Please use this identifier to cite or link to this item:
Appears in Collections:Computing Science and Mathematics Journal Articles
Peer Review Status: Refereed
Title: Competing risks analysis for neutrophil to lymphocyte ratio as a predictor of diabetic retinopathy incidence in the Scottish population
Author(s): Rajendrakumar, Aravind Lathika
Hapca, Simona M
Nair, Anand Thakarakkattil Narayanan
Huang, Yu
Chourasia, Mehul Kumar
Kwan, Ryan Shun-Yuen
Nangia, Charvi
Siddiqui, Moneeza K
Vijayaraghavan, Prathiba
Matthew, Shona Z
Leese, Graham P
Mohan, Viswanathan
Pearson, Ewan R
Doney, Alexander S F
Palmer, Colin N A
Contact Email:
Keywords: Diabetic retinopathy
Neutrophil-lymphocyte ration
Competing risks
Subdistribution hazard ration
Cause-specific hazard ratio
Issue Date: 10-Aug-2023
Date Deposited: 22-Sep-2023
Citation: Rajendrakumar AL, Hapca SM, Nair ATN, Huang Y, Chourasia MK, Kwan RS, Nangia C, Siddiqui MK, Vijayaraghavan P, Matthew SZ, Leese GP, Mohan V, Pearson ER, Doney ASF & Palmer CNA (2023) Competing risks analysis for neutrophil to lymphocyte ratio as a predictor of diabetic retinopathy incidence in the Scottish population. <i>BMC Medicine</i>, 21, Art. No.: 304.
Abstract: Background Diabetic retinopathy (DR) is a major sight-threatening microvascular complication in individuals with diabetes. Systemic inflammation combined with oxidative stress is thought to capture most of the complexities involved in the pathology of diabetic retinopathy. A high level of neutrophil–lymphocyte ratio (NLR) is an indicator of abnormal immune system activity. Current estimates of the association of NLR with diabetes and its complications are almost entirely derived from cross-sectional studies, suggesting that the nature of the reported association may be more diagnostic than prognostic. Therefore, in the present study, we examined the utility of NLR as a biomarker to predict the incidence of DR in the Scottish population. Methods The incidence of DR was defined as the time to the first diagnosis of R1 or above grade in the Scottish retinopathy grading scheme from type 2 diabetes diagnosis. The effect of NLR and its interactions were explored using a competing risks survival model adjusting for other risk factors and accounting for deaths. The Fine and Gray subdistribution hazard model (FGR) was used to predict the effect of NLR on the incidence of DR. Results We analysed data from 23,531 individuals with complete covariate information. At 10 years, 8416 (35.8%) had developed DR and 2989 (12.7%) were lost to competing events (death) without developing DR and 12,126 individuals did not have DR. The median (interquartile range) level of NLR was 2.04 (1.5 to 2.7). The optimal NLR cut-off value to predict retinopathy incidence was 3.04. After accounting for competing risks at 10 years, the cumulative incidence of DR and deaths without DR were 50.7% and 21.9%, respectively. NLR was associated with incident DR in both Cause-specific hazard (CSH = 1.63; 95% CI: 1.28–2.07) and FGR models the subdistribution hazard (sHR = 2.24; 95% CI: 1.70–2.94). Both age and HbA1c were found to modulate the association between NLR and the risk of DR. Conclusions The current study suggests that NLR has a promising potential to predict DR incidence in the Scottish population, especially in individuals less than 65 years and in those with well-controlled glycaemic status.
DOI Link: 10.1186/s12916-023-02976-7
Rights: Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Licence URL(s):

Files in This Item:
File Description SizeFormat 
s12916-023-02976-7.pdfFulltext - Published Version1.21 MBAdobe PDFView/Open

This item is protected by original copyright

A file in this item is licensed under a Creative Commons License Creative Commons

Items in the Repository are protected by copyright, with all rights reserved, unless otherwise indicated.

The metadata of the records in the Repository are available under the CC0 public domain dedication: No Rights Reserved

If you believe that any material held in STORRE infringes copyright, please contact providing details and we will remove the Work from public display in STORRE and investigate your claim.