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vol. 12
Clinical research

Vitamin D and inflammation: evaluation with neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio

Emin Murat Akbas
Adem Gungor
Adalet Ozcicek
Nergis Akbas
Seda Askin
Murat Polat

Arch Med Sci 2016; 12, 4: 721–727
Online publish date: 2016/07/01
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Hypovitaminosis D is a common and emerging health problem worldwide [1]. Vitamin D is an essential component of bone and mineral metabolism; its deficiency classically causes growth retardation, skeletal deformities in children, and osteomalacia and osteoporosis in adults. Moreover, vitamin D plays a role in diseases other than those of bone such as cardiovascular diseases, obesity, metabolic syndrome, insulin resistance, infection, allergy, cancers and autoimmune diseases [2–14].
Although there are studies that failed to find a relationship [10, 15–20], inflammatory cytokines such as C-reactive protein (CRP), tumor necrosis factor- (TNF-), and interleukin (IL)-6 were found to be inversely associated with vitamin D levels [21–25]. Additionally, there are studies suggesting that vitamin D deficiency is associated with elevated TNF-, IL-6, and CRP concentrations, which are correctable by supplementation [4, 26, 27].
Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were introduced as easily measured, reproducible, and inexpensive markers to determine inflammation. Neutrophil-to-lymphocyte ratio has been found to be associated with different types of malignancies, metabolic syndrome, infectious diseases, cardio vascular disease, end stage renal disease and other inflammatory diseases [28–38]. Also PLR has been found to be associated with different types of malignancies, cardiovascular disease and end stage renal disease [28, 37, 39–42].
The goal of this study was to investigate and evaluate the association between 25-hydroxy vitamin D (25(OH)D) and inflammation with the novel inflammatory markers NLR and PLR.

Material and methods

Study design, data collection and procedures

This study was performed retrospectively using Ataturk University Hospital database. The database was screened from 2008 until 2013. Results of the simultaneously performed measurements of 25(OH)D levels by competitive electrochemiluminescence protein binding assay (Cobas-601, Roche/Cobas Diagnostics, Tokyo, Japan); parathyroid hormone (PTH) levels by chemiluminescence assay (UniCel DXi 800 immunoassay system, Beckman Coulter, Fullerton CA, USA); albumin, calcium, phosphorus, alkaline phosphatase (ALP), and creatinine levels by spectrophotometric assay (AU5800 – Beckman Coulter, Beckman coulter, Mishima, Japan); and complete blood count (CBC) (Beckman Coulter, Fullerton CA, USA) were recorded. Patients whose ages were under 18 years, patients with primary hyperparathyroidism, high creatinine levels (creatinine > 1.2 mg/dl) and patients with abnormal lymphocyte (normal values: 1000–4800/mm3), platelet (normal values: 150 000–450 000/mm3) and neutrophil (normal values: 1500–8000/mm3) count values were excluded from the evaluation to exclude the effects of undesirable factors such as acute infection. In repeated applications, initial tests were recorded. Study participants’ age and gender were recorded. The data of 4120 patients who met the criteria were included in the study.
Neutrophil-to-lymphocyte ratio and PLR were calculated as the ratio of neutrophils to lymphocytes and platelets to lymphocytes respectively. Corrected calcium (C-calcium) was calculated by a standard formula: (C-calcium = total calcium + 0.8 × (4 – albumin)).
Patients were separated into groups according to aging stages (young adulthood (18–34 years), young middle-age (35–44 years), later middle age (45–64 years), early old age (65–74 years), middle old age (75–84 years), very old age (over 85 years)). Vitamin D status was classified as vitamin deficiency (< 20 ng/ml) and non-deficiency (> 20 ng/ml) according to Holick et al. [43].

Statistical analysis

Statistical analyses were carried out using the Statistical Package for Social Sciences, Windows version 15.0 (SPSS, Chicago, IL, USA). Descriptive statistics for each variable were determined. Results for continuous variables without normal distribution were presented as median (interquartile range (IQR)). Statistically significant differences between the groups were determined by the 2 test for categorical variables and the Mann-Whitney U test for continuous variables without normal distribution. Kruskal-Wallis analysis was used to compare means of several groups without normal distribution. Associations between the variables were explored using Spearman’s rho (for data that are not normally distributed). Binary logistic regression analysis was also performed to define variables associated with 25(OH)D. A p-value less than 0.05 was considered significant.


