Predictive value of the neutrophil to lymphocyte ratio for disease deterioration and serious adverse outcomes in patients with COVID-19: a prospective cohort study

Abstract

Background: Early identification of patients who are at high risk of poor clinical outcomes is of great importance in saving the lives of patients with novel coronavirus disease 2019 (COVID-19) in the context of limited medical resources.

Objective: To evaluate the value of the neutrophil to lymphocyte ratio (NLR), calculated at hospital admission and in isolation, for the prediction of the subsequent presence of disease progression and serious clinical outcomes (e.g., shock, death).

Methods: We designed a prospective cohort study of 352 hospitalized patients with COVID-19 between January 9 and February 26, 2020, in Yichang City, Hubei Province. Patients with an NLR equal to or higher than the cutoff value derived from the receiver operating characteristic curve method were classified as the exposed group. The primary outcome was disease deterioration, defined as an increase of the clinical disease severity classification during hospitalization (e.g., moderate to severe/critical; severe to critical). The secondary outcomes were shock and death during the treatment.

Results: During the follow-up period, 51 (14.5%) patients' conditions deteriorated, 15 patients (4.3%) had complicated septic shock, and 15 patients (4.3%) died. The NLR was higher in patients with deterioration than in those without deterioration (median: 5.33 vs. 2.14, P < 0.001), and higher in patients with serious clinical outcomes than in those without serious clinical outcomes (shock vs. no shock: 6.19 vs. 2.25, P < 0.001; death vs. survival: 7.19 vs. 2.25, P < 0.001). The NLR measured at hospital admission had high value in predicting subsequent disease deterioration, shock and death (all the areas under the curve > 0.80). The sensitivity of an NLR ≥ 2.6937 for predicting subsequent disease deterioration, shock and death was 82.0% (95% confidence interval, 69.0 to 91.0), 93.3% (68.0 to 100), and 92.9% (66.0 to 100), and the corresponding negative predictive values were 95.7% (93.0 to 99.2), 99.5% (98.6 to 100) and 99.5% (98.6 to 100), respectively.

Conclusions: The NLR measured at admission and in isolation can be used to effectively predict the subsequent presence of disease deterioration and serious clinical outcomes in patients with COVID-19.

Keywords: COVID-19; Death; Deterioration; Neutrophil to lymphocyte ratio; Shock.

Fig. 1

Neutrophil to lymphocyte ratio for patients with and without disease deterioration, shock and death. Disease deterioration (panel a), shock (panel b) and death (panel c). The bottom and top edges of each box represent the first (P25) and third quartiles (P75), respectively. The band within the box represents the median (P50), and the whiskers represent values that are 1.5 times the interquartile range. The horizontal line represents the cutoff value of 2.6937 for the NLR. Two extreme outliers (> 3 times the interquartile range), including a patient with an NLR of 85.52 in the groups without adverse outcomes and a patients with an NLR of 54.36 in the groups with adverse outcomes, were not shown. NLR represents the neutrophil to lymphocyte ratio

Fig. 2

Receiver operating characteristic curves of neutrophil to lymphocyte ratios in predicting serious clinical outcomes in patients with COVID-19. CI represents the confidence interval