Clinical Utility of Red Cell Distribution Width-to-Lymphocyte Ratio (RLR) in

Predicting Severity of Outcomes among Adult Filipino Patients Diagnosed with

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) in a Tertiary

Hospital in Valenzuela City

Submitted by:

MAYOLINE M. QUILANG, MD
Principal Author
Level III Resident
Department of Internal Medicine | Valenzuela Medical Center
Contact Number: +639171178831 or +639190955058
Email address: mayolinemedranoquilangmd@gmail.com

Authors:
MICHELLE MARIE Q. PIPO, MD, FPCP, FPCC
Medical Specialist III
Department of Internal Medicine | Valenzuela Medical Center
Contact Number: +639178380610
Email address: mitch_pipo@yahoo.com

FAIROZ M. ADAP, MD, FPCP

Medical Officer IV
Department of Internal Medicine | Valenzuela Medical Center
Contact Number: +639959624141
Email address: fairoz.adap@gmail.com

Co-Author:
LUCILLE OSIAS, MD, FPCP, FPSHBT
Medical Specialist II
Department of Internal Medicine | Valenzuela Medical Center
Contact Number: +639177949249
Email address: lucilleosias@yahoo.com
Quilang, M. M., et al. | March 2021

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 Quilang, M. M., et al. | March 2021

TABLE OF CONTENTS

LIST OF TABLES …………………………………………………………………………………………………………………………………………………… 4

LIST OF FIGURES ………………………………………………………………………………………………………………………………………………… 5

ACKNOWLEDGEMENT ………………………………………………………………………………………………………………………………………………… 6

ABSTRACT …………………………………………………………………………………………………………………………………………………………………… 7

I. INTRODUCTION: Background of the Study ……………………………………………………………………………… 9

II. REVIEW of RELATED LITERATURE …………………………………………………………………………………………………… 10
A. Coronavirus Disease-19 (COVID-19): Current Guidelines on
diagnosis…………………………………………………………………………………………………………………………………………………… 10
B. Red Cell Distribution Width (RDW) as a biomarker of disease …………… 14
C. Red Cell Distribution Width (RDW)-to-Lymphocyte Ratio (RLR) as
biomarker ………………………………………………………………………………………………………………………………………………… 16
D. Significance of the study ……………………………………………………………………………………………………… 17

III. RESEARCH QUESTION ……………………………………………………………………………………………………………………………… 18

IV. OBJECTIVES …………………………………………………………………………………………………………………………………………………… 18

A. General Objectives ……………………………………………………………………………………………………………………… 18
B. Specific Objectives …………………………………………………………………………………………………………………… 18

V. METHODOLOGY …………………………………………………………………………………………………………………………………………………… 20
A. General Schema of the Study ………………………………………………………………………………………………… 21
B. Study Duration …………………………………………………………………………………………………………………………………… 21
C. Setting ……………………………………………………………………………………………………………………………………………………… 21
D. Sample Size Computation …………………………………………………………………………………………………………… 21
E. Study Population ……………………………………………………………………………………………………………………………… 21
1. Inclusion criteria ………………………………………………………………………………………………… 21
2. Exclusion criteria ………………………………………………………………………………………………… 22
F. Data Sources ………………………………………………………………………………………………………………………………………… 22
G. Definition of Terms ……………………………………………………………………………………………………………………… 24
H. Data Elements Abstracted ………………………………………………………………………………………………………… 26
I. Outcomes of Interest …………………………………………………………………………………………………………………… 27
J. Statistical Methods ……………………………………………………………………………………………………………………… 28
K. Confidentiality ………………………………………………………………………………………………………………………………… 30
L. Regulatory and Ethical Consideration ………………………………………………………………………… 30

VI. RESULTS …………………………………………………………………………………………………………………………………………………………… 31

A. Demographics ………………………………………………………………………………………………………………………………………… 31
B. Difference of In-hospital Mortality and No Event ………………………………………… 33
C. Cut-off Point for Red Cell Distribution Width (RDL)-to-
Lymphocyte Ratio (RLR)………………………………………………………………………………………………………………… 34
D. Association of Red Cell Distribution Width (RDL)-to-
Lymphocyte Ratio (RLR) and Different Clinical Parameters …………………… 35
E. Performance Measures of RLR in Predicting In-hospital Mortality … 36

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 Quilang, M. M., et al. | March 2021

