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De Rop L, Bos DA, Stegeman I, Holtman G, Ochodo EA, Spijker R, Otieno JA, Alkhlaileh F, Deeks JJ, Dinnes J, Van den Bruel A, McInnes MD, Leeflang MM, Verbakel JY. Accuracy of routine laboratory tests to predict mortality and deterioration to severe or critical COVID-19 in people with SARS-CoV-2. Cochrane Database Syst Rev 2024; 8:CD015050. [PMID: 39105481 DOI: 10.1002/14651858.cd015050.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
BACKGROUND Identifying patients with COVID-19 disease who will deteriorate can be useful to assess whether they should receive intensive care, or whether they can be treated in a less intensive way or through outpatient care. In clinical care, routine laboratory markers, such as C-reactive protein, are used to assess a person's health status. OBJECTIVES To assess the accuracy of routine blood-based laboratory tests to predict mortality and deterioration to severe or critical (from mild or moderate) COVID-19 in people with SARS-CoV-2. SEARCH METHODS On 25 August 2022, we searched the Cochrane COVID-19 Study Register, encompassing searches of various databases such as MEDLINE via PubMed, CENTRAL, Embase, medRxiv, and ClinicalTrials.gov. We did not apply any language restrictions. SELECTION CRITERIA We included studies of all designs that produced estimates of prognostic accuracy in participants who presented to outpatient services, or were admitted to general hospital wards with confirmed SARS-CoV-2 infection, and studies that were based on serum banks of samples from people. All routine blood-based laboratory tests performed during the first encounter were included. We included any reference standard used to define deterioration to severe or critical disease that was provided by the authors. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from each included study, and independently assessed the methodological quality using the Quality Assessment of Prognostic Accuracy Studies tool. As studies reported different thresholds for the same test, we used the Hierarchical Summary Receiver Operator Curve model for meta-analyses to estimate summary curves in SAS 9.4. We estimated the sensitivity at points on the SROC curves that corresponded to the median and interquartile range boundaries of specificities in the included studies. Direct and indirect comparisons were exclusively conducted for biomarkers with an estimated sensitivity and 95% CI of ≥ 50% at a specificity of ≥ 50%. The relative diagnostic odds ratio was calculated as a summary of the relative accuracy of these biomarkers. MAIN RESULTS We identified a total of 64 studies, including 71,170 participants, of which 8169 participants died, and 4031 participants deteriorated to severe/critical condition. The studies assessed 53 different laboratory tests. For some tests, both increases and decreases relative to the normal range were included. There was important heterogeneity between tests and their cut-off values. None of the included studies had a low risk of bias or low concern for applicability for all domains. None of the tests included in this review demonstrated high sensitivity or specificity, or both. The five tests with summary sensitivity and specificity above 50% were: C-reactive protein increase, neutrophil-to-lymphocyte ratio increase, lymphocyte count decrease, d-dimer increase, and lactate dehydrogenase increase. Inflammation For mortality, summary sensitivity of a C-reactive protein increase was 76% (95% CI 73% to 79%) at median specificity, 59% (low-certainty evidence). For deterioration, summary sensitivity was 78% (95% CI 67% to 86%) at median specificity, 72% (very low-certainty evidence). For the combined outcome of mortality or deterioration, or both, summary sensitivity was 70% (95% CI 49% to 85%) at median specificity, 60% (very low-certainty evidence). For mortality, summary sensitivity of an increase in neutrophil-to-lymphocyte ratio was 69% (95% CI 66% to 72%) at median specificity, 63% (very low-certainty evidence). For deterioration, summary sensitivity was 75% (95% CI 59% to 87%) at median specificity, 71% (very low-certainty evidence). For mortality, summary sensitivity of a decrease in lymphocyte count was 67% (95% CI 56% to 77%) at median specificity, 61% (very low-certainty evidence). For deterioration, summary sensitivity of a decrease in lymphocyte count was 69% (95% CI 60% to 76%) at median specificity, 67% (very low-certainty evidence). For the combined outcome, summary sensitivity was 83% (95% CI 67% to 92%) at median specificity, 29% (very low-certainty evidence). For mortality, summary sensitivity of a lactate dehydrogenase increase was 82% (95% CI 66% to 91%) at median specificity, 60% (very low-certainty evidence). For deterioration, summary sensitivity of a lactate dehydrogenase increase was 79% (95% CI 76% to 82%) at median specificity, 66% (low-certainty evidence). For the combined outcome, summary sensitivity was 69% (95% CI 51% to 82%) at median specificity, 62% (very low-certainty evidence). Hypercoagulability For mortality, summary sensitivity of a d-dimer increase was 70% (95% CI 64% to 76%) at median specificity of 56% (very low-certainty evidence). For deterioration, summary sensitivity was 65% (95% CI 56% to 74%) at median specificity of 63% (very low-certainty evidence). For the combined outcome, summary sensitivity was 65% (95% CI 52% to 76%) at median specificity of 54% (very low-certainty evidence). To