Neutrophil to lymphocyte ratio explained

In medicine neutrophil to lymphocyte ratio (NLR) is used to show there is inflammation in the body. It is calculated by dividing the number of neutrophils by number of lymphocytes, usually from peripheral blood sample,^[1] but sometimes also from cells that infiltrate tissue, such as tumor.^[2] Recently Lymphocyte Monocyte ratio (LMR) has also been studied as a marker of inflammation including tuberculosis and various cancers.

Uses

Prognosis of cardiovascular diseases

Higher NLR contributes to predicting mortality rates (prognostic marker) in patients undergoing certain medical procedures, such as angiography or cardiac revascularization.^[3]

Prognostic marker in cancer

Increased NLR is associated with poor prognosis of various cancers,^[4] such as esophageal,^[5] liver,^[6] ovarian,^[7] pancreatic,^[8] prostate^[9] and stomach cancer.^[10]

Prognostic marker in COVID-19

NLR can be used as a prognostic marker for COVID-19 given the significant difference of NLR between those died and recovered from COVID-19.^[11]

Reference values

A 2017 study found that the normal NLR range for healthy adults is between 0.78 and 3.53.^[12]

History

Neutrophil to Lymphocyte ratio was first demonstrated as useful parameter after a correlation of a relationship between the neutrophil lymphocyte ratio to reactions of the immune response was noted. A study in 2001 was conducted by the Department of Anaesthesiology and Intensive Care Medicine, St. Elizabeth Cancer Institute in Bratislava by Zahorec which suggested the routine used of the ratio as a stress factor in clinical ICU practice in intervals of 6-12 and 24 hours.^[13]

The first study to demonstrate that pre-therapeutic NLR can be used as a predictor of chemotherapy sensitivity to thoracic esophageal cancer was demonstrated by Hiroshi Sato, Yasuhiro Tsubosa, and Tatsuyuki Kawano in a 2012 study published in World Journal of Surgery journal.^[14]

Further reading

• Socorro Faria . Sara . Fernandes Jr . Paulo César . Barbosa Silva . Marcelo José . Lima . Vladmir C . Fontes . Wagner . Freitas-Junior . Ruffo . Eterovic . Agda Karina . Forget . Patrice . The neutrophil-to-lymphocyte ratio: a narrative review . ecancermedicalscience . 12 December 2016 . 10 . 702 . 10.3332/ecancer.2016.702 . 28105073 . 5221645. for risk stratification for breast cancer
• Tang . Xingxing . Du . Peng . Yang . Yong . 4910519 . The clinical use of neutrophil-to-lymphocyte ratio in bladder cancer patients: a systematic review and meta-analysis . International Journal of Clinical Oncology . 27 July 2017 . 22 . 5 . 817–825 . 10.1007/s10147-017-1171-5 . 28752351.
• Huang . Qi-tao . Zhou . Lin . Zeng . Wen-juan . Ma . Qian-qian . Wang . Wei . Zhong . Mei . Yu . Yan-hong . Prognostic Significance of Neutrophil-to-Lymphocyte Ratio in Ovarian Cancer: A Systematic Review and Meta-Analysis of Observational Studies . Cellular Physiology and Biochemistry . 2017 . 41 . 6 . 2411–2418 . 10.1159/000475911 . 28467978. free .
• Yin . Xiaotao . Xiao . Yi . Li . Fanglong . Qi . Siyong . Yin . Zhaoyang . Gao . Jiangping . Prognostic Role of Neutrophil-to-Lymphocyte Ratio in Prostate Cancer . Medicine . January 2016 . 95 . 3 . e2544 . 10.1097/MD.0000000000002544. 26817900 . 4998274 .
• Azab . Basem . Camacho-Rivera . Marlene . Taioli . Emanuela . Zhang . Jian . Average Values and Racial Differences of Neutrophil Lymphocyte Ratio among a Nationally Representative Sample of United States Subjects . PLOS ONE . 6 November 2014 . 9 . 11 . e112361 . 10.1371/journal.pone.0112361 . 25375150. 4223021 . 2014PLoSO...9k2361A . free .