VII. DISCUSSION ………………………………………………………………………………………………………………………………………………… 37

VIII. LIMITATIONS OF THE STUDY ………………………………………………………………………………………………………… 39

IX. CONCLUSION …………………………………………………………………………………………………………………………………………………… 40

X. RECOMMENDATIONS ………………………………………………………………………………………………………………………………………… 41

APPENDICES ……………………………………………………………………………………………………………………………………………………………… 42
A. Letter of Intent to Do Chart Reviews ………………………………………………………………… 42
B. Data Collection Forms ………………………………………………………………………………………………………… 43
C. Gantt Chart …………………………………………………………………………………………………………………………………… 45
D. Budget Allocation …………………………………………………………………………………………………………………… 46

REFERENCES ……………………………………………………………………………………………………………………………………………………………… 47

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 Quilang, M. M., et al. | March 2021

LIST OF TABLES

Table 1. Demographic and baseline characteristics of the study

population ………………………………………………………………………………………………………………… 31

Table 2. Comparison of In-hospital Mortality Cohort and No

Event Groups according to Hematologic Parameters……………… 33

Table 3. Association of RLR and Clinical Outcomes of COVID-19

Patients ……………………………………………………………………………………………………………………… 35

Table 4. Performance Measures of RLR in Predicting

In-hospital Mortality …………………………………………………………………………………… 36

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 Quilang, M. M., et al. | March 2021

LIST OF FIGURES

Figure 1. Conceptual Framework of the Study …………………………………………………… 20

Figure 2. Receiver Operating Characteristic (ROC) Curve of RLR … 35

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 Quilang, M. M., et al. | March 2021

ACKNOWLEDGEMENT

The completion of this research would have never been fulfilled without the help of

the following:

First and foremost, praises and thanks to God, the Almighty, for his showers of

blessing throughout my research to complete this work successfully.

I am extremely grateful to my family for their love, prayers, care and sacrifices. It

was great relief to know that I have you to rely on when I needed comfort and inspiration.

I would like to express my deep and sincere gratitude to my mentor and research

supervisor Dr. Michelle Q. Pipo for giving me opportunity to do my research and providing

invaluable guidance throughout this research. And to all my consultants and co-residents

who have been always helping and encouraging me throughout my 3-year residency

training. Your encouragement when the times get rough are much appreciated and duly

noted.

I am feeling obliged in taking the opportunity to sincerely thanks to all the staff

members at laboratory, HIMD department and COVID ward for their generous attitude

and friendly behavior to me during the accomplishment of this research.

I have no valuable words to express my thanks, but my heart is still full of the favors

received from all of you.

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 Quilang, M. M., et al. | March 2021

ABSTRACT

Background: The Coronavirus Disease 2019 (COVID-19) pandemic is causing

substantial morbidity and mortality. Predicting the clinical outcome of COVID-19 is
important for both clinicians and patients. However, predictors of in-hospital mortality
have been less intensively addressed thus far.

Objective: This current study investigated the utility of Red Cell Distribution Width
(RDW)-to-Lymphocyte Ratio (RLR) as biomarker to predict severity of clinical outcomes
of COVID-19 patients.

Methodology: This study employed a hospital-based retrospective cohort approach of

adult in-patients with laboratory-confirmed SARS-CoV-2 infection as determined by PCR
which performed posteriori, using information and data from chart review.

Findings: A total of 163 COVID-19 patients admitted from March 2020 to February 2021
were included in the study of which 90 patients had low RLR level while 73 patients had
high RLR level. RLR was significantly associated with Body Mass Index (BMI) (p = 0.019)
but not with age, gender, co-morbidities, symptoms, and duration between onset of
symptoms and admission. There is a significant difference between the mean RLR in the
in-hospital mortality group and no event group (p = 0.033); however, mean RDW and
mean lymphocyte count did not vary significantly across cohorts. High RLR was
significantly associated with need for mechanical ventilation (p < 0.001), higher in-hospital
mortality (p < 0.001) and shorter length of hospital stay (p = 0.001). The optimal cut-off
point of RLR was determined to be 1.238 (with optimal criterion of 0.319) with a sensitivity,
specificity, positive predictive value, negative predictive value, positive likelihood ratio and
negative likelihood ratio as follows: 59.30% (95% CI: 48.50-69.50%); 72.60% (95% CI:
60.90-82.40%); 73.00% (95% CI: 61.40-80.80%); 58.90% (95% CI: 48.10-71.70%); 2.166
(95% CI: 1.437-3.265); 0.560 (95% CI: 0.421-0.745) respectively.

