higher neutrophil-lymphocyte ratio (NLR) vs lower NLR
- Outcome
- All-cause and cardiovascular mortality
- Follow-up
- Median 91 months (IQR 55-131 months)
Methodological detailsNHANES 2003–2016, weighted multivariable Cox regression, restricted cubic spline, maximally selected rank statistics cutoff, time-dependent ROC analysis
- NHANES 2003–2016
- Weighted multivariable Cox regression
- Restricted cubic spline
- Maximally selected rank statistics cutoff
- Time-dependent ROC analysis
Main finding
As reported in the abstract
median follow-up 91 months
Each group vs lower NLREstimate (95% CI)P value
Higher NLR
HR (all-cause mortality) 2.03(1.64–2.51)
P < 0.0001Higher NLR
HR (cardiovascular mortality) 2.76(1.84–4.14)
P < 0.0001- Deaths overall
- 896 (27.5%)
- Cardiovascular deaths
- 261 (8.0%)
- Noncardiovascular deaths
- 635 (19.5%)
- Restricted cubic spline (RCS): positive linear association of NLR with all-cause and cardiovascular mortality
- both p > 0.05 for nonlinearity
Observational data: associations, not effects.
Further findings
Subgroups by age, sex, smoking, drinking and hypertension
- Association consistent across subgroups; no significant interaction
- P for interaction > 0.05
Time-dependent ROC AUC of NLR, all-cause mortality (1-, 3-, 5-, 10-year)
- AUC 1-, 3-, 5-, 10-year
- 0.72, 0.66, 0.64, 0.64
Time-dependent ROC AUC of NLR, cardiovascular mortality (1-, 3-, 5-, 10-year)
- AUC 1-, 3-, 5-, 10-year
- 0.69, 0.71, 0.69 and 0.65
Original publication
The neutrophil–lymphocyte ratio as a risk factor for all-cause and cardiovascular mortality among individuals with diabetes: evidence from the NHANES 2003–2016. Cardiovasc Diabetol. Published 29 September 2023. doi:10.
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