Inflammation ( # 2014)

DOI: 10.1007/s10753-014-9978-y

The Relationship Between Inflammatory Marker Levels

and Pulmonary Tuberculosis Severity

Ozlem Abakay,1,2 Abdurrahman Abakay,1 Hadice Selimoglu Sen,1 and Abdullah C. Tanrikulu1

Abstract—We aimed to investigate the correlation between red cell distribution width (RDW), neutro-
phil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and other inflammatory markers
with pulmonary tuberculosis (PTB) severity. Seventy patients with active pulmonary tuberculosis were
compared with 50 age-matched and gender-matched healthy controls. The mean age of PTB patients
was 50.4±21.8 years. There were no differences in terms of age, gender, and smoking history between
PTB patients and controls. Patients with advanced PTB had a significantly higher white blood cell count,
neutrophil count, RDW, NLR, and C-reactive protein when compared to patients with mild to moderate
PTB. RDW (17.7 versus 15.7 %, p=0.002) and NLR (4.7 versus 3.1, p=0.009) values were higher in
patients with advanced PTB as opposed to patients with mild to moderate PTB. NLR and RDW levels
may be used as markers of inflammation to help clinically manage patients with TB and to determine
disease severity.

KEY WORDS: inflammatory markers; neutrophil to lymphocyte ratio; pulmonary tuberculosis; radiological extent;
red blood cell distribution width.

INTRODUCTION that C-reactive protein (CRP), platelet count, plateletcrit

Tuberculosis (TB) infections occur by inhaling My-
cobacterium tuberculosis bacilli (MTB). Roughly, 10 % of
tuberculosis diagnoses are made during the first and second
decades of life, and this disease affects three times as many
men as women [1]. The progression to active disease
results from changes in bacterial virulence and/or an im-
paired host immune system. The most significant risk
factor that promotes the progression of latent to active
disease is contracting HIV while infected with TB [2].
The current understanding of the immunology of myco-
bacterial infections has provided insight into how PTB
causes self-limited hematological abnormalities.
Developing point-of-care diagnostic testing will
greatly benefit public health by decreasing morbidity and
mortality and reducing TB transmission rates. Yet in order
to develop such a test, it is necessary to determine bio-
markers that are both highly specific and sensitive in
detecting active TB. Recently, several studies suggested
1
Department of Chest Diseases, Medical Faculty, Dicle University,
Diyarbakir, Turkey
2
To whom correspondence should be addressed at Department of Chest
Diseases, Medical Faculty, Dicle University, Diyarbakir, Turkey.
E-mail: o.abakay@hotmail.com
(PCT), and platelet distribution width (PDW) may be
potential biomarkers of PTB severity [3–5].
Red blood cell distribution width (RDW) is a measure
of the size variability of circulating blood cells and is part
of the complete blood count (CBC) panel. It is mainly used
as a tool in the differential diagnosis of anemia, but the
RDW may be elevated in any condition in which reticulo-
cytes are released into the circulation such as inflammatory
diseases and sepsis [6, 7]. In addition to diagnosing ane-
mia, recent studies have demonstrated that RDW also gives
information regarding the prognosis of congestive heart
failure, acute myocardial infarction, pulmonary embolism,
pneumonia, obstructive sleep apnea syndrome, chronic
obstructive pulmonary disease, sepsis, and other illnesses
[7–11]. It is not completely understood why RDW is
elevated in these patients, but it has been suggested that
inflammation contributes to higher RDW levels [11].
White blood cell count (WBC) is a well-known indi-
cator of inflammation. In recent years, several studies
investigated the potential role of various leukocyte ratios
in chronic inflammatory diseases [12–15]. The inflamma-
tory response is central to the pathophysiology of PTB. To
the best of our knowledge, an investigation regarding
whether the neutrophil to lymphocyte ratio (NLR), platelet
to lymphocyte ratio (PLR), and RDW are biomarkers of