predict mortality, neutrophil-to-lymphocyte ratio increase had higher accuracy compared to d-dimer increase (RDOR (diagnostic Odds Ratio) 2.05, 95% CI 1.30 to 3.24), C-reactive protein increase (RDOR 2.64, 95% CI 2.09 to 3.33), and lymphocyte count decrease (RDOR 2.63, 95% CI 1.55 to 4.46). D-dimer increase had higher accuracy compared to lymphocyte count decrease (RDOR 1.49, 95% CI 1.23 to 1.80), C-reactive protein increase (RDOR 1.31, 95% CI 1.03 to 1.65), and lactate dehydrogenase increase (RDOR 1.42, 95% CI 1.05 to 1.90). Additionally, lactate dehydrogenase increase had higher accuracy compared to lymphocyte count decrease (RDOR 1.30, 95% CI 1.13 to 1.49). To predict deterioration to severe disease, C-reactive protein increase had higher accuracy compared to d-dimer increase (RDOR 1.76, 95% CI 1.25 to 2.50). The neutrophil-to-lymphocyte ratio increase had higher accuracy compared to d-dimer increase (RDOR 2.77, 95% CI 1.58 to 4.84). Lastly, lymphocyte count decrease had higher accuracy compared to d-dimer increase (RDOR 2.10, 95% CI 1.44 to 3.07) and lactate dehydrogenase increase (RDOR 2.22, 95% CI 1.52 to 3.26). AUTHORS' CONCLUSIONS Laboratory tests, associated with hypercoagulability and hyperinflammatory response, were better at predicting severe disease and mortality in patients with SARS-CoV-2 compared to other laboratory tests. However, to safely rule out severe disease, tests should have high sensitivity (> 90%), and none of the identified laboratory tests met this criterion. In clinical practice, a more comprehensive assessment of a patient's health status is usually required by, for example, incorporating these laboratory tests into clinical prediction rules together with clinical symptoms, radiological findings, and patient's characteristics.
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Affiliation(s)
- Liselore De Rop
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - David Ag Bos
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Inge Stegeman
- Department of Otorhinolaryngology and Head & Neck Surgery, University Medical Center Utrecht, Utrecht, Netherlands
- Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gea Holtman
- Department of Primary- and Long-term Care, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Eleanor A Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - René Spijker
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Amsterdam, Netherlands
| | - Jenifer A Otieno
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Fade Alkhlaileh
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Jonathan J Deeks
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Jacqueline Dinnes
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Ann Van den Bruel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Matthew Df McInnes
- Department of Radiology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Mariska Mg Leeflang
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Jan Y Verbakel
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Sharafi F, Jafarzadeh Esfehani R, Moodi Ghalibaf A, Jarahi L, Shamshirian A, Mozdourian M. Leukopenia and leukocytosis as strong predictors of COVID-19 severity: A cross-sectional study of the hematologic abnormalities and COVID-19 severity in hospitalized patients. Health Sci Rep 2023; 6:e1574. [PMID: 37779668 PMCID: PMC10533955 DOI: 10.1002/hsr2.1574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 10/03/2023] Open
Abstract
Background and Aims Predicting severe disease is important in provocative decision-making for the management of patients with the coronavirus disease 2019 (COVID-19); However, there are still some controversies about the COVID-19's severity predicting factors. This study aimed to investigate the relationships between clinical and laboratory findings regarding COVID-19's severity in patients admitted to a tertiary hospital in Mashhad, Iran. Methods A cross-sectional study was conducted on patients with documented COVID-19 infection based on the reverse transcription-polymerase chain reaction test. Clinical symptoms, vital signs, and medical history of the patients were recorded from their medical records. Laboratory findings and computed tomography (CT) study findings were documented. Disease severity was defined based on CT scan findings. Results A total of 564 patients (58.8 ± 16.8 years old) were evaluated. The frequency of severe disease was 70.4%. There was a significant difference in heart rate (p = 0.0001), fever (p = 0.002), dyspnea (p = 0.0001), chest pain (p = 0.0001), diarrhea (p = 0.021), arthralgia (p = 0.0001), and chills (p = 0.044) as well as lymphopenia (p = 0.014), white blood cell count (p = 0.001), neutrophil count (p < 0.0001), lymphocyte count (p < 0.0001), and prothrombin time (p = 0.001) between disease severity groups. Predictors of severe COVID-19 were pulse rate (crude odds ratio [cOR] = 1.014, 95% confidence interval [CI] for cOR: 1.001, 1.027) and leukopenia (cOR = 3.910, 95% CI for cOR: 1.294, 11.809). Predictors for critical COVID-19 were pulse rate (cOR = 1.075, 95% CI for cOR: 1.046, 1.104), fever (cOR = 2.516, 95%CI for cOR: 1.020, 6.203), dyspnea (cOR = 4.190, 95% CI for cOR: 1.227, 14.306), and leukocytosis (cOR = 3.866, 95% CI for cOR: 1.815, 8.236). Conclusions Leukopenia and leukocytosis have the strongest correlation with the COVID-19 severity. These findings could be a valuable guild for clinicians in COVID-19 patient management in the inpatient setting.
