Response Letter The Neutrophil–Lymphocyte Ratio and Inflammation Sevket Balta, MD 1 , Cengiz Ozturk, MD 1 , Ilknur Balta, MD 2 , Sait Demirkol, MD 1 , Mustafa Demir, MD 1 , Turgay Celik, MD 1 , and Atila Iyisoy, MD 1 Acikgoz 1 commented on our article entitled ‘‘Neutrophil- lymphocyte ratio (NLR) and carotid-intima media thickness in patients with Behc ¸et disease without cardiovascular involvement.’’ 2 He concluded that although the NLR seems to be a useful inflammatory marker and predictor of the activity of Behc ¸et disease (BD), more research is required to define its exact role in patient management. Behc ¸et disease is a chronic, inflammatory disorder, 3 and endothelial dysfunction (ED) is considered to play a major role in the pathogenesis of vasculitis and thrombosis in BD. 4,5 Recently, several studies highlighted the relation between ED, BD, and inflammatory markers. 4,6-9 Similarly, we reported 5 that patients with BD had significantly higher serum levels of endo- can (as a novel endothelial inflammatory marker), and these lev- els correlated positively with C-reactive protein, erythrocyte sedimentation rate, and BD activity. Serum levels of endocan were higher in patients with systemic involvement. 5 The NLR is a readily available biomarker that conveys information about inflammatory conditions. 10 Furthermore, epidemiological studies reported that chronic inflammation measured by the NLR is related to classic risk factors such as diabetes mellitus, hypertension, 11 metabolic syndrome, 12 obesity, smoking, and elevated cholesterol values. 10 Further- more, recent evidence reported that the NLR has a significant prognostic value for several conditions in prospective long- term studies. 13 Also, the NLR is influenced by several con- ditions including medication 14 dehydration, overhydration, diluted blood specimens, and in vitro specimen handling. 10 The NLR may change after medications, and the levels of NLR can be changed by severity of chronic diseases. 11 We agree with Acikgoz that the NLR may also be related to other inflammatory markers and ED. 1 It is also considered that NLR levels positively correlated with carotid intima–media thick- ness. 2 So, a high NLR may be related to endothelial dysfunc- tion and reflects BD activity. 2,9 In conclusion, the NLR levels may reflect the severity of diseases with an inflammatory component. Conditions that are related to NLR levels should be kept in mind when NLR levels are interpreted. We need to evaluate this marker for managing and following clinical outcomes in many conditions. We suggest that the NLR should be evaluated together with clinic outcomes such as vascular involvement. References 1. Acikgoz N. The neutrophil-lymphocyte ratio and Behcet’s Dis- ease. Angiology. 2015. doi: 10.1177/0003319715611805. 2. Ozturk C, Balta S, Balta I, et al. Neutrophil-lymphocyte ratio and carotid-intima media thickness in patients with Behc ¸et disease with- out cardiovascular involvement. Angiology. 2015;66(3):291-296. 3. Balta I, Akbay G, Kalkan G, Eksioglu M. Demographic and clin- ical features of 521 Turkish patients with Behc ¸et’s disease. Int J Dermatol. 2014;53(5):564-569. 4. Balta I, Balta S, Koryurek OM, et al. Mean platelet volume is associated with aortic arterial stiffness in patients with Behc ¸et’s disease without significant cardiovascular involvement. J Eur Acad Dermatol Venereol. 2014;28(10):1388-1393. 5. Balta I, Balta S, Koryurek OM, et al. Serum endocan levels as a marker of disease activity in patients with Behc ¸et disease. J Am Acad Dermatol. 2014;70(2):291-296. 6. Balta I, Balta S, Demirkol S, Ku ¨c ¸u ¨k U, Aydın E. Flow-mediated dilatation measurement as a simple practical method in Behc ¸et’s diseases without cardiovascular involvement. Anadolu Kardiyol Derg. 2013;13(7):720-7211. 7. Balta S, Balta I, Demirkol S, Ozturk C, Demir M. Endothelial function and Behc ¸et’s Disease. Angiology. 2014;65(8):657-659. 8. Ekiz O, Balta I, Sen BB, et al. Mean platelet volume as an inflam- matory indicator in Behcet disease. Angiology. 2014;65(2):167. 9. Ozturk C, Balta S, Balta I, Celik T. neutrophil-lymphocyte ratio in Behc ¸et disease. Angiology. 2015;66(7):695. 10. Balta S, Celik T, Mikhailidis DP, et al. The relation between atherosclerosis and the neutrophil-lymphocyte ratio. Clin Appl Thromb Hemost. 2015. doi:1076029615569568. 1 Department of Cardiology, Gulhane Medical Academy, Ankara, Turkey 2 Department of Dermatology, Ankara Training and Research Hospital, Ankara, Turkey Corresponding Author: Sevket Balta, Department of Cardiology, Gulhane School of Medicine, Tevfik Saglam St, 06018 Etlik-Ankara, Turkey. Email: drsevketb@gmail.com; sevketb@gata.edu.tr Angiology 2016, Vol. 67(3) 298-299 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0003319715615252 ang.sagepub.com