0360-3997/14/0000-0001/0 # 2014 Springer Science+Business Media New York


active PTB has not yet been published. As chronic inflam-
mation has been found to be associated with increased
inflammatory marker levels in PTB patient serum, we
hypothesized that RDW, NLR, and PLR levels are also
affected by PTB severity. The objective of this study was to
investigate the relationship between the RDW, NLR, and
PLR and known acute phase reactants in patients with
chest X-ray-confirmed active PTB.
MATERIALS AND METHODS
Patients
This is a retrospective chart review study. Data were
collected by scanning Dicle University Hospital patient
records archived from January 2011 to December 2013.
In this time frame, there was record of 70 culture-positive
pulmonary tuberculosis patients. We then included 50 age-
matched and gender-matched healthy controls. This study
was performed in accordance with the principles of the
Declaration of Helsinki and was reviewed and approved by
the Dicle University Medical Faculty ethics committee.
Patients were excluded from the study if they were
taking antibiotics or had conditions that are known to affect
WBC counts such as hematologic disorders, chronic in-
flammatory conditions, severe cardiovascular disease,
chronic inflammatory diseases, significant liver disease,
autoimmune disorders, neoplasms, and being immuno-
compromised. Further exclusion criteria were if hemogram
data were missing from the chart, if the patient was mis-
takenly diagnosed with PTB, or if the patient was found to
have pulmonary edema during follow-up.
Demographics such as age, gender, current smoking
status, and smoking history were obtained. Clinical data
such as symptoms, duration of symptoms, and history of
previous TB infections were gathered. Lastly, laboratory
findings including hemogram parameters, serum CRP lev-
el, and erythrocyte sedimentation rate (ESR) were archived
in the patient files. Symptom duration was defined as the
time between symptom onset and diagnosis. Patients were
assigned into the pulmonary TB group once MTB was
cultured from samples obtained from either sputum or
bronchial lavage. A positive diagnosis for active PTB
consisted of detecting acid fast bacilli with Ziehl–Neelsen
stain from sputum samples and at least one positive culture
in Löwenstein–Jensen media using the BACTEC TB 460
system. All patients in this study met these criteria for
active PTB.
Patients with PTB were classified according to the
extent of disease evident on chest radiography: stage 1 was
Abakay, Abakay, Sen, and Tanrikulu
minimal to mild disease, stage 2 was moderate disease, and
stage 3 was advanced disease [5, 16, 17]. Lesions were
considered minimal if there was no evidence of cavitation
and the lesions were of slight to moderate density located
above the second chondrosternal junction. Moreover, the
lesions must only involve a segment of one or both lungs,
and the combined extent of the lesions must be smaller than
the volume of a single lung. Disseminated lesions of slight
characterized moderate disease to moderate density in one
or both lungs, and the collective lesion volume cannot
exceed that of a single lung. In moderate disease, the
lesions may also be densely packed so to appear confluent,
but areas of high-density lesions cannot take up more than
one third of the volume of one lung. Moreover, the total
diameter of cavitations cannot exceed 4 cm in patients with
moderate disease. If lesions were found to be more exten-
sive than moderate disease, then it was considered ad-
vanced disease. After PTB patients were classified accord-
ing to stage, they were divided into two groups: group 1
consisted of patients with mild–moderate disease, and
group 2 patients had advanced disease.
Laboratory Analysis
All laboratory samples were collected before the pa-
tients were started on treatment. Complete blood count
analyses were performed with the Beckman Coulter LH-
750 Hematology Analyzer (Beckman Coulter, Inc., Fuller-
ton, CA, USA). In accordance with hospital laboratory
policy, the CBC was performed within 1 h of sample
collection. Analyses were performed at room temperature.
Total WBC, neutrophil, lymphocyte, and platelet counts in
addition to PDW, mean platelet volume (MPV), and RDW
were determined by performing CBC analyses. The NLR
was defined as the absolute neutrophil count divided by the
absolute lymphocyte count. The PLR was defined as the
absolute platelet count divided by the absolute lymphocyte
count. Serum CRP levels were measured by the
immunoturbidometric method (Roche Diagnostics,
GmbH, Mannheim, Germany) within 1 h of sample col-
lection, and a normal CRP value was 0.5 mg/dL.
Statistical Analysis
The Kolmogorov–Smirnov test was used to test
whether continuous variables conformed to a normal dis-
tribution. Data that followed a normal distribution were
expressed as the mean±one standard deviation. The inde-
pendent Student’s t test and the χ2 test or Fisher’s exact test
were utilized to compare data between patient subgroups.
Student’s t test, used to evaluate normally distributed data,
Inflammatory Marker Levels and Pulmonary Tuberculosis Severity

