Thus, NLR was selected as a potential predictive factor and further analysed. Multivariable logistic regression was used to analyse the correlation between NLR levels and the progress of severe cases Table 4.
NLR was divided into tertiles. The lowest NLR level was used as the reference, and the categorical variables were analysed.
After adjustments for age, C-reactive protein, interleukin-6, procalcitonin, diabetes and hypertension, the highest tertile remained statistically significant, and the relative risk was OR 7.
Their clinical characteristics and laboratory findings were analysed. Compared with the mild group, the severe group was older, mostly had a high fever and had at least one underlying disorder. These clinical features were mostly similar to those in previous studies [ 1 , 7 ]. This finding suggested that owing to their weakened immune function, older than younger patients with chronic diseases were more likely to be infected with COVID Early identification of risk factors for severe patients is vital to afford appropriate supportive care or access to ICU if necessary.
Severe cases presented lower lymphocyte counts and higher neutrophil levels. The severe group also showed elevated biomarkers for infection. As a widely used factor for systemic infection and inflammation, NLR was used to assess the severity of bacterial infection and the clinical prognosis of pneumonia [ 8 — 10 ].
In this study, the patients in the highest NLR tertile presented a 5. Qin et al. The biological mechanism underlying this association has yet to be determined, and several plausible explanations exist. One of the most convincing explanations is based primarily on the physiological link between neutrophilia and lymphopenia with systemic inflammation and stress. Another explanation is that neutrophils are the important cellular components of the host defenses in the innate immune system, whereas lymphocytes are considered as the major cells involved in adaptive immunity [ 9 ].
Lymphocytes play a key role in the regulation of inflammatory response, and sustained reduction in severe cases is associated with the non-resolution of inflammation [ 13 ]. The mechanism underlying this regulation requires further research. A well-coordinated innate immune response is known to be the first line of defense against viral infections. However, when the first line of defense is dysregulated, excessive inflammatory cell infiltration, inflammatory storm and even death may occur [ 14 ].
Zhao et al. On the basis of the current study, patients with COVID who are suffering from pneumonia and those with increased NLR should be admitted to an isolation ward with respiratory monitoring and supportive care rather putting them into centralised isolation.
This finding should largely reduce the progression of critical illness caused by untimely treatment to reduce mortality. Our study has several advantages.
One is the previously determined biological plausibility of a strong association between NLR and the risk of incidence of severe cases.
The second is the analysis, which eliminates several potential confounding variables to avoid bias. This study also has some limitations: it was a small-sized, single-centre and retrospective study a larger cohort would be better to eliminate potential bias , and for some patients, repeated measurement data were provided on the first day.
The first data point was always used, resulting in potentially incomplete information on variations in intraday cell count. Patients with a higher NLR should be admitted to an isolation ward with respiratory monitoring and supportive care. We thank the men who have fought bravely against the virus on the front line during the COVID epidemic; some of them have even lost their lives.
We also thank the clinics that allowed us access to their databases. National Center for Biotechnology Information , U. Epidemiol Infect. Published online Jul 9. Author information Article notes Copyright and License information Disclaimer. Author for correspondence: Zhongxin Lu, E-mail: moc. Neutrophils are the first immune cell population recruited to sites of infection, including viral infections, and exhibit both protective and pathologic functions.
In antibacterial and antifungal immunity, the role of neutrophils is well defined. However, in antiviral immunity, much less is known. We analyzed with Fisher's exact test and Bonferroni correction.
During the study period, patients were suspected of having DAH. Consequently, 68 patients were included in our analysis Fig. The backgrounds of patients are shown in Table 1. The etiological diseases of DAH were immune disease 8. No variable was significantly different between the survival and death groups. The clinical characteristics of patients on admission are displayed in Table 2.
