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. 2023 Oct 18;11(10):2819.
doi: 10.3390/biomedicines11102819.

Characterisation of Ferritin-Lymphocyte Ratio in COVID-19

Alexander Liu  1 , Robert Hammond  1 , Kenneth Chan  2 , Chukwugozie Chukwuenweniwe  2 , Rebecca Johnson  2 , Duaa Khair  2 , Eleanor Duck  2 , Oluwaseun Olubodun  2 , Kristian Barwick  2 , Winston Banya  3 , James Stirrup  2 , Peter D Donnelly  1 , Juan Carlos Kaski  4 , Anthony R M Coates  5
Affiliations

Characterisation of Ferritin-Lymphocyte Ratio in COVID-19

Alexander Liu et al. Biomedicines. .

Abstract

Introduction: The ferritin-lymphocyte ratio (FLR) is a novel inflammatory biomarker for the assessment of acute COVID-19 patients. However, the prognostic value of FLR for predicting adverse clinical outcomes in COVID-19 remains unclear, which hinders its clinical translation. Methods: We characterised the prognostic value of FLR in COVID-19 patients, as compared to established inflammatory markers. Results: In 217 study patients (69 years [IQR: 55-82]; 60% males), FLR was weakly correlated with CRP (R = 0.108, p = 0.115) and white cell count (R = -0.144; p = 0.034). On ROC analysis, an FLR cut-off of 286 achieved a sensitivity of 86% and a specificity of 30% for predicting inpatient mortality (AUC 0.60, 95% CI: 0.53-0.67). The negative predictive values of FLR for ruling out mortality, non-invasive ventilation requirement and critical illness (intubation and/or ICU admission) were 86%, 85% and 93%, respectively. FLR performed similarly to CRP (AUC 0.60 vs. 0.64; p = 0.375) for predicting mortality, but worse than CRP for predicting non-fatal outcomes (all p < 0.05). On Kaplan-Meier analysis, COVID-19 patients with FLR values > 286 had worse inpatient survival than patients with FLR ≤ 286, p = 0.041. Conclusions: FLR has prognostic value in COVID-19 patients, and appears unrelated to other inflammatory markers such as CRP and WCC. FLR exhibits high sensitivity and negative predictive values for adverse clinical outcomes in COVID-19, and may be a good "rule-out" test. Further work is needed to improve the sensitivity of FLR and validate its role in prospective studies for guiding clinical management.

Keywords: C-reactive protein; coronavirus disease 19; ferritin–lymphocyte ratio; inflammatory biomarkers; risk stratification; white cell count.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Distribution of ferritin–lymphocyte (FLR) and other inflammatory markers. Panel (A): the numbers of patients in each FLR range are indicated above the bars; the inset shows distribution of FLR values between 0 and 5000. Panels (B,C) demonstrate the distribution of C-reactive protein (CRP) and white cell count (WCC) levels, respectively.
Figure 2
Figure 2
Correlations of ferritin–lymphocyte ratio (FLR) with CRP (Panel (A)) and WCC (Panel (B)). Each point represents data from a single patient. Pearson’s correlation co-efficient (R) values as indicated. CRP: C-reactive protein; WCC: white cell count.
Figure 3
Figure 3
Comparison of the prognostic value of ferritin–lymphocyte ratio (FLR) with other inflammatory markers. Receiver operator characteristics (ROC) curves are shown for predicting inpatient mortality (Panel (A)), requirement for non-invasive ventilation (Panel (B)) and critical illness, as defined by a composite of intubation, mechanical ventilation or intensive care unit admission (Panel (C)). AUC: area under the ROC curve; CRP: C-reactive protein; WCC: white cell count.
Figure 4
Figure 4
Kaplan–Meier analysis of inpatient survival based on ferritin–lymphocyte ratio (FLR). The optimal FLR threshold (286) was derived from receiver operating characteristics curves.
See this image and copyright information in PMC

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