or the Mann–Whitney U test, used to evaluate data that do Table 2. Comparison of Laboratory Results Between PTB Patients and
Controls
not conform to a normal distribution, was used to compare
data between two groups. The Spearman test was used to Parameter PTB patients Controls p value
assess the correlation between variables. Statistical (n=70) (n=50)
analyses were performed with the Statistical Package for
Social Sciences version 15 for the Windows® operating WBC count (×109/μL) 9.5±3.3 9.7±1.9 NS
Neutrophil count (×109/μL) 6.6±2.8 5.7±1.4 0.033
system (SPSS® Inc. Chicago, IL, USA). Two-tailed statis-
Lymphocyte count (×109/μL) 2.2±1.7 3.5±0.9 <0.001
tical significance testing was performed, and p values less Platelet count (×109/μL) 352.3±111.0 257.2±99.0 <0.001
than 0.05 were considered significant. PDW (%) 17.3±1.2 10.9±3.2 <0.001
MPV (fL) 7.4±1.3 7.6±1.2 NS
RDW (%) 16.6±2.6 12.5±1.4 <0.001
NLR 3.9±2.6 1.6±0.3 <0.001
RESULTS PLR 201.1±111.3 78.7±39.2 <0.001
CRP (mg/dL) 6.1±4.2 0.3±0.2 <0.001
ESR (mm/h) 39.8±21.2 5.8±2.1 <0.001
A total of 70 patients diagnosed with PTB and 50 age-
matched and gender-matched healthy control subjects were Data are expressed as the mean±one standard deviation
included in this study. For the PTB patients, the mean age PTB pulmonary tuberculosis, NLR neutrophil to lymphocyte ratio, PLR
platelet to lymphocyte ratio, NS not significant, CRP C-reactive protein,
was 50.4±21.8 years, and ages ranged from 18 to 82 years; ESR erythrocyte sedimentation rate, PDW platelet distribution width,
the average age for controls was 48.5±14.6 years ranging ESR erythrocyte sedimentation rate
from 19 to 86 years. In PTB group, 67 % of patients were
male, and 66 % of patients were male in the control group. WBC count, neutrophil count, RDW, NLR, CRP, and
Thirty-seven (52.8 %) of the PTB patients were smokers. ESR when compared to patients with mild to moderate
During the diagnosis, 66 (94 %) patients had cough, 54 disease (Table 3). The RDW (17.7 versus 15.7 %) and
(77 %) had dyspnea, and 40 (57 %) had weight loss. NLR (4.7 versus 3.1) values were found to be higher in
Demographic and clinical characteristics of both patient the advanced PTB group than in patients with mild to
and control groups are shown in Table 1. There were no moderate PTB.
differences in age, gender, and smoking history between Spearman’s correlation analysis showed a signif-
PTB patients and control subjects (p>0.05). icant correlation between NLR and the serum CRP
Neutrophil count, platelet count, RDW, PDW, NLR,
PLR, ESR, and CRP values were significantly higher in
PTB group when compared to the control group (Table 2). Table 3. Comparison of Laboratory Results Between Patients with Mild
Patients with advanced PTB had a significantly higher to Moderate and Advanced PTB

Parameter Mild to moderate Advanced PTB p value

Table 1. Demographic and Clinical Characteristics PTB (n=37) (n=33)