Eighteen Univariate analysis of factors associated with in-hospital death are presented in Table 3. DAH diffuse alveolar hemorrhage, AT antithrombotic therapy. An year-old woman experienced stroke as a complication following discontinuation of AT. She had been administered aspirin for angina pectoris and warfarin for atrial fibrillation. She discontinued these medicines on the day of admission, and then was diagnosed as having experienced an insular cortex stroke 15 days after discontinuation, which caused higher brain dysfunction, but was not critical.
This study investigated the prognostic factors of DAH. The main findings were 1 High neutrophils percentage in BALF was associated with a higher rate of in-hospital deaths, and 2 A higher percentage of lymphocytes in BALF was related with lower mortality.
Table 4 lists the review of the previous observational studies of prognostic factors of DAH. Furthermore, both pre-existing cardiac disease and severity of multiple organ failure were identified as factors associated with mortality in three studies [ 2 , 3 , 5 , 9 ].
Although the influence of serological findings was analyzed in all the studies, the results differed from study to study. To our knowledge, our study is the only one to have focused on the relationship between the BALF cell pattern and prognosis. We found that a high neutrophils percentage in BALF was predictive of a higher rate of in-hospital death.
Recent studies have revealed that NETs, which are released by neutrophils and composed of deoxyribonucleic acid, histones and granule-derived proteins, are cytotoxic to lung epithelium and endothelium, and can be harmful in various respiratory diseases [ 12 , 13 ]. In addition, elevated serum levels of NETs have been associated with mortality in pneumonia [ 16 ]. Diffuse alveolar damage, which is the pathological finding in ARDS and one of the pathological patterns of DAH, has been reported to be associated with an increased percentage of neutrophils in BALF and with poor prognosis [ 17 , 18 ].
These facts may result from NETs production. Because lung biopsy is usually invasive and risky in the acute phase of DAH, histopathological examination of NETs is practically difficult.
Instead, the BALF cell pattern may be a useful predictor of prognosis. A high lymphocytes percentage in BALF has been found to be associated with in-hospital survival. Glucocorticoids exert a wide range of immunosuppressive activity, including the induction of T lymphocyte apoptosis [ 19 ].
The lymphocytic cell pattern in BALF was confirmed in organizing pneumonia, nonspecific interstitial pneumonia, and hypersensitivity pneumonitis, among other conditions [ 20 ].
These diseases are usually responsive to glucocorticoids and administration of glucocorticoids was recommended [ 21 ]. Additionally, a high lymphocytes percentage in BALF was correlated with good prognosis in interstitial pneumonia or acute respiratory failure in the studies that most of cases had been administered glucocorticoids [ 22 , 23 ].
We speculate that enriched lymphocytes in BALF is associated with good responsiveness to glucocorticoids and, as a result, with good prognosis in DAH.
However, our analysis showed that in patients with higher neutrophils percentage in BALF, higher lymphocytes did not correlate with lower in-hospital mortality. Coexisting with neutrophilic inflammation, glucocorticoids treatment may not indicate a significant effect in spite of enriched lymphocytes. In our study, lower eGFR was associated with higher in-hospital mortality, as also found in a previous study [ 2 ].
Renal dysfunction has been proven as a prognostic factor in various systemic diseases listed as etiologies of DAH in our study, such as anti-neutrophil cytoplasmic antibody-related vasculitis, chronic heart failure and community-acquired pneumonia [ 24 , 25 , 26 ].
Low eGFR as prognostic factor in our study might reflect those underlying diseases. In the present study, AT was not significantly correlated with prognosis. Patients with complicated DAH-AT tended to have worse mortality because of systemic disease and that is why they tended also to have neutrophilic inflammation in their BALF.
The occurrence of complications was not significantly different between discontinuation and continuation. There were two limitations in our study. First, this was a retrospective single-center study with a small number of patients. Our sample size was insufficient for multivariate analysis. Second, our analysis excluded 59 patients who had not received bronchoscopy, so we might have missed patients who were so severe that we could not perform BAL.
In conclusion, a higher neutrophils percentage in BALF was found to be significantly associated with in-hospital mortality. Show More. Login Register.
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