Role of Neutrophil-Lymphocyte Ratio in Predicting Severity of COVID-19
Abstract
Background: Higher neutrophil-lymphocyte ratio (NLR) is considered as cardinal findings with prognostic potentials in identification of severe COVID-19 cases. However, whether baseline NLR could be a predictor of disease severity and outcome remained to be investigated. Hence, this study was conducted with an aim to evaluate the relation of NLR (on admission) with disease severity. Objective: The objective of the study was to estimate the neutrophil-lymphocyte ratio among COVID-19 patients and its role in predicting disease severity. Method: This cross-sectional study was conducted in Bangabandhu Sheikh Mujib Medical University (BSMMU) from July 2020 to June 2021. Ninety-four COVID-19 admitted patients were enrolled following inclusion & exclusion criteria. Informed consent was taken from the subjects. Ethical clearance was obtained from institutional review board (IRB) of BSMMU. Complete blood count for N-L ratio was done by standard procedure on admission by SYSMEX XN-2000 haematology analyser. Clinical and laboratory information were recorded with a semi-structured questionnaire. After collection of all the required data, analysis was done by SPSS 24.0. Results: Mean age of the patients was 56.59±12.25 years, wherein maximum patients were male (67%), non-smoker (80.9%), and retired/current service holder (51.1%). Maximum patients were hypertensive (61.7%) and diabetic (56.4%). Besides, maximum study patients (64.9%) were in severe category of COVID-19, followed by moderate (20.2%) and mild (14.9%) category according to National Guidelines on Clinical Management of COVID-19 criteria. Mean NLR was 5.40±4.35 (SD), wherein on admission NLR was significantly higher among severe COVID-19 patients compared to mild/moderate category (6.90±4.64 vs 2.61±1.53, p <0.05). 28-days hospital mortality was found to be significantly associated with NLR (p<0.05). Receiver operator curve analysis found highly significant cut-off value for NLR (3.42) with 75.4% sensitivity and 75.8% specificity in predicting severe COVID-19 patients (AUC= 0.841, p value <0.001). Multivariate logistic regression analysis found NLR as an independent predictor for severe COVID-19 (OR=4.68, 95% CI: 1.29-16.81, P=0.019). Pearson correlation analysis showed that NLR had significant positive correlation with CRP and D-dimer as p value <0.05. Conclusion: NLR can predict the disease severity and outcome of hospitalized COVID-19 patients. However, further larger study is recommended.
Full text article
References
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. New England Journal of Medicine. 2020;382(8):727–733.
Li X, Liu C, Mao Z, Xiao M, Wang L, Qi S, Zhou F. Predictive values of neutrophil-to-lymphocyte ratio on disease severity and mortality in COVID-19 patients: a systematic review and meta-analysis. Crit Care. 2020;24(1):647.
Liu YP, Li GM, He J, Liu Y, Li M, Zhang R, et al. Combined use of the neutrophil-to-lymphocyte ratio and CRP to predict 7-day disease severity in 84 hospitalized patients with COVID-19 pneumonia: a retrospective cohort study. Ann Transl Med. 2020;8(10):635.
Faria SS, Fernandes PC Jr, Silva MJ, Lima VC, Fontes W, Freitas-Junior R, et al. The neutrophil-to-lymphocyte ratio: a narrative review. Ecancermedicalscience. 2016;10:702.
Russell CD, Parajuli A, Gale HJ, Bulteel NS, Schuetz P, de Jager CPC, et al. The utility of peripheral blood leucocyte ratios as biomarkers in infectious diseases: A systematic review and meta-analysis. J Infect. 2019;78(5):339-348
Liu J, Liu Y, Xiang P, Pu L, Xiong H, Li C, et al. Neutrophil-to-lymphocyte ratio predicts critical illness patients with 2019 coronavirus disease in the early stage. J Transl Med. 2020;18(1):206.
Qin C, Zhou L, Hu Z, Zhang S, Yang S, Tao Y, et al. Dysregulation of Immune Response in Patients With Coronavirus 2019 (COVID-19) in Wuhan, China. Clin Infect Dis. 2020;71(15):762-768.
Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020;8(5):475-481.
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020;382(18):1708-1720.