Characteristics PTB patients Controls p value WBC count 8.6±2.7 10.6±3.6 0.01
(n=70) (n=50) (×109/μL)
Neutrophil count 5.5±2.4 7.7±2.8 0.001
Age, years 50.4±21.8 48.5±14.6 NS (×109/μL)
Gender: male/female, n/n 47/23 32/18 NS Lymphocyte count 2.2±0.9 2.2±2.3 NS
Current smoker, n 37 25 NS (×109/μL)
Smoking history, packet/years 13.9 11.2 NS Platelet count 350.4±111.9 354.5±111.7 NS
Mean symptom duration, 1.5 – – (×109/μL)
months PDW (%) 17.4±1.2 17.2±1.3 NS
Symptoms, n (%) MPV (fL) 7.4±1.3 7.3±1.2 NS
Cough 66 (94) – – RDW (%) 15.7±2.1 17.7±2.7 0.002
Dyspnea 54 (77) – – NLR 3.1±2.2 4.7±2.8 0.009
Weight loss 40 (57) – – PLR 189.2±104.2 214.5±118.9 NS
Fever 35 (50) – – CRP (mg/dL) 4.1±4.0 8.2±3.4 <0.001
Hemoptysis 21 (30) – – ESR (mm/h) 34.3±19.6 46.0±21.6 0.021
Previous TB infection, n (%) 18 (26) – –
Data are expressed as the mean±one standard deviation. For abbrevia-
NS not significant, TB tuberculosis tions, refer to the legend of Table 2

