key: cord-0835464-quo9quiv authors: Acar, Ethem; Demir, Ahmet; Yıldırım, Birdal; Kaya, Mehmet Gökhan; Gökçek, Kemal title: The role of hemogram parameters and C‐reactive protein in predicting mortality in COVID‐19 infection date: 2021-04-30 journal: Int J Clin Pract DOI: 10.1111/ijcp.14256 sha: f74d70ec78c2fe27f789b91a814e7eaae12c2db5 doc_id: 835464 cord_uid: quo9quiv AIM: This study aimed to investigate hemogram parameters and C‐reactive protein (CRP) that can be used in clinical practice to predict mortality in hospitalized patients with a diagnosis of COVID‐19. METHODS: This cohort study was conducted at University Hospital, which is a designated hospital for COVID‐19 patients. Adult patients who were admitted to our hospital emergency department with suspected COVID‐19 and who were hospitalized in our institution with a COVID‐19 diagnosis were analysed. RESULTS: There were 148 patients hospitalized with COVID‐19. All‐cause mortality of follow‐up was 12.8%. There were statistically significant results between the two groups (survivors and nonsurvivors), which were classified based on hospital mortality rates, in terms of the lymphocyte to C‐reactive protein ratio (LCRP), systemic immune inflammation index (SII), neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR), CRP concentration and comorbid disease. In a receiver operating characteristic (ROC), curve analysis, LCRP, NLR, PLR and SII area under the curve (AUC) for in‐hospital mortality were 0.817, 0.816, 0.733 and 0.742, respectively. Based on an LCRP value of 1 for in‐hospital mortality, the sensitivity and specificity rates were 100% and 86.8%, respectively. Based on the average SII of 2699 for in‐hospital mortality, the sensitivity, specificity and accuracy rates were 68.4%, 77.5% and 76.3%, respectively. A total of 19 patients died during hospitalization. All of these patients had an LCRP level ≤ 1; 14 had an NLR level ≤ 10.8; 13 had an SII ≥ 2699 (Fisher's exact test, P = .000). Independent predictors of in‐hospital mortality rates were LCRP < 1, PLR, SII ≥ 2699, white blood cell count, CRP, age, comorbidities, and ICU stay. CONCLUSIONS: We concluded that inflammatory parameters, such as LRCP, SII and NLR, were associated with disease severity and could be used as potentially important risk factors for COVID‐19 progression. The new coronavirus referred to as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) appeared in Wuhan, China, on 31 December 2019 and spread across the globe. 1 The World Health Organisation subsequently declared a pandemic. 2, 3 COVID-19 has infected approximately 20 million people and caused 724 000 deaths. 4 The patient load has seriously disturbed medical institutions. The media has reported that health institutions in some countries were insufficient and that there was nowhere for patients to be hospitalized. In hospitals where there are many patient admissions, distinguishing critical patients is one of the most sensitive issues. It is important to determine which patients have a high risk of death and which have critical illness. It has become important to classify risk factors that could reveal the severity of cases of coronavirus disease 2019 (COVID- 19) . The high pathogenicity of COVID-19 is known. However, the reason has not yet been revealed. The disease progresses more seriously in patients with comorbidities. Proinflammatory cytokines and immune inflammation may be involved in its pathophysiology. The occurrence of lymphopenia and neutrophilia has been reported in several studies. Systemic immune inflammation (SII) index, which is an inflammation-related index, is a comprehensive combination based on the counting's of peripheral lymphocyte, neutrophil and platelet. The formula of SII index is as follows: SII =platelet count ×neutrophil/lymphocyte count. The D dimer concentration, troponin concentration, neutrophil count, lymphocyte count, neutrophil-tolymphocyte ratio (NLR) and C-reactive protein (CRP) concentration, which are markers of inflammation, have been analysed in previous studies. 1, [5] [6] [7] [8] The LRCP is a parameter that can be used as an inflammation marker, similar to NLR. This rate occurs, especially in bacterial infections, by dividing the lymphocyte level the amount of which will decrease relatively, with the CRP whose blood value will increase. Its use as an inflammatory marker is extremely new. In a review that we recently conducted, only two studies that have investigated this ratio have been identified in the literature, and both works involved cancer patients. At the end of these studies, they reported that the LCRP was an inflammation marker associated with mortality and postoperative management. 9,10 However, the clinical implications of these results still remain unclear. In this retrospectively reviewed, we aimed to investigate whether severe or fatal COVID-19 in patients who presented to the emergency department (ED) of our hospital was related to specific laboratory test results and comorbidities during the first admission. This single-center cohort study was conducted at XXX University Diagnoses of COVID-19 were made according to World Health Organization interim guidance and confirmed by RNA detection of SARS-CoV-2 by an onsite clinical laboratory. 