Neutrophil-to-lymphocyte ratio on admission to predict the severity and mortality of COVID-19 patients: a meta-analysis

The neutrophil-to-lymphocyte ratio (NLR), an inflammatory marker, was suggested to be predictive of severity and mortality in COVID-19 patients, thus allowing early risk stratification. In this study, we investigated whether NLR levels on admission could predict the severity and mortality of COVID-19 patients. A literature search was conducted on 23 July 2020 to retrieve all published articles, including grey literature and preprints, investigating the association between on-admission NLR values and severity or mortality in COVID-19 patients. The risk of bias was assessed using the Newcastle Ottawa Scale (NOS). A meta-analysis was performed to determine the overall standardized mean difference (SMD) in NLR values and the pooled risk ratio (RR) for severity and mortality with the 95% Confidence Interval (95%CI). Meta-regression analysis was done to identify potential confounders. A total of 38 articles, including 5699 patients with severity outcomes and 6033 patients with mortality outcomes, were included. The meta-analysis showed that severe and non-survivors of COVID-19 had higher on-admission NLR levels than non-severe and survivors (SMD 0.88; 95%CI 0.72-1.04; I²=75% and 1.68; 95%CI 0.98-2.39; I²=99%, respectively). Regardless of the different NLR cut-off values, the pooled mortality RR in patients with elevated vs. normal NLR levels was 2.75 (95%CI 0.97-7.72). Meta-regression analysis showed that the association between NLR levels on admission and COVID-19 severity and mortality was unaffected by age (p=0.236; p=0.213, respectively). High NLR levels on admission were associated with severe COVID-19 and mortality. Further studies need to focus on determining the optimal cut-off value for NLR before clinical use.