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Predictive Value of Neutrophil-to-Lymphocyte Ratio (NLR) for Amputation in Patients with Diabetic Foot Ulcer: A
Ruibin Feng1,2, Cairu Chen2, Qikai Hua1
1Department of Diabetic Foot Salvage and Limb Reconstruction, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.
Abstract:
Diabetic foot ulcers frequently lead to amputation, and early risk identification remains challenging. Although the neutrophil-to-lymphocyte ratio (NLR) may predict amputation risk, supporting evidence remains limited. This study evaluated the association between NLR and amputation risk in patients with diabetic foot (DF). We systematically searched PubMed, Embase, Scopus, Cochrane Library, and Web of Science up to May 31, 2026. Studies reporting NLR value in DF patients with and without amputation were included. The primary outcome was the pooled mean difference (MD) in NLR between groups. Additionally, We performed a diagnostic accuracy analysis extracting sensitivity and specificity. Odds ratios (ORs) for amputation based on NLR were summarized descriptively. Study quality was assessed with the Newcastle-Ottawa Scale (NOS). Fifteen studies comprising 2757 patients were included. The amputation group had significantly higher NLR than the non-amputation group (pooled MD 3.66, 95% CI 2.60-4.71; I2 = 81%). For major versus minor amputation, the pooled MD was 4.00 (95% CI 1.81-6.19; I2 = 96%). Diagnostic analysis showed moderate discriminatory ability (area under the curve [AUC] 0.798), with a pooled sensitivity of 0.71 (95% CI 0.66-0.75), specificity of 0.71 (95% CI 0.66-0.75), and a diagnostic odds ratio of 6.85 (95% CI 3.54-13.27). Furthermore, studies reporting ORs indicated a positive association between elevated NLR and amputation risk. In conclusion, elevated NLR is significantly associated with amputation risk in DF patients, including major versus minor amputation. Diagnostic analysis suggests moderate discriminatory ability. However, substantial heterogeneity was observed across studies, which warrants caution in interpreting the pooled estimates. Despite this limitation, NLR remains a valuable, cost-effective biomarker for identifying high-risk patients, particularly in resource-limited settings.
