Original Article

Association between the Neutrophil-to-Lymphocyte Ratio and Inpatient Mortality in Hospitalized Older Veterans with COVID-19 Infection

Authors: Amy M. Gonnell, MD, Natasha M. Resendes, MD, Alma Diaz Quinones, MD, Andria Chada, MD, Christian Gomez, MD, Shivaan Oomrigar, MD, Jorge G. Ruiz, MD

Abstract

Objectives: Determine the association of high neutrophil-to-lymphocyte ratio (NLR) values with inpatient mortality and other outcomes in older veterans hospitalized with coronavirus disease 2019 (COVID-19).

Methods: This was a retrospective, multicenter, cohort study of hospitalized adults, with laboratory-confirmed COVID-19 infection who were studied for 1 year after discharge or until death. The NLR was categorized into tertiles, and we determined frailty status with the 31-item Veterans Affairs Frailty Index. Multivariate logistic regression and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were performed to assess the association between NLR and clinical outcomes.

Results: The study included 615 hospitalized adult veterans, mean age 66.12 (standard deviation 14.79) years, 93.82% (n = 577) male, 57.56% (n = 354) White, 81.0% (n = 498) non-Hispanic, median body mass index of 30.70 (interquartile range 25.64–34.99, standard deviation 7.13), and median length of stay of 8 days (interquartile range 3–15). Individuals in the middle and upper tertile groups had higher inpatient mortality (8.37%, n = 17 and 18.36%, n = 38, respectively) as compared with the lower tertile (2.93%, n = 6, P < 0.001). Compared with the lowest tertile, the middle and upper tertiles had a higher risk of inpatient mortality (aOR 3.75, 95% CI 1.38–10.21, P = 0.01, and aOR 8.13, 95% CI 3.18–20.84, P < 0.001, respectively). The highest tertile had a higher odds of intensive care unit admission (aOR 4.47, 95% CI 2.33–8.58, P < 0.001) and intensive care unit transfer (aOR 3.54, 95% CI 1.84–6.81, P < 0.001).

Conclusions: The NLR score is a clinically useful tool to predict in-hospital mortality in older patients with COVID-19.
Posted in: Infectious Disease136

Full Article

Having trouble viewing the article content below? Click here to open it directly.

Images

Download Image

Download Image

Download Image

Download Image

Download Image

References

1. Lithander FE, Neumann S, Tenison E, et al. COVID-19 in older people: a rapid clinical review. Age Ageing, 2020;49:501–515.
 
2. Becerra-Muñoz VM, Núñez-Gil IJ, Eid CM, et al. Clinical profile and predictors of in-hospital mortality among older patients hospitalised for COVID-19. Age Ageing 2021;50:326–334.
 
3. CDC COVID-19 Response Team. Severe outcomes among patients with coronavirus disease 2019 (COVID-19) - United States, February 12-March 16, 2020. https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm. Published March 27, 2020. Accessed December 17, 2022.
 
4. Epidemiology Working Group for NCIP Epidemic Response, Chinese Center for Disease Control and Prevention. [The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China [in Chinese]. Zhonghua Liu Xing Bing Xue Za Zhi 2020;41:145–151.
 
5. Dumitrascu F, Branje KE, Hladkowicz ES, et al. Association of frailty with outcomes in individuals with COVID-19: a living review and meta-analysis. J Am Geriatr Soc 2021;69:2419–2429.
 
6. Hu B, Huang S, Yin L, et al. The cytokine storm and COVID-19. J Med Virol 2021;93:250–256.
 
7. Wang Y, Pang SC, Yang Y, et al. A potential association between immunosenescence and high COVID-19 related mortality among elderly patients with cardiovascular diseases. Immun Ageing 2021;18:25.
 
8. Thomas B, Goodacre S, Lee E, et al. Prognostic accuracy of emergency department triage tools for adults with suspected COVID-19: the PRIEST observational cohort study. Emerg Med J 2021;38:587–593.
 
9. Zahorec R. “Neutrophil-to-lymphocyte ratio, past, present and future perspectives.” Bratisl Lek Listy 2021;122:474–488.
 
10. Blomaard LC, Speksnijder C, Lucke JA, et al. Geriatric screening, triage urgency, and 30-day mortality in older emergency department patients. J Am Geriatr Soc 2020;68:1755–1762.
 
11. Alkhatip AAAMM, Kamel MG, Hamza MK, et al. The diagnostic and prognostic role of neutrophil-to-lymphocyte ratio in COVID-19: a systematic review and meta-analysis. Expert Rev Mol Diagn 2021;21:505–514.
 
12. Ozdin M, Hakan K, Gulact U, et al. The diagnostic value of neutrophil to lymphocyte ratio in determining the severity of COVID-19. IMC J Med Sci 2021;16:1–7.
 
13. Li Y, Du X, Chen J, et al. Neutrophil-to-lymphocyte ratio as an independent risk factor for mortality in hospitalized patients with COVID-19. J Infect 2020;81:e6–e12.
 
14. Moradi EV, Teimouri A, Rezaee R, et al. Increased age, neutrophilto-lymphocyte ratio (NLR) and white blood cells count are associated with higher COVID-19 mortality. Am J Emerg Med 2021;40:11–14.
 