Baseline characteristics and laboratory data of patients according to aging stages are given in Table I. Briefly, while there were no significant differences between groups according to the sex distribution, there were statistically significant differences with respect to the following variables between groups: 25(OH)D, PTH, ALP, calcium, C-calcium, phosphorus, albumin, creatinine, WBC, PLR and NLR.
When patients were separated into two groups according to 25(OH)D levels (group 1 – 25(OH)D < 20 ng/ml; group 2 – 25(OH)D ≥ 20 ng/ml), while there were no significant differences between groups according to age, phosphorus and WBC, there were statistically significant differences between groups for the following variables: PTH, ALP, calcium, C-calcium, albumin, creatinine, PLR and NLR (Table II).
The correlations between 25(OH)D and several other parameters were tested using bivariate correlation analysis. As shown in Table III, 25(OH)D was significantly positively correlated with male sex, calcium, C-calcium, phosphorus, albumin, creatinine, and WBC, and negative correlated with age, PTH, ALP, PLR, and NLR.
We also performed logistic regression analysis to define the variables of 25(OH)D (Table IV). Age, sex, PTH, ALP, calcium, phosphorus, albumin, creatinine, NLR and PLR were included in this model. Sex (male), PTH, calcium, creatinine and PLR were found to be independent variables of 25(OH)D.


This was the first study evaluating the relationship between vitamin D deficiency and inflammation with the novel inflammatory markers NLR and PLR. There were three main findings of the present study. First, PLR and NLR were significantly higher in patients with lower 25(OH)D levels. Second, 25(OH)D levels were significantly correlated with PLR and NLR as well as age, male sex and PTH, ALP, calcium, phosphorus, albumin, and creatinine levels. Finally, PLR was found to be an independent predictor of 25(OH)D levels along with PTH, calcium, sex and creatinine.
Vitamin D insufficiency and deficiency are considered to be a global problem, affecting a large percentage of the population [1]. Although the association of vitamin D deficiency and many chronic inflammatory diseases has been described in the literature, there is not a clear consensus regarding the relationship between vitamin D and inflammatory markers [4–9, 15–24, 26, 27].
This relationship was studied with cross sectional studies and clinical trials. Amer et al. studied the association of 25(OH)D and CRP in 15 167 patients and observed a statistically significant inverse relation between 25(OH)D at levels < 21 ng/ml and CRP in a cross sectional study [21]. They reported that 25(OH)D at a level ≥ 21 ng/ml is associated with an increase in serum CRP. The authors concluded that the role of vitamin D supplementation to reduce inflammation might be beneficial only among those with a lower serum 25(OH)D. In several other cross sectional studies, low 25(OH)D levels were inversely correlated with inflammatory markers such as high-sensitivity C-reactive protein (hs-CRP), IL-6, TNF- and asymmetric dimethylarginine concentrations – a marker of endothelial dysfunction [22–25, 44]. Our study supports the findings of studies mentioned above and revealed an inverse association between 25(OH)D levels and the novel inflammatory markers NLR and PLR.
In contrast to these studies, several studies have found no association of 25(OH)D with inflammatory markers such as IL-6 and hs-CRP [15, 20]. Yildirim et al. studied the association of 25(OH)D with CRP, erythrocyte sedimentation rate and white blood cells (WBC) in the population with and without chronic kidney disease [16]. They could not find a significant relation between inflammatory markers and 25(OH)D levels. There was also no association between 25(OH)D levels and WBC in our study, while there were statistically significant relations between 25(OH)D levels and PLR and NLR. These findings can be attributed to the sensitivity of NLR and PLR. Moreover, PLR was found to be superior to NLR in terms of inflammation [28]. Also, PLR was superior to NLR in our study. While PLR was a predictor of 25(OH)D, this association was not seen with NLR in logistic regression analysis.
In addition to the cross-sectional studies, the association of 25(OH)D and inflammatory markers has been investigated in clinical trials and conflicting results have been reported. In a 12-week randomized controlled trial, Shab-Bidar et al. studied the association of 25(OH)D supplementation and inflammatory markers in patients receiving a vitamin D fortified drink (1000 IU/day 25(OH)D), compared with those receiving an unfortified drink [27]. Comparison of the changes of the variables revealed that a significant increase in serum 25(OH)D was accompanied by a significant decrease in TNF-, IL-6, hs-CRP, and serum amyloid A, and an increase in the anti-inflammatory cytokine IL-10. In another clinical trial, Dutta et al. randomized prediabetic individuals into three groups (25(OH)D < 30 ng/ml, receiving cholecalciferol; 25(OH)D < 30 ng/ml, receiving calcium carbonate; and 25(OH)D > 30 ng/ml, also receiving calcium carbonate) and followed them over 2 years [4]. At the end of the study, the authors reported improvement in glycemic status, insulin resistance and inflammation following an increase in serum 25(OH)D levels, in the 25(OH)D receiving group. A study performed by Timms et al. in a population free of known diabetes or major illness revealed that vitamin D insufficiency was associated with increased CRP, correctable by supplementation [26]. In contrast to those studies, some clinical trials have failed to demonstrate beneficial effects of 25(OH)D supplementation on inflammatory markers [17–19, 45].
The PLR and NLR were used to determine inflammation in different types of malignancies, metabolic syndrome, infectious diseases, cardiovascular disease, end stage renal disease and other inflammatory diseases [28–37, 39–42]. However, these easily measured, reproducible, and inexpensive markers are not used to determine the association of inflammation and vitamin D deficiency, on which there is no clear consensus yet. In this study, we observed that NLR and PLR levels tended to rise with increasing age. Additionally, without a significant effect of age, in the vitamin D deficient group compared to the non-deficient group, PLR and NLR were high.
There are studies that support an association of endothelial dysfunction and vitamin D deficiency and explain the relation between vitamin D deficiency and inflammation with endothelial dysfunction [22, 44, 46, 47]. Furthermore, there are studies revealing the relation of NLR, PLR and endothelial dysfunction [37, 48, 49]. In this perspective, NLR and PLR might be simple and inexpensive endothelial dysfunction markers in vitamin D deficiency.
Limitations of this study include the weakness of a retrospective study and the cross-sectional nature. Based on our data, seasonal differences, the role of obesity, and the reason for the patients’ admission to the hospital were not investigated. Despite the difficulties in using retrospective study results, the strength of our study is the large cohort of patients.
In conclusion, PLR and NLR were significantly higher in patients with lower 25(OH)D levels, and PLR was found to be an independent predictor of 25(OH)D levels. Our study demonstrated an inverse association of vitamin D levels and inflammation with these inexpensive and universally available markers. Further and larger studies are required to confirm our findings, and to better elucidate the relationship between vitamin D deficiency, NLR and PLR.