level (r=0.257; p=0.032) (Fig. 1). There is a positive
correlation between NLR and ESR (r=0.317; p=0.008)
(Fig. 2).
DISCUSSION
Inflammation plays a significant role in the pathogen-
esis of PTB. Yaranal et al. demonstrated that hematological
abnormalities are more commonly observed in cases of
severe tuberculosis. Most often, it was observed that pa-
tients with severe tuberculosis had anemia, elevated ESR,
and thrombocytosis [18]. Other studies also reported that
patients with advanced pulmonary TB demonstrated ane-
mia, leukocytosis, elevated ESR, and thrombocytosis [5,
19–23]. In our study, we found that NLR, RDW, ESR, and
CRP values are higher in patients with advanced stage PTB
when compared to patients with mild to moderate PTB.
These data suggest that the inflammatory response
mounted in patients with severe PTB tends to be greater.
Moreover, besides CRP and ESR, the NLR may be a useful
marker by itself and may be used to distinguish between
patients with advanced PTB and mild to moderate PTB.
The NLR may be easily obtained from routine labo-
ratory testing, and this simple ratio may be determined in
many hospitals. Additionally, the NLR is an easier and less
expensive test to perform as compared to other inflamma-
tory biomarkers such as CRP and procalcitonin [24].
Fig. 1. Correlation between the NLR and serum CRP levels in study su-
bjects (r=0.257; p=0.032).
Abakay, Abakay, Sen, and Tanrikulu
Fig. 2. Correlation between the NLR and erythrocyte sedimentation rate
(ESR) levels in study subjects (r=0.317; p=0.008).
WBC count is a marker of inflammation, and NLR
may be used to predict the prognosis of patients with
systemic inflammatory diseases [25–27]. Gary et al. inves-
tigated NLR and its association with critical limb ischemia
(CLI) in patients with peripheral arterial occlusive disease
(PAOD) [28]. It was determined that an elevated NLR is
significantly associated with a high risk of CLI and other
vascular health problems. Holub et al. assessed the sensi-
tivity and specificity of the NLR in diagnosing community-
acquired bacterial pneumonia in patients hospitalized with
a febrile illness. It was suggested that the NLR may serve
as a simple marker that may aid in discriminating between
severe bacterial and viral infections [29]. Yoon et al. in-
vestigated the usefulness of the NLR in differentiating
between pulmonary TB from bacterial community-
acquired pneumonia (CAP). They showed that serum
NLR levels were significantly lower in patients with pul-
monary TB than in patients with bacterial CAP [30]. In our
study, we found that NLR levels were significantly higher
in patients with advanced PTB as opposed to patients with
mild to moderate PTB.
RDW is a biomarker that has been mostly studied
in cardiac diseases, pneumonia, and pulmonary em-
bolism [8–11, 31]. Ozsu et al. demonstrated that obstruc-
tive sleep apnea syndrome patients have an elevated
RDW when compared with controls. They found that
RDW was an independent predictor of cardiovascular
diseases in obstructive sleep apnea syndrome (OSAS)
patients, but there was no association between OSAS
Inflammatory Marker Levels and Pulmonary Tuberculosis Severity
severity and RDW [32]. Kurt et al. investigated the
relationship of MPV, PDW, and RDW with OSAS
severity, yet no correlation was identified [33]. Yet in
our study, we found that there is a significant in-
crease in RDW in patients with advanced PTB when
contrasted with patients with mild to moderate PTB.
As such, there was a positive relationship between
PTB severity and RDW.
Reactive thrombocytosis in patients with PTB has
been shown to be correlated with increased disease
severity and higher levels of other acute phase reac-
tants [4, 34]. Tozkoparan et al. determined that the
platelet count and related indices including PDW,
MPV, and PCT were higher in patients with active
PTB than in patients with pneumonia or inactive
tuberculosis. They found that these platelet-related
indices decreased following treatment. These data sug-
gested that an increase in platelet count and its asso-
ciated indices may be used to aid in determining
whether tuberculosis infection is becoming activated