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Affiliation(s)
- Fateme Sharafi
- Department of Internal MedicineMashhad University of Medical ScienceMashhadIran
| | - Reza Jafarzadeh Esfehani
- Blood Born Infections Research Center, Academic Center for EducationCulture and Research (ACECR)—Khorasan RazaviMashhadIran
| | - AmirAli Moodi Ghalibaf
- Student Research Committee, Faculty of MedicineBirjand University of Medical SciencesBirjandIran
| | - Lida Jarahi
- Department of Community Medicine, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Ali Shamshirian
- Student Research Committee, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Mahnaz Mozdourian
- Lung Diseases Research CenterMashhad University of Medical ScienceMashhadIran
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Liana P, Samosir AP, Sari NP, Andriani RAL, Verdiansah V, Hidayatullah H, Ahmad Z, Umar TP. CD4+ and CD8+ cell counts are significantly correlated with absolute lymphocyte count in hospitalized COVID-19 patients: a retrospective study. PeerJ 2023; 11:e15509. [PMID: 37377785 PMCID: PMC10292192 DOI: 10.7717/peerj.15509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/15/2023] [Indexed: 06/29/2023] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) is a contagious respiratory illness that was declared a pandemic in March 2020. Lymphopenia is one of the specific laboratory results disturbance in COVID-19 patients. Such findings are frequently associated with substantial changes in T-cell counts, particularly CD4+ and CD8+ T-cells. This study aimed to examine the correlation between CD4+ and CD8+ cell counts and absolute lymphocyte count (ALC) in COVID-19 patients and analyze its difference based on the COVID-19 patients' severity. Methods From March 2022 to May 2022, we conducted a retrospective cohort study using medical records and laboratory data from patients diagnosed with COVID-19 at our hospital who met the inclusion and exclusion criteria. The total sampling method was used to recruit study participants. We conducted bivariate analysis, which consisted of correlation and comparative analysis. Results Thirty-five patients met the inclusion and exclusion criteria and were divided into two severity groups (mild-moderate and severe-critical). The findings of this study revealed a significant correlation between CD4+ cell count and ALC on admission (r = 0.69, p < 0.001) and the tenth day of onset (r = 0.559, p < 0.001). Similarly, there was a correlation between CD8+ and ALC at admission (r = 0.543, p = 0.001) and on the tenth day of onset (r = 0.532, p = 0.001). Individuals with severe-critical illness had lower ALC, CD4+, and CD8+ cell counts than those with mild-moderate illness. Conclusion According to the findings of this study, there is a correlation between CD4+ and CD8+ cell counts and ALC in COVID-19 patients. All lymphocyte subsets also showed a lower value in severe forms of the disease.