Conflict of interest

The authors declare no conflict of interest.


1. Mithal A, Wahl DA, Bonjour JP, et al. Global vitamin D status and determinants of hypovitaminosis D. Osteoporos Int 2009; 20: 1807-20.
2. Holick MF. Vitamin D: important for prevention of osteoporosis, cardiovascular heart disease, type 1 diabetes, autoimmune diseases, and some cancers. South Med J 2005; 98: 1024-7.
3. Pittas AG, Sun Q, Manson JE, Dawson-Hughes B, Hu FB. Plasma 25-hydroxyvitamin D concentration and risk of incident type 2 diabetes in women. Diabetes Care 2010; 33: 2021-3.
4. Dutta D, Mondal SA, Choudhuri S, et al. Vitamin-D supplementation in prediabetes reduced progression to type 2 diabetes and was associated with decreased insulin resistance and systemic inflammation: an open label randomized prospective study from Eastern India. Diabetes Res Clin Pract 2014; 103: e18-23.
5. Guillot X, Semerano L, Saidenberg-Kermanac’h N, Falgarone G, Boissier MC. Vitamin D and inflammation. Joint Bone Spine 2010; 77: 552-7.
6. Balden R, Selvamani A, Sohrabji F. Vitamin D deficiency exacerbates experimental stroke injury and dysregulates ischemia-induced inflammation in adult rats. Endocrinology 2012; 153: 2420-35.
7. Naesgaard PA, Leon de la Fuente RA, Nilsen ST, et al. Vitamin D predicts all-cause and cardiac mortality in females with suspected acute coronary syndrome: a comparison with brain natriuretic peptide and high-sensitivity C-reactive protein. Cardiol Res Pract 2013; 2013: 398034.
8. Choi YM, Kim WG, Kim TY, et al. Low levels of serum vitamin D3 are associated with autoimmune thyroid disease in pre-menopausal women. Thyroid 2014; 24: 655-61.
9. Pludowski P, Holick MF, Pilz S, et al. Vitamin D effects on musculoskeletal health, immunity, autoimmunity, cardiovascular disease, cancer, fertility, pregnancy, dementia and mortality – a review of recent evidence. Autoimmun Rev 2013; 12: 976-89.
10. Makariou S, Liberopoulos E, Florentin M, et al. The relationship of vitamin D with non-traditional risk factors for cardiovascular disease in subjects with metabolic syndrome. Arch Med Sci 2012; 8: 437-43.
11. Ertek S, Akgul E, Cicero AF, et al. 25-Hydroxy vitamin D levels and endothelial vasodilator function in normotensive women. Arch Med Sci 2012; 8: 47-52.
12. Caprio M, Mammi C, Rosano GM. Vitamin D: a novel player in endothelial function and dysfunction. Arch Med Sci 2012; 8: 4-5.
13. Michalska-Kasiczak M, Sahebkar A, Mikhailidis DP, et al. Analysis of vitamin D levels in patients with and without statin-associated myalgia. A systematic review and meta-analysis of 7 studies with 2420 patients. Int J Cardiol 2014; 178C: 111-6.
14. Demir M, Demir C, Keceoglu S. The relationship between vitamin D deficiency and coronary artery ectasia. Postep Kardiol Interw 2014; 10: 238-41.
15. Kim M, Na W, Sohn C. Correlation between vitamin D and cardiovascular disease predictors in overweight and obese Koreans. J Clin Biochem Nutr 2013; 52: 167-71.
16. Yildirim I, Hur E, Kokturk F. Inflammatory markers: C-reactive protein, erythrocyte sedimentation rate, and leukocyte count in vitamin D deficient patients with and without chronic kidney disease. Int J Endocrinol 2013; 2013: 802165.
17. Wamberg L, Kampmann U, Stodkilde-Jorgensen H, Rejnmark L, Pedersen SB, Richelsen B. Effects of vitamin D supplementation on body fat accumulation, inflammation, and metabolic risk factors in obese adults with low vitamin D levels – results from a randomized trial. Eur J Intern Med 2013; 24: 644-9.