[3]. In our study, platelet count and the PLR level
were higher in patients with PTB as opposed to con-
trols. However, no significant difference was found in
platelet count and the PLR level between patients with
mild to moderate and advanced PTB.
The NLR and PLR are associated with a poorer
prognosis in various diseases. Sunbul et al. investigat-
ed the association between NLR and PLR in patients
with dipper versus non-dipper hypertension. They
found that patients with non-dipper hypertension had
significantly higher NLR and PLR levels when com-
pared to patients with dipper hypertension [35].
Yavuzcan et al. compared preoperative MPV values
and other systemic inflammatory response markers,
namely the NLR and PLR, between patients with ad-
vanced stage endometriosis with endometrioma and
patients with a benign adnexal mass. They demonstrat-
ed that MPV, NLR, and PLR values are not useful in
distinguishing patients with advanced stage endometri-
osis and those with benign disease, even though ad-
vanced endometriosis is characterized by severe in-
flammation [36]. Feng et al. investigated the prognos-
tic value of the NLR and PLR in patients with small
cell carcinoma of the esophagus. They reported that
PLR was superior to NLR in predicting small cell
carcinoma prognosis [37]. In our study, we showed
that there is a significant increase in NLR and PLR
values in patients with pulmonary tuberculosis when
compared to healthy controls. However, PLR was not
associated with PTB severity.
In conclusion, it is imperative to identify novel bio-
markers that help indicate the severity of inflammation in
patients with PTB so as to identify active TB or disease
reactivation. To the best of our knowledge, this is the first
clinical study demonstrating that the NLR, PLR, and RDW
become elevated in patients with PTB. Hence, NLR and
RDW may be used as markers of inflammation in the
clinical management of patients with PTB as these bio-
markers are quickly, cheaply, and easily obtained with
routine CBC analysis.
Conflict of Interest. The authors declare that there are no
conflicts of interest.
Funding. This research received no specific grant from
any funding agency in the public, commercial, or not-for-
profit sectors.
REFERENCES
1. WHO 2010–2011 TB factsheet. Available at: www.who.int/tb/
publications/2010/factsheet_tb_2010_rev21feb11.pdf/ Accessed
18 Feb 2014.
2. Nunn, P., B. Williams, K. Floyd, C. Dye, G. Elzinga, et al. 2005.
Tuberculosis control in the era of HIV. Nature Reviews Immunology
5: 819–826.
3. Tozkoparan, E., O. Deniz, E. Ucar, H. Bilgic, and K. Ekiz. 2007.
Changes in platelet count and indices in pulmonary tuberculosis. Clin-
ical Chemistry and Laboratory Medicine 45: 1009–1013.
4. Unsal, E., S. Aksaray, D. Köksal, and T. Sipit. 2005. Potential role of
interleukin 6 in reactive thrombocytosis and acute phase response in
pulmonary tuberculosis. Postgraduate Medical Journal 81: 604–607.
5. Sahin, F., E. Yazar, and P. Yildiz. 2012. Prominent features of
platelet count, plateletcrit, mean platelet volume and platelet
distribution width in pulmonary tuberculosis. Multidisciplinary
Respiratory Medicine 7: 38.
6. Hotchkiss, R.S., and I.E. Karl. 2003. The pathophysiology and treat-
ment of sepsis. New England Journal of Medicine 348: 138–150.
7. Jo, Y.H., K. Kim, J.H. Lee, et al. 2013. Red cell distribution width is a
prognostic factor in severe sepsis and septic shock. American Journal of
Emergency Medicine 31: 545–548.
8. Sincer, I., A. Zorlu, M.B. Yilmaz, et al. 2012. Relationship between red
cell distribution width and right ventricular dysfunction in patients with
chronic obstructive pulmonary disease. Heart & Lung 41: 238–
243.
9. Felker, G.M., L.A. Allen, S.J. Pocock, et al. 2007. Red cell distribution
width as a novel prognostic marker in heart failure: data from the
CHARM Program and the Duke Databank. Journal of the American
College of Cardiology 50: 40–47.
10. Dabbah, S., H. Hammerman, W. Markiewicz, et al. 2010. Relation
between red cell distribution width and clinical outcomes after acute
myocardial infarction. American Journal of Cardiology 105: 312–317.