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Affiliation(s)
- Phey Liana
- Department of Clinical Pathology, Faculty of Medicine, Universitas Sriwijaya, Palembang, South Sumatera, Indonesia
| | | | - Nurmalia Purnama Sari
- Department of Clinical Pathology, Faculty of Medicine, Universitas Sriwijaya, Palembang, South Sumatera, Indonesia
| | - Raden Ayu Linda Andriani
- Department of Internal Medicine, Faculty of Medicine, Universitas Sriwijaya, Palembang, South Sumatera, Indonesia
| | - Verdiansah Verdiansah
- Department of Clinical Pathology, Faculty of Medicine, Universitas Sriwijaya, Palembang, South Sumatera, Indonesia
| | - Hidayatullah Hidayatullah
- Department of Internal Medicine, Faculty of Medicine, Universitas Sriwijaya, Palembang, South Sumatera, Indonesia
| | - Zen Ahmad
- Department of Internal Medicine, Faculty of Medicine, Universitas Sriwijaya, Palembang, South Sumatera, Indonesia
| | - Tungki Pratama Umar
- Faculty of Medicine, Universitas Sriwijaya, Palembang, South Sumatera, Indonesia
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Gajendra S. Spectrum of hematological changes in COVID-19. AMERICAN JOURNAL OF BLOOD RESEARCH 2022; 12:43-53. [PMID: 35291254 PMCID: PMC8918700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/24/2022] [Indexed: 06/14/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is caused by pathogenic and highly transmissible Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is a single stranded RNA virus. It rapidly emerged from an epidemic to a global pandemic form spreading in alarming levels. The pathogenesis involving spike protein which is present on the viral surface, plays a key role in host attachment and penetration. SARS-CoV-2 infection significantly affects respiratory system, but may involve other systems including haematopoietic system and homeostasis. Aim of the review article is to discuss spectrum of haematological changes in the blood counts, coagulation, peripheral blood and bone marrow in COVID-19 for complete understanding the disease process, the knowledge of which is helpful in early diagnosis and management of these patients. An extensive immune profiling of B and T cell population with analysis of spectrum of immune changes during the period of infection were also discussed. In COVID-19, changes in laboratory parameters and hematologic abnormalities have been reported and its association with early diagnosis, disease prognosis and severity has been repeatedly discussed in the literature. Changes in laboratory investigations help in risk stratification and early intervention. The most common laboratory finding in COVID-19 is lymphopenia. COVID-19 patients presented with coagulopathy is at high risk of morbidity and mortality. In severe COVID-19 patients, bone marrow aspirate shows histiocytic proliferation with hemophagocytosis. To understand the correlations between immune responses and severity of COVID-19, immune profiling of B and T cell population was compared with extensive clinical data. A deep understanding of the laboratory findings and haematological abnormalities associated with SARS-CoV-2 infection would help to raise disease suspicion in absence of Real time polymerase chain reaction or antibody results. Also the blood counts along with the morphological changes in peripheral blood would be helpful in prompt screening, diagnosis, prognosis and management of COVID-19 patients.
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Affiliation(s)
- Smeeta Gajendra
- Department of Laboratory Oncology, Dr BRA IRCH, All India Institute of Medical Sciences New Delhi, India
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Marwah M, Marwah S, Blann A, Morrissey H, Ball P, Wandroo FA. Analysis of laboratory blood parameter results for patients diagnosed with COVID-19, from all ethnic group populations: A single centre study. Int J Lab Hematol 2021; 43:1243-1251. [PMID: 33939271 PMCID: PMC8239882 DOI: 10.1111/ijlh.13538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/26/2021] [Indexed: 01/08/2023]
Abstract
Introduction Although factors such as age, sex, diabetes, obesity and changes in certain laboratory investigations are important prognostic factors in COVID‐19 infection, these may not apply to all ethnic/racial groups. We hypothesized differences in routine biochemistry and haematology indices in Caucasian and a combined group of Black, Asian and Minority Ethnic (BAME) patients who tested positive for COVID‐19 who died, compared to survivors. Methods We tested our hypothesis in 445 patients (229 Caucasian, 216 BAME) admitted to secondary care with proven COVID‐19 infection, in whom standard routine laboratory indices were collected on admission. Results After 28 weeks, 190 (42.7%) had died within 28 days of COVID diagnosis (97 Caucasians [42.4%], 93 BAMEs [43.1%], P = .923). A general linear model analysis found the ethnicity interaction with mortality to be significant for fibrinogen, ferritin and HbA1c (after controlling for age). In a multivariate analysis, a neutrophil/lymphocyte ratio > 7.4 and a urea/albumin ratio > 0.28 increased the odds of death for both the Caucasian and the BAME group. Additional factors increasing the odds ratio in the BAME group included age >60 years and being diabetic. Conclusion Neutrophil/lymphocyte ratio and urea/albumin ratio are simple metrics that predict death to aid clinicians in determining the prognosis of COVID‐19 and help provide early intensive intervention to reduce mortality. In the BAME groups, intensive monitoring even at younger age and those with diabetes may also help reduce COVID‐19 associated mortality.
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Affiliation(s)
| | - Sukhjinder Marwah
- Department of Haematology, Sandwell and West Birmingham Hospitals, NHS Trust, West Bromwich, UK
| | | | | | | | - Farooq A Wandroo
- Department of Haematology, Sandwell and West Birmingham Hospitals, NHS Trust, West Bromwich, UK
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