18. Sokol SI, Srinivas V, Crandall JP, et al. The effects of vitamin D repletion on endothelial function and inflammation in patients with coronary artery disease. Vasc Med 2012; 17: 394-404.
19. Asemi Z, Hashemi T, Karamali M, Samimi M, Esmaillzadeh A. Effects of vitamin D supplementation on glucose metabolism, lipid concentrations, inflammation, and oxidative stress in gestational diabetes: a double-blind randomized controlled clinical trial. Am J Clin Nutr 2013; 98: 1425-32.
20. Garcia-Bailo B, Josse AR, Jamnik J, Badawi A, El-Sohemy A. Positive association between 25-hydroxyvitamin D and C-reactive protein is confounded by hormonal contraceptive use. J Womens Health (Larchmt) 2013; 22: 417-25.
21. Amer M, Qayyum R. Relation between serum 25-hydroxyvitamin D and C-reactive protein in asymptomatic adults (from the continuous National Health and Nutrition Examination Survey 2001 to 2006). Am J Cardiol 2012; 109: 226-30.
22. Ngo DT, Sverdlov AL, McNeil JJ, Horowitz JD. Does vitamin D modulate asymmetric dimethylarginine and C-reactive protein concentrations? Am J Med 2010; 123: 335-41.
23. Bellia A, Garcovich C, D’Adamo M, et al. Serum 25-hydroxyvitamin D levels are inversely associated with systemic inflammation in severe obese subjects. Intern Emerg Med 2013; 8: 33-40.
24. Itariu BK, Zeyda M, Leitner L, Marculescu R, Stulnig TM. Treatment with n-3 polyunsaturated fatty acids overcomes the inverse association of vitamin D deficiency with inflammation in severely obese patients: a randomized controlled trial. PLoS One 2013; 8: e54634.
25. Eleftheriadis T, Antoniadi G, Liakopoulos V, Stefanidis I, Galaktidou G. Inverse association of serum 25-hydroxyvitamin D with markers of inflammation and suppression of osteoclastic activity in hemodialysis patients. Iran J Kidney Dis 2012; 6: 129-35.
26. Timms PM, Mannan N, Hitman GA, et al. Circulating MMP9, vitamin D and variation in the TIMP-1 response with VDR genotype: mechanisms for inflammatory damage in chronic disorders? QJM 2002; 95: 787-96.
27. Shab-Bidar S, Neyestani TR, Djazayery A, et al. Improvement of vitamin D status resulted in amelioration of biomarkers of systemic inflammation in the subjects with type 2 diabetes. Diabetes Metab Res Rev 2012; 28: 424-30.
28. Turkmen K, Erdur FM, Ozcicek F, et al. Platelet-to-lymphocyte ratio better predicts inflammation than neutrophil-to-lymphocyte ratio in end-stage renal disease patients. Hemodial Int 2013; 17: 391-6.
29. Erdur MF, Tonbul HZ, Ozbiner H, et al. The relationship between atherogenic index of plasma and epicardial adipose tissue in hemodialysis and peritoneal dialysis patients. Ren Fail 2013; 35: 1193-8.
30. Turkmen K, Ozcicek F, Ozcicek A, Akbas EM, Erdur FM, Tonbul HZ. The relationship between neutrophil-to-lymphocyte ratio and vascular calcification in end-stage renal disease patients. Hemodial Int 2014; 18: 47-53.
31. Kaya H, Ertas F, Islamoglu Y, et al. Association between neutrophil to lymphocyte ratio and severity of coronary artery disease. Clin Appl Thromb Hemost 2014; 20: 50-4.
32. Imtiaz F, Shafique K, Mirza SS, Ayoob Z, Vart P, Rao S. Neutrophil lymphocyte ratio as a measure of systemic inflammation in prevalent chronic diseases in Asian population. Int Arch Med 2012; 5: 2.