15. Lian J, Jin C, Hao S, et al. High neutrophil-to-lymphocyte ratio associated with progression to critical illness in older patients with COVID-19: a multicenter retrospective study. Aging (Albany NY) 2020;12:13849–13859.
 
16. Pillai J, Mistry PPK, Le Roux DA, et al. Laboratory parameters associated with prolonged hospital length of stay in COVID-19 patients in Johannesburg, South Africa. S Afr Med J 2022;112:201–208.
 
17. Liu G, Zhang S, Hu H, et al. The role of neutrophil-lymphocyte ratio and lymphocyte–monocyte ratio in the prognosis of type 2 diabetics with COVID-19. Scott Med J 2020;65:154–160.
 
18. Kashefizadeh A, Ohadi L, Golmohammadi M, et al. Clinical features, and short-term outcomes of COVID-19 in Tehran, Iran: an analysis of mortality and hospital stay. Acta Biomed 2020;91:e2020147.
 
19. Jeraiby MA, Hakamy MI, Albarqi MB, et al. Routine laboratory parameters predict serious outcome as well as length of hospital stay in COVID-19. Saudi Med J 2021;42:1165–1172.
 
20. Chelariu AC, Coman AE, Lionte C, et al. The value of early and follow-up elevated scores based on peripheral complete blood cell count for predicting adverse outcomes in COVID-19 patients. J Pers Med 2022;12:2037.
 
21. Haran C, Gimpel D, Clark H, et al. Preoperative neutrophil and lymphocyte ratio as a predictor of mortality and morbidity after cardiac surgery. Heart Lung Circ 2021;30:414–418.
 
22. Da Silva M, Cleghorn MC, Elnahas A, et al. Postoperative day one neutrophil-to-lymphocyte ratio as a predictor of 30-day outcomes in bariatric surgery patients. Surg Endosc 2017;31:2645–2650. .
 
23. Uthamalingam S, Patvardhan EA, Subramanian S, et al. Utility of the neutrophil to lymphocyte ratio in predicting long-term outcomes in acute decompensated heart failure. Am J Cardiol 2011;107:433–438.
 
24. Ergin ÖN, Bayram S, Anarat FB, et al. Prognostic factors affecting survival of patients with intertrochanteric femoral fractures over 90 years treated with proximal femoral nailing. Eur J Trauma Emerg Surg 2020;46: 663–669.
 
25. Seropian IM, Romeo FJ, Pizarro R, et al. Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as predictors of survival after heart transplantation. ESC Heart Fail 2018;5:149–156.
 
26. Tan L, Wang Q, Zhang D, et al. Lymphopenia predicts disease severity of COVID-19: a descriptive and predictive study. Signal Transduct Target Ther 2020;5:61.
 
27. Sotoodeh Ghorbani S, Taherpour N, Bayat S, et al. Epidemiologic characteristics of cases with reinfection, recurrence, and hospital readmission due to COVID-19: a systematic review and meta-analysis. J Med Virol 2022;94:44–53.
 
28. Kimura LF, Sant’Anna MB, Andrade SA, et al. COVID-19 induces proatherogenic alterations in moderate to severe non-comorbid patients: a single-center observational study. Blood Cells Mol Dis 2021;92:102604.
 
29. Miller EA, Simpson E, Nadash P, et al. Thrust into the spotlight: COVID-19 focuses media attention on nursing homes. J Gerontol B Psychol Sci Soc Sci 2021;76:e213–e218.
 
30. Lai YF, Lim YW, Kuan WS, et al. Asian attitudes and perceptions toward hospital-at-home: a cross-sectional study. Front Public Health 2021;9:704465.
 
31. Kojima G. Frailty as a predictor of nursing home placement among community-dwelling older adults: a systematic review and meta-analysis. J Geriatr Phys Ther 2018;41:42–48.
 
32. Hao Q, Zhou L, Dong B, et al. The role of frailty in predicting mortality and readmission in older adults in acute care wards: a prospective study. Sci Rep 2019;9:1207.
 
33. Sherman RL, Judon KM, Koufacos NS, et al. Utilizing a health information exchange to facilitate COVID-19 VA primary care follow-up for veterans diagnosed in the community. JAMIA Open 2021;4:ooab020.
 
34. Nuti SV, Qin L, Rumsfeld JS, et al. Association of admission to Veterans Affairs hospitals vs non-Veterans Affairs hospitals with mortality and readmission rates among older men hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA 2016;315:582–592.
 
35. Anhang Price R, Sloss EM, Cefalu M, et al. Comparing quality of care in Veterans Affairs and non-Veterans Affairs settings. J Gen Intern Med 2018;33:1631–1638.
 
36. Austin CA, Mohottige D, Sudore RL, et al. Tools to promote shared decision making in serious illness: a systematic review. JAMA Intern Med 2015;175: 1213–1221.
 
37. Ellis G, Langhorne P. Comprehensive geriatric assessment for older hospital patients. Br Med Bull 2005;71:45–59.
 
38. Hshieh TT, Yang T, Gartaganis SL, et al. Hospital Elder Life Program: systematic review and meta-analysis of effectiveness. Am J Geriatr Psychiatry 2018;26: 1015–1033.