Evaluation of Serum Ferritin, Procalcitonin, and C-Reactive Protein for the Prediction of Severity and Mortality in Hemorrhagic Fever With Renal Syndrome

Abstract

This study aimed to analyze the clinical significance of serum ferritin, procalcitonin (PCT), and C-reactive protein (CRP) in patients with hemorrhagic fever with renal syndrome (HFRS). The demographical, clinical, and laboratory data of 373 patients with HFRS in northeastern China were retrospectively analyzed. The levels of serum ferritin and PCT in severe patients (n = 108) were significantly higher than those in mild patients (n = 265, p < 0.001) and associated with HFRS severity. The area under the receiver operating characteristic curve (AUC) values of serum ferritin and PCT for predicting the severity of HFRS were 0.732 (95% CI 0.678-0.786, p < 0.001) and 0.824 (95% CI 0.773-0.875, p < 0.001), respectively, showing sensitivity and specificity of 0.75 and 0.88 for serum ferritin, and 0.76 and 0.60 for PCT. The CRP level in HFRS with bacterial co-infection (n = 115) was higher than that without bacterial co-infection (n = 258, p < 0.001). The AUC value of CRP for predicting bacterial co-infection was 0.588 (95% CI 0.525-0.652, p < 0.001), showing sensitivity and specificity of 0.43 and 0.76, respectively. The serum ferritin level in non-survivors (n = 14) was significantly higher than in survivors (n = 359, p < 0.001). The AUC value of serum ferritin for predicting mortality was 0.853 (95% CI 0.774-0.933, p < 0.001), showing sensitivity and specificity of 0.933 and 0.739. Serum ferritin and PCT have a robust association with HFRS severity and mortality, which may be promising predictors, and CRP is an effective biomarker to assess bacterial co-infection in HFRS.

Keywords: C-reactive protein; hantaviruses; hemorrhagic fever with renal syndrome; procalcitonin; serum ferritin.

FIGURE 1

Performance of serum ferritin, PCT, and CRP as predictors of severity by receiver operating characteristics curve analysis. The AUC of serum ferritin = 0.732, the AUC of PCT = 0.824, and the AUC of CRP = 0.614, all p < 0.01.

FIGURE 2

Receiver operating characteristics curve showing the performance of serum ferritin as a predictor of bacterial co-infection. The AUC of serum ferritin = 0.540, the AUC of PCT = 0.527, and the AUC of CRP = 0.588, only p_CRP < 0.01.

FIGURE 3

Receiver operating characteristics curve showing the performance of serum ferritin, PCT, and CRP as predictors of mortality. The AUC of serum ferritin = 0.853, the AUC of PCT = 0.737, and the AUC of CRP = 0.703, only p_{Serum ferritin} < 0.001.