33. Liu CL, Lee JJ, Liu TP, Chang YC, Hsu YC, Cheng SP. Blood neutrophil-to-lymphocyte ratio correlates with tumor size in patients with differentiated thyroid cancer. J Surg Oncol 2013; 107: 493-7.
34. Yao Y, Yuan D, Liu H, Gu X, Song Y. Pretreatment neutrophil to lymphocyte ratio is associated with response to therapy and prognosis of advanced non-small cell lung cancer patients treated with first-line platinum-based chemotherapy. Cancer Immunol Immunother 2013; 62: 471-9.
35. Wang GY, Yang Y, Li H, et al. A scoring model based on neutrophil to lymphocyte ratio predicts recurrence of HBV-associated hepatocellular carcinoma after liver transplantation. PLoS One 2011; 6: e25295.
36. Yoon NB, Son C, Um SJ. Role of the neutrophil-lymphocyte count ratio in the differential diagnosis between pulmonary tuberculosis and bacterial community-acquired pneumonia. Ann Lab Med 2013; 33: 105-10.
37. Sunbul M, Gerin F, Durmus E, et al. Neutrophil to lymphocyte and platelet to lymphocyte ratio in patients with dipper versus non-dipper hypertension. Clin Exp Hypertens 2014; 36: 217-21.
38. Akbas EM, Demirtas L, Ozcicek A, et al. Association of epicardial adipose tissue, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio with diabetic nephropathy. Int J Clin Exp Med 2014; 7: 1794-801.
39. Feng JF, Huang Y, Zhao Q, Chen QX. Clinical significance of preoperative neutrophil lymphocyte ratio versus platelet lymphocyte ratio in patients with small cell carcinoma of the esophagus. Sci World J 2013; 2013: 504365.
40. Gary T, Pichler M, Belaj K, et al. Platelet-to-lymphocyte ratio: a novel marker for critical limb ischemia in peripheral arterial occlusive disease patients. PLoS One 2013; 8: e67688.
41. Raungkaewmanee S, Tangjitgamol S, Manusirivithaya S, Srijaipracharoen S, Thavaramara T. Platelet to lymphocyte ratio as a prognostic factor for epithelial ovarian cancer. J Gynecol Oncol 2012; 23: 265-73.
42. Miglani RK, Bhateja N, Bhat RS, Kumar KV. Diagnostic role of platelet lymphocyte ratio (PLR) in pancreatic head masses. Indian J Surg 2013; 75: 4-9.
43. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011; 96: 1911-30.
44. Ashraf AP, Fisher G, Alvarez J, et al. Associations of C-reactive protein to indices of vascular health and the influence of serum 25(OH)D status in healthy adults. J Nutr Metab 2012; 2012: 475975.
45. Witham MD, Crighton LJ, Gillespie ND, Struthers AD, McMurdo ME. The effects of vitamin D supplementation on physical function and quality of life in older patients with heart failure: a randomized controlled trial. Circ Heart Fail 2010; 3: 195-201.
46. Chitalia N, Ismail T, Tooth L, et al. Impact of vitamin D supplementation on arterial vasomotion, stiffness and endothelial biomarkers in chronic kidney disease patients. PLoS One 2014; 9: e91363.
47. Bednarek-Skublewska A, Smolen A, Jaroszynski A, Zaluska W, Ksiazek A. Effects of vitamin D3 on selected biochemical parameters of nutritional status, inflammation, and cardiovascular disease in patients undergoing long-term hemodialysis. Pol Arch Med Wewn 2010; 120: 167-74.
48. Solak Y, Yilmaz MI, Sonmez A, et al. Neutrophil to lymphocyte ratio independently predicts cardiovascular events in patients with chronic kidney disease. Clin Exp Nephrol 2013; 17: 532-40.
49. Turkmen K, Erdur FM, Guney I, et al. Relationship between plasma pentraxin-3, neutrophil-to-lymphocyte ratio, and atherosclerosis in renal transplant patients. Cardiorenal Med 2012; 2: 298-307.
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