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Conclusions: RLR is an inexpensive and easily calculated index that can potentially
predict mortality of COVID-19 patients. The combined information provided by RDW and
lymphocyte count assessment may be a better prognostic predictor than RDW or
lymphocytopenia taken individually. However, it is recommended that future multicenter
studies are needed to confirm our results.

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I. INTRODUCTION: Background of the study

Coronavirus disease 2019 (COVID-19) is a respiratory disease caused by a novel

coronavirus named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).

On January 7, 2020, the responsible novel coronavirus was identified by the Chinese

Center for Disease Control and Prevention (CDC), and was subsequently named as

SARS-CoV-2 which was previously known as 2019-nCoV by WHO, and pneumonia

caused by 2019-nCoV was named COVID-19.1 The epidemiological and clinical

characteristics of COVID-19 have been well described in various literatures. But more

importantly, the rapid increase in cases has led to heavy burdens on public healthcare

resources and medical facilities.2 The COVID-19 pandemic has been spreading rapidly

worldwide since March 2020 now affecting almost 113 million human beings as to date,

of which 2.5 million had died.3 Locally, a good number of 570,000 Filipinos have been

affected while 12,200 had died.3

Studies reveal that the majority of infected individuals are not severely affected

and can recover without medical intervention, whereas a small number of cases need to

be carefully treated and hospitalized.4 The mortality rate for severe cases, particularly

those that are critically ill, is quite high.2 It is therefore critical to identify reliable predictors

for disease severity to improve outcomes and conserve medical resources. Predicting the

clinical outcome of COVID-19 patients is important for both clinicians and patients;

however, such predictions remain difficult because of lack of sensitivity and specificity.

Multivariable analysis showed older age, coronary artery disease, cancer, low lymphocyte

count and high Radiographic Assessment of Lung Edema (RALE) score as factors

independently associated with an increased risk of mortality.5

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Novel biomarkers to predict outcome would be useful in the management of

COVID-19 as potential surrogate measures. Red Cell Distribution Width (RDW) and

lymphocyte count are inexpensive parameters that have been considered as novel

prognostic markers that may reflect an underlying inflammatory state. Many clinical

studies have proved that the alterations of RDW levels may be associated with the

incidence and prognosis in many diseases.5 On the other hand, based on the findings of

the study of Liu et al. on COVID-19 in Wuhan, China, lymphocytopenia on admission

could predict that patients who are initially not tagged as severe cases would develop

severe disease in the hospital.1 RDW and lymphocyte count taken together can be a

predictive marker and can play a significant role in the prognostication of COVID-19. This

present study investigated the relationship between RDW-to-lymphocyte (RTL) ratio upon

admission and clinical outcomes of patients. To the best of our knowledge, no study

regarding the prognostic value of RTL in SARS-CoV-2 patients has been conducted.

II. REVIEW OF RELATED LITERATURE

A. Coronavirus Disease-19 (COVID-19): Current Guidelines on Diagnosis

Coronavirus Disease-19, shortened to COVID-19, is caused by a newly emergent

coronavirus – the Severe Acute Respiratory Syndrome Coronavirus 2 or SARS-CoV-2.

In January 24, 2020, Huang, C. et al. published in Lancet the clinical features of the first

41 patients admitted with then-called 2019-nCoV or 2019 novel coronavirus. It was noted

then that men were mostly infected with less than half had underlying diseases. Their

common symptoms were fever, cough, and myalgia or fatigue. Dyspnea developed in

more than half of the patients with all patients noted to have pneumonia with abnormal

findings on chest CT. Lymphopenia was also noted in more than half of patients while

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more than one-fourth developed acute respiratory distress syndrome. 6 Since then, our

knowledge about SARS-CoV-2 and COVID-19 had long been involving with the disease

causing pandemic that have resulted in significant social and economic disruption.

Transmission mainly occurs from both symptomatic and asymptomatic people to

others by close contact through respiratory droplets or by direct contact with infected

persons, or by contact with contaminated objects and surfaces, or by aerosols, i.e. in

enclosed spaces indoors, crowded and inadequately ventilated spaces, where infected

persons spend long periods of time with others, which may include restaurants, choir

practices, fitness classes, nightclubs, offices and places of worship, or during aerosol-

generating procedures.7

Clinical and virologic studies that have collected repeated biological samples from

confirmed patients demonstrate that shedding of SARS-CoV-2 is highest in the upper

respiratory tract (URT) (nose and throat) within the first 3 days from onset of symptoms.