11 If a patient's PCR test was negative, the presence of clinical signs (fever of 38.3°C, cough or shortness of breath) that could not be explained by any other disease or the presence of COVID-19 findings on thoracic CT caused the patient to be evaluated as a possible case of COVID-19. We also examined the data of patients who were hospitalized in the • SII and LCRP are two new markers in this topic. • CRP, SII, PLR and NLR exhibited the largest area under the curve, with the highest specificity and sensitivity. • Decreased LCRP and increased SII can be considered independent biomarkers for indicating poor clinical outcomes. As a general practice in our hospital, these patients are evaluated by an emergency medicine specialist after being admitted to the ED. Complete blood count, glucose, kidney, liver function, electrolyte and CRP examinations are requested; a chest radiograph or chest CT is performed; and if necessary, a consultation is requested. The patients evaluated by a consultant are admitted based on laboratory test and CT results. According to the severity of COVID-19, patients are admitted to the general ward or ICU by the consultant who evaluates the patients. All these data are saved in the patients' files and the hospital's electronic medical record. The data of the patients were obtained from the electronic medical record of our hospital and the individual patient files. For each patient, one senior emergency medicine resident who blinded to the study objectives and hypothesis manually abstracted all data (demographics, clinical characteristics, hemodynamic parameters, laboratory test results, and outcomes) from clinician notes or medical history sections within the electronic health record, entered them into standardized chart abstraction tool, and then imported the data into SPSS 22.0 (SPSS, Inc, Chicago, IL) for statistical analyses. Because the laboratory markers and other parameters were studied routinely in the daily practice of our hospital for hospitalized patient, no missing data were found. A form was created to be individually The blood test results of the patients during their first admissions to the ED of our hospital were reviewed. During the study period, blood samples were drawn in tubes containing sodium citrate and analysed at room temperature using a Pentra DF Nexus Hariba medical device in the biochemistry laboratory. These blood samples were analysed for the following parameters: WBC count (4.5-11.0 × 103/µL), Hb The data were analysed using the Statistical Package for Social was calculated using the Kaplan-Meier method, and differences in survival between the groups were compared using the log-rank test. To identify variables associated with in-hospital mortality, the data were initially analysed with a univariate analysis. Significant variables were subsequently used for a stepwise forward logistic regression analysis. In addition, sensitivity and specificity evaluations for mortality were conducted. There were 160 patients hospitalized in our ED with suspected COVID-19. Of these, nine were excluded due to younger than 18 years, two were excluded because they were pregnant, and one was excluded due to lacked data. After excluding these patients, 148 patients included this study ( ratios below the cut-off value and SII ratios above the cut-off value had significantly higher mortality rates than those with LCRP ratios above the cut-off value and SII ratios below the cut-off value (logrank test = 2.663; P = .00). Independent predictors for in-hospital F I G U R E 2 Receiver operating characteristic (ROC) curve analizi neutrophil lymphocyte ratio (NLR) mortality were LCRP ≤ 1, PLR, CRP concentration, age, comorbidities, SII ≥ 2699 and ICU stay (Table 4 ). Based on the blood tests performed at the time of ED admission, the LCRP and SII were associated with both the need for mortality. Patients' comorbidities are an important predictor of mortality in COVID-19. In our study, the LRCP ratio, SII and comorbidities were independent predictors of mortality (odds ratios for comorbid disease, LCRP and SII: 3.03, 2.34 and 7.47, respectively). In our study, 19 patients died during hospitalization, and all of these patients had an LCRP ratio ≤ 1, and 14 patients had an SII ≥ 2699. Our study is valuable because it is the first study of the LCRP ratio and SII in SARS- COVID-19 is a global disease, and a significant number of patients require critical care. 10 As it is difficult to follow a large number of patients in the hospital, choosing patients with a worse prognosis seems to be one of the most important goals for medicine at present. Viral infection is closely related to the human immune system, and good immune function can help the body eliminate foreign microorganisms and control infections. 12, 13 Irregular immune cell responses are thought to play important roles in the severity of viral disease. 12, 14 In addition, peripheral blood inflammatory parameters also significantly change with COVID-19 progression. Therefore, new research has focused on available laboratory data to assess and predict clinical severity in patients with 60 years and that these cases involved comorbidities more frequently than the mild cases. 27 In our study, the mortality of our patients increased with age and comorbidities, and these results are compatible with those in the literature. In summary, we cautiously conclude that immunoinflammatory parameters, such as the NLR, PLR, SII and LRCP ratio, are associated with disease mortality and can be used to predict disease progression and mortality. In addition, a decreased LCRP ratio and increased PLR, SII and NLR, which reflect inflammation, can also indicate a poor prognosis. Therefore, inflammatory parameters, especially the LCRP ratio, SII, NLR and PLR, in COVID-19 can assist in the diagnosis of prediction of mortality. First, our study has limited data, because it is a retrospective study. It is known that some of the index/ratios obtained from the hemogram are also affected by conditions such as obesity and Abbreviations: ICU, intensive care unit; LCRP, lymphocyte C reactive protein ratio; NLR, neutrophil lymphocyte ratio; PLR, platelet lymphocyte ratio, SII, systemic immune-inflammation index. 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