11. Braun, E., E. Domany, Y. Kenig, et al. 2011. Elevated red cell distri-
bution width predicts poor outcome in young patients with community
acquired pneumonia. Critical Care 15: R194.
12. Thomsen, M., T.S. Ingebrigtsen, J.L. Marott, M. Dahl, P. Lange, J.
Vestbo, et al. 2013. Inflammatory biomarkers and exacerbations in
chronic obstructive pulmonary disease. JAMA 309: 2353–2361.
13. Goldenberg, A.S. 1996. Hematologic abnormalities and mycobacterial
infection. In Tuberculosis, ed. N.R. Williams and G.M. Stuart,
645–647. Boston: Little – Brown Company.
14. Ahsen, A., M.S. Ulu, S. Yuksel, K. Demir, M. Uysal, M. Erdogan,
et al. 2013. As a new inflammatory marker for familial Mediterranean
fever: neutrophil-to-lymphocyte ratio. Inflammation 36: 1357–1362.
15. Ertaş, G., O. Sönmez, M. Turfan, S. Kul, E. Erdoğan, A. Tasal, et al.
2013. Neutrophil/lymphocyte ratio is associated with thromboembolic
stroke in patients with non-valvular atrial fibrillation. Journal of the
Neurological Sciences 324: 49–52.
16. 1961. National Tuberculosis Association of the USA: Diagnostic
standards and classification of tuberculosis. New York: National
Tuberculosis Association.
17. Seaton, A., D. Seaton, and A.G. Leitch. 1989. Crofton and Douglas’s
respiratory diseases, 4th ed, 409–410. Oxford: Blackwell.
18. Yaranal, P.J., T. Umashankar, and S.G. Harish. 2013. Hematological
profile in pulmonary tuberculosis. International Journal of Health and
Rehabilation Sciences 2: 50–55.
19. Bazick, H.S., D. Chang, K. Mahadevappa, et al. 2011. Red cell
distribution width and all-cause mortality in critically ill patients.
Critical Care Medicine 39: 1913–1921.
20. Baynes, R.D., H. Flax, T.H. Bothwell, W.R. Bezwoda, A.P. MacPhail,
P. Atkinson, et al. 1986. Haematological and iron-related measure-
ments in active pulmonary tuberculosis. Scandinavian Journal of
Haematology 36: 280–287.
21. Olaniyi, J.A., and Y.A. Aken’Ova. 2003. Haematological profile of
patients with pulmonary tuberculosis in Ibadan, Nigeria. African
Journal of Medicine and Medical Sciences 32: 239–242.
22. Das, B.S., U. Devi, C. Mohan Rao, V.K. Srivastava, P.K. Rath, and B.S.
Das. 2003. Effect of iron supplementation on mild to moderate anaemia
in pulmonary tuberculosis. British Journal of Nutrition 90: 541–550.
23. Akintunde, E.O., W.A. Shokunbi, and C.O. Adekunle. 1995. Leuco-
cyte count, platelet count and erythrocyte sedimentation rate in pul-
monary tuberculosis. African Journal of Medicine and Medical
Sciences 24: 131–134.
24. Kang, Y.A., S.Y. Kwon, H.I. Yoon, J.H. Lee, and C.T. Lee. 2009. Role
of C-reactive protein and procalcitonin in differentiation of tuberculo-
sis from bacterial community acquired pneumonia. Korean Journal of
Internal Medicine 24: 337–342.
25. Celikbilek, M., S. Dogan, O. Ozbakır, G. Zararsız, H. Kücük, S.
Gürsoy, A. Yurci, K. Güven, and M. Yücesoy. 2013. Neutrophil–
Abakay, Abakay, Sen, and Tanrikulu
lymphocyte ratio as a predictor of disease severity in ulcerative colitis.
Journal of Clinical Laboratory Analysis 27: 72–76.
26. Okyay, G.U., S. Inal, K. Oneç, R.E. Er, O. Paşaoğlu, H. Paşaoğlu, U.
Derici, and Y. Erten. 2013. Neutrophil to lymphocyte ratio in evalua-
tion of inflammation in patients with chronic kidney disease. Renal
Failure 35: 29–36.
27. Güngör B, Ozcan KS, Erdinler I, Ekmekçi A, Alper AT, Osmonov D,
Calık N, Akyuz S, Toprak E, Yılmaz H, Yıldırım A, Bolca O.
Elevated levels of RDW is associated with non-valvular atrial fibril-
lation. J Thromb Thrombolysis 2013.
28. Gary, T., M. Pichler, K. Belaj, F. Hafner, A. Gerger, H. Froehlich, P.
Eller, E. Pilger, and M. Brodmann. 2013. Neutrophil-to-lymphocyte
ratio and its association with critical limb ischemia in PAOD patients.
PLoS One 8: e56745.
29. Holub, M., O. Beran, N. Kaspříková, and P. Chalupa. 2012. Neutro-
phil to lymphocyte count ratio as a biomarker of bacterial infections.
Central European Journal of Medicine 7: 258–261.
30. Yoon, N.B., C. Son, and S.J. Um. 2013. Role of the neutrophil-
lymphocyte count ratio in the differential diagnosis between pulmo-
nary tuberculosis and bacterial community-acquired pneumonia.
Annals of Laboratory Medicine 33: 105–110.
31. Ozsu, S., Y. Abul, S. Gunaydin, A. Orem, and T. Ozlu. 2014. Prog-
nostic value of red cell distribution width in patients with pulmonary
embolism. Clinical and Applied Thrombosis/Hemostasis 20: 365–370.
32. Ozsu, S., Y. Abul, A. Gulsoy, Y. Bulbul, S. Yaman, and T. Ozlu. 2012.
Red cell distribution width in patients with obstructive sleep apnea
syndrome. Lung 190: 319–326.
33. Kurt, O.K., and N. Yildiz. 2013. The importance of laboratory param-
eters in patients with obstructive sleep apnea syndrome. Blood
Coagulation and Fibrinolysis 24: 371–374.
34. Mirsaeidi, M., P. Peyrani, S. Aliberti, G. Filardo, J. Bordon, F. Blasi,
et al. 2010. Thrombocytopenia and thrombocytosis at time of hospi-
talization predict mortality in patients with community-acquired pneu-
monia. Chest 137: 416–420.
35. Sunbul M, Gerin F, Durmus E, Kivrak T, Sari I, Tigen K, Cincin A.
2013. Neutrophil to lymphocyte and platelet to lymphocyte ratio in
patients with dipper versus non-dipper hypertension. Clin Exp
Hypertens.
36. Yavuzcan, A., M. Caglar, Y. Ustun, S. Dilbaz, I. Ozdemir, E. Yildiz, A.
Ozkara, and S. Kumru. 2013. Evaluation of mean platelet volume,
neutrophil/lymphocyte ratio and platelet/lymphocyte ratio in advanced
stage endometriosis with endometrioma. Journal of the Turkish
German Gynecological Association 14: 210–215.
37. Feng, J.F., Y. Huang, Q. Zhao, and Q.X. Chen. 2013. Clinical signif-
icance of preoperative neutrophil lymphocyte ratio versus platelet
lymphocyte ratio in patients with small cell carcinoma of the esoph-
agus. ScientificWorldJournal 2013: 504365.