Prognostic value of neutrophil-to-lymphocyte ratio in COVID-19 patients: A systematic review and meta-analysis

Background: Neutrophil-to-lymphocyte ratio (NLR) is an accessible and widely used biomarker. NLR may be used as an early marker of poor prognosis in patients with COVID-19. Objective: To evaluate the prognostic value of the NLR in patients diagnosed with COVID-19. Methods: We conducted a systematic review and meta-analysis. Observational studies that reported the association between baseline NLR values (ie, at hospital admission) and severity or all-cause mortality in COVID-19 patients were included. The quality of the studies was assessed using the Newcastle-Ottawa Scale (NOS). Random effects models and inverse variance method were used for meta-analyses. The effects were expressed as odds ratios (ORs) and their 95% confidence intervals (CIs). Small study effects were assessed with the Egger's test. Results: We analysed 61 studies (n = 15 522 patients), 58 cohorts, and 3 case-control studies. An increase of one unit of NLR was associated with higher odds of severity (OR 6.22; 95%CI 4.93 to 7.84; P <.001) and higher odds of all-cause mortality (OR 12.6; 95%CI 6.88 to 23.06; P <.001). In our sensitivity analysis, we found that 41 studies with low risk of bias and moderate heterogeneity (I² = 53% and 58%) maintained strong association between NLR values and both outcomes (severity: OR 5.36; 95% CI 4.45 to 6.45; P <.001; mortality: OR 10.42 95% CI 7.73 to 14.06; P =.005). Conclusions: Higher values of NLR were associated with severity and all-cause mortality in hospitalised COVID-19 patients.