The incubation period for COVID-19, which is the time between exposure to the virus

(becoming infected) and symptom onset, is, on average, 5–7 days, but can be up to 14

days. During this period, also known as the “presymptomatic” period, some infected

persons can be contagious, from 1–3 days before symptom onset. An asymptomatic case

is a person infected with SARS-CoV-2 who does not develop symptoms.7

The proportion of persons who become infected with SARS-CoV-2 and remain

asymptomatic remains to be better understood, recent meta-analysis reported an overall

estimate of 31%. Most people with COVID-19 develop only mild (40%) or moderate (40%)

disease. Nonetheless, approximately 15% develop severe disease that requires oxygen

support, and 5% have critical disease with complications such as respiratory failure, acute

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respiratory distress syndrome (ARDS), sepsis and septic shock, thromboembolism,

and/or multiorgan failure, including acute kidney injury and cardiac injury.7 As of February

28, 2021, the global death-to-case ratio is 2.22 percent.3

The World Health Organization has released guidelines for the clinical

management of COVID-19, the latest of which was dated January 25, 2021.7 Locally, the

Philippine Society for Microbiology and Infectious Diseases (PSMID) alongside with

Philippine College of Chest Physicians (PCCP), Philippine College of Physicians (PCP),

Philippine Rheumatology Association (PRA) and Philippine College of Hematology and

Transfusion Medicine (PCHTM) released an interim guidance on the clinical management

of adult patients with suspected or confirmed COVID-19 infection. Version 3.1 released

in July 20, 2020 provided recommendations which are based on limited, often low-quality

evidence, and need to be carefully balanced with clinical judgment.8

All symptomatic individuals with suspected SARS CoV-2 respiratory tract infection

should undergo testing for COVID-19 as well as ancillary tests warranted by their clinical

condition. All symptomatic individuals suspected of having COVID-19 patients should

undergo SARS CoV-2 RT-PCR assay testing to diagnose COVID-19 infection.8 WHO

does not currently recommend the use of antigen-detecting rapid diagnostic tests for

patient care, although research into their performance and potential diagnostic utility is

highly encouraged. Laboratory based immunoassays such as chemiluminescence assay

(CLIA) and enzyme-linked immunosorbent assay (ELISA) are the preferred tests for

antibody determination. This is best done on the third week onwards from the onset of

symptoms.8

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PSMID recommends that the following ancillary tests should be done on patients

suspected for COVID-19 with the consequent diagnostic findings to be found on high-risk

patients: (1) leukopenia or lymphopenia in complete blood count (CBC) on which patients

where an absolute lymphocyte count of <0.8 is considered a poor prognostic factor; (2)

metabolic panel (creatinine, liver function tests, sodium, potassium, magnesium, calcium,

albumin) where ALT, AST and bilirubin may be noted to be elevated while albumin may

be decreased; (3) inflammatory markers like elevated lactate dehydrogenase (LDH),

ferritin, C-reactive protein (CRP), and low procalcitonin may point to COVID-19; (4)

prothrombin; (5) D-dimer of >2.4 increases ICU stay; (6) arterial blood gas (ABG)

measurement; (7) blood cultures if concomitant bacterial infection is suspected; (8)

respiratory tract specimen for influenza testing; (9) Sputum, endotracheal aspirate (ETA),

or bronchoalveolar lavage fluid culture and sensitivity; (10) Chest radiograph which may

be normal initially but mostly with bilateral infiltrates; (10) Plain high-resolution chest

computed tomography (CT) scan (HRCT) which may show ground glass opacities that

are typically bilateral and peripheral in distribution, fine regular opacities, and vascular

thickening; and, (11) electrocardiogram (ECG).8

In a retrospective study of 191 patients by Zhou et al., odds of in-hospital death

were higher in patients with diabetes or coronary heart disease. Age, lymphopenia,

leukocytosis, elevated ALT, lactate dehydrogenase, high-sensitivity cardiac troponin I,

creatine kinase, d-dimer, serum ferritin, IL-6, prothrombin time, creatinine, and

procalcitonin were also associated with death on univariate analysis. Older age, higher