Notes and References

1. Wang X . Neutrophil to lymphocyte ratio in relation to risk of all-cause mortality and cardiovascular events among patients undergoing angiography or cardiac revascularization : A meta-analysis of observational studies. Atherosclerosis . Mar 2014 . 24681815 . 10.1016/j.atherosclerosis.2014.03.003 . 234 . 1 . 206–213.
2. Wang J . The clinical significance of tumor-infiltrating neutrophils and neutrophil-to-CD8+lymphocyte ratio in patients with resectable esophageal squamous cell carcinoma . J. Transl. Med. . 12 . Jan 2014 . 24397835 . 10.1186/1479-5876-12-7 . 3895663 . 7 . free .
3. Wang X . Neutrophil to lymphocyte ratio in relation to risk of all-cause mortality and cardiovascular events among patients undergoing angiography or cardiac revascularization : A meta-analysis of observational studies. Atherosclerosis . Mar 2014 . 24681815 . 10.1016/j.atherosclerosis.2014.03.003 . 234 . 1 . 206–213.
4. 24875653 . 10.1093/jnci/dju124 . 106 . 6 . Prognostic role of neutrophil-to-lymphocyte ratio in solid tumors: a systematic review and meta-analysis . 2014 . J. Natl. Cancer Inst. . dju124 . Templeton AJ, McNamara MG, Šeruga B, Vera-Badillo FE, Aneja P, Ocaña A, Leibowitz-Amit R, Sonpavde G, Knox JJ, Tran B, Tannock IF, Amir E . free .
5. Pirozzolo G, Gisbertz SS, Castoro C, van Berge Henegouwen MI, Scarpa M . Neutrophil-to-lymphocyte ratio as prognostic marker in esophageal cancer: a systematic review and meta-analysis . J Thorac Dis . 11 . 7 . 3136–3145 . July 2019 . 31463142 . 6688029 . 10.21037/jtd.2019.07.30 . free .
6. Wang Y, Peng C, Cheng Z, Wang X, Wu L, Li J, Huang C, Guo Q, Cai H . The prognostic significance of preoperative neutrophil-lymphocyte ratio in patients with hepatocellular carcinoma receiving hepatectomy: A systematic review and meta-analysis . Int J Surg . 55 . 73–80 . July 2018 . 29787804 . 10.1016/j.ijsu.2018.05.022 . 44102006 .
7. Yin X, Wu L, Yang H, Yang H . Prognostic significance of neutrophil-lymphocyte ratio (NLR) in patients with ovarian cancer: A systematic review and meta-analysis . Medicine (Baltimore) . 98 . 45 . e17475 . November 2019 . 31702609 . 6855616 . 10.1097/MD.0000000000017475 .
8. Yang JJ, Hu ZG, Shi WX, Deng T, He SQ, Yuan SG . Prognostic significance of neutrophil to lymphocyte ratio in pancreatic cancer: a meta-analysis . World J Gastroenterol . 21 . 9 . 2807–15 . March 2015 . 25759553 . 4351235 . 10.3748/wjg.v21.i9.2807 . free .
9. Guo J, Fang J, Huang X, Liu Y, Yuan Y, Zhang X, Zou C, Xiao K, Wang J . Prognostic role of neutrophil to lymphocyte ratio and platelet to lymphocyte ratio in prostate cancer: A meta-analysis of results from multivariate analysis . Int J Surg . 60 . 216–223 . December 2018 . 30468905 . 10.1016/j.ijsu.2018.11.020 . free .
10. Szor DJ, Dias AR, Pereira MA, Ramos MF, Zilberstein B, Cecconello I, Ribeiro-Júnior U . Prognostic Role of Neutrophil/Lymphocyte Ratio in Resected Gastric Cancer: A Systematic Review and Meta-analysis . Clinics (Sao Paulo) . 73 . e360 . 2018 . 29924187 . 5996440 . 10.6061/clinics/2018/e360 .
11. Eslamijouybari M, Heydari K, Maleki, Moosazadeh M, Hedayatizadeh-Omran A, Vahedi L . Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in COVID-19 Patients and Control Group and Relationship with Disease Prognosis . Caspian J Intern Med . 11. Supplement 1. 2020 . 531–535 . 33425271 . 7780872 .
12. Forget. Patrice. What is the normal value of the neutrophil-to-lymphocyte ratio?. BMC Research Notes. 10. 1. 12. 5217256. 2017. 28057051. 10.1186/s13104-016-2335-5 . free .
13. Ratio of neutrophil to lymphocyte counts--rapid and simple parameter of systemic inflammation and stress in critically ill.. Bratislavske Lekarske Listy. 102. 1. 5–14. Bratisl Lek Listy. 2001. 11723675. Zahorec. R..
14. Correlation Between the Pretherapeutic Neutrophil to Lymphocyte Ratio and the Pathologic Response to Neoadjuvant Chemotherapy in Patients With Advanced Esophageal Cancer. World Journal of Surgery. 36. 3. 617–622. March 2012. 10.1007/s00268-011-1411-1. 22223293. Sato. Hiroshi. Tsubosa. Yasuhiro. Kawano. Tatsuyuki. 13393640.