Lippi G, Plebani M, Henry BM. Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A meta-analysis. Clin Chim Acta. 2020;506:145-148.
Abensur Vuillaume L, Le Borgne P, Alamé K, Lefebvre F, Bérard L, Delmas N, et al. Neutrophil-to-Lymphocyte Ratio and Early Variation of NLR to Predict In-Hospital Mortality and Severity in ED Patients with SARS-CoV-2 Infection. J Clin Med. 2021;10(12):2563.
Yang AP, Liu JP, Tao WQ, Li HM. The diagnostic and predictive role of NLR, d-NLR and PLR in COVID-19 patients. Int Immunopharmacol. 2020;84:106504.
Xia X, Wen M, Zhan S, He J, Chen W. [An increased neutrophil/lymphocyte ratio is an early warning signal of severe COVID-19]. Nan Fang Yi Ke Da Xue Xue Bao. 2020 Mar 30;40(3):333-336.
Jain R, Gopal A, Pathak BK, Mohakuda SS, Tilak T, Singh AR. Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio and Their Role as Predictors of Disease Severity of Coronavirus Disease 2019 (COVID-19). J Lab Physicians. 2021 Mar;13(1):58-63.
Foroughi P, Varshochi M, Hassanpour M, et al. The Predictive Role of Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio on Intensive Care Unit Admission and Mortality of COVID-19 Patients in Iran, 25 March 2021, PREPRINT (Version 1) available at Research Square [https://doi.org/10.21203/rs.3.rs-334097/v1]
Chan AS, Rout A. Use of Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in COVID-19. J Clin Med Res. 2020;12(7):448-453.
Gelzo M, Cacciapuoti S, Pinchera B, De Rosa A, Cernera G, Scialò F, et al. Prognostic Role of Neutrophil to Lymphocyte Ratio in COVID-19 Patients: Still Valid in Patients That Had Started Therapy? Front Public Health. 2021;9:664108.
Shenoy GC, Ramaiah M, Kamaraddi S, Somashekar P, Subramanya SK. Comparison of neutrophil-lymphocyte ratio among severe acute respiratory illness COVID-19 positive and negative patients and to correlate with disease severity. International Journal of Advances in Medicine. 2021;8(8):1120.
Henry BM, de Oliveira MHS, Benoit S, Plebani M, Lippi G. Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (COVID-19): a meta-analysis. Clin Chem Lab Med. 2020;58(7):1021-1028.
Chen G, Wu D, Guo W, Cao Y, Huang D, Wang H, et al. Clinical and immunological features of severe and moderate coronavirus disease 2019. J Clin Invest. 2020;130(5):2620-2629.
Pimentel GD, Dela Vega MCM, Laviano A. High neutrophil to lymphocyte ratio as a prognostic marker in COVID-19 patients. Clin Nutr ESPEN. 2020;40:101-102.
Cataudella E, Giraffa CM, Di Marca S, Pulvirenti A, Alaimo S, Pisano M, et al. Neutrophil-To-Lymphocyte Ratio: An Emerging Marker Predicting Prognosis in Elderly Adults with Community-Acquired Pneumonia. J Am Geriatr Soc. 2017;65(8):1796-1801.
Lagunas-Rangel FA. Neutrophil-to-lymphocyte ratio and lymphocyte-to-C-reactive protein ratio in patients with severe coronavirus disease 2019 (COVID-19): A meta-analysis. J Med Virol. 2020;92(10):1733-1734.
Yan X, Li F, Wang X, Yan J, Zhu F, Tang S, et al. Neutrophil to lymphocyte ratio as prognostic and predictive factor in patients with coronavirus disease 2019: A retrospective cross-sectional study. J Med Virol. 2020;92(11):2573-2581.
Authors
Copyright (c) 2024 Md. Saroar Jahan Rajib, Md. Raiq Raihan Chowdhury, Md. Samim Reza, Mily Dey, Nasrin Akhter, Md. Maruf Reza Kabir, Md. Mosharaf Hossain, Md. Abdul Bari Khandakar, Md. Salahuddin Shah
This work is licensed under a Creative Commons Attribution 4.0 International License.
This is an open access article published under the Creative Commons Attribution 4.0 International License, which permits its free use, distribution, and reproduction in any medium or format, even used for commercial purposes, provided the original work is properly cited.