SOFA score, and D-dimer greater than 1 μg/mL at admission were associated with

increased odds of death.9

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In a large cohort study done by Liu and colleagues involving 1190 patients with

confirmed COVID-19, 22% developed a severe illness after admission. Multivariable

logistic regression demonstrated that higher SOFA score and lymphocytopenia on

admission were independent risk factors for in-hospital deterioration from not severe to

severe disease and for death in severe patients. On admission D-dimer greater than 1

µg/L, leukocytopenia, thrombocytopenia, and history of diabetes were also associated

with higher risks of in-hospital death in severe COVID-19 patients.1

Patients with low-risk or mild disease are patients noted to have mild symptoms

but without pneumonia nor hypoxia. If patient has pneumonia but is not oxygen requiring,

patient is tagged to have moderate-risk. However, if patient has pneumonia with SpO2 of

<92, respiratory rate of >30 and systolic BP of <90 mmHg, patient is considered to have

be severe or critical ill and tagged to be a high-risk patient. These are also patients who

have advanced age (>60 years old) and pre-existing comorbids like chronic lung disease,

chronic kidney disease, diabetes mellitus, hypertension, cerebrovascular disease,

cardiac disease, previous transplantation, immunosuppression and cancer.7,8

B. Red Cell Distribution Width (RDW) as a biomarker of disease

Red cell distribution width is the coefficient of variation in red blood cell (RBC)

volume, or the standard deviation divided by the mean. It quantifies the variation which of

individual RBC volumes, which vary from one cell to the next and for the same cell as it

circulates during its approximately 115-day life span. RDW appears to be a nonspecific

marker of illness that has the potential to provide general quantitative risk stratification

that may be particularly useful for a new and unknown disease.

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Elevated RDW is associated with an increased risk for all-cause mortality; mortality

from heart disease, pulmonary disease, sepsis, influenza, and cancer; complications

associated with heart failure, severity of coronary artery disease and viral hepatitis,

advanced stage and grade for many cancers; and the development of diabetes, chronic

obstructive pulmonary disease, stroke, anemia, and many other conditions.10

In a retrospective study done by Foy et al. with a total of 1641 patients included,

elevated RDW (>14.5%) was associated with an increased mortality risk in patients of all

ages. Moreover, patients whose RDW increased during hospitalization had higher

mortality compared with those RDW did not change, i.e. for those with normal RDW,

mortality increased from 6% to 24%, and for those with an elevated RDW at admission,

mortality increased from 22% to 40%.10

In another study, RDW-Coefficient of Variation (CV) and RDW-Standard Deviation

(SD) were significantly higher in the poor outcome group than in the good outcome group.

The area under the ROC curve (AUC) of RDW-SD was at 0.870. Of the different

hematologic parameters, RDW-SD was the most significant single parameter for

predicting the prognosis of severe patients.11 However, the study only included 98

patients from January 20, 2020 to March 30, 2020.

The specific mechanism or mechanisms for the alteration of RDW in COVID-19

should be studied further but it is to be noted that RDW is a nonspecific marker of general

disease. The association of elevated RDW with COVID-19 severity could be consistent

with previous reports suggesting that RDW can become elevated when RBC production

kinetics have slowed in the setting of increased WBC and platelet kinetics.12

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C. Red Cell Distribution Width (RDW)-to-Lymphocyte Ratio (RLR) as biomarker

In several studies above-mentioned, RDW can be a statistically useful biomarker

in prognosticating patients with COVID-19. Lymphopenia, on the other hand, has been

found in early publications about COVID-19 to be significantly common in patients with

severe disease.6 Mechanisms on lymphocyte deficiency have been speculated: (1)

Lymphocytes express the coronavirus receptor ACE2 and may be a direct target of

viruses, resulting to lymphocyte death;13 (2) Acute lymphocyte decline might be related to

lymphocytic dysfunction, and the direct damage of novel coronavirus virus to organs such

as thymus and spleen cannot be ruled out; (3) Inflammatory cytokines continued to be

disordered, perhaps leading to lymphocyte apoptosis;14 and, (4) Inhibition of lymphocytes

by metabolic molecules produced by metabolic disorders, such as hyperlactic acidemia

which might suppress the proliferation of lymphocytes.15

Sharma and colleagues noted that lymphopenia was observed to be present in

80% of its symptomatic patients. Among the patients who died of COVID-19, lymphopenia

was observed in 82% of patients. RDW was slightly raised in both groups with a median

RDW of 15.3% in COVID 19 patients which was raised as compared to that observed in

normal population (range: 12.8 ± 1.2 %). However, only 35 symptomatic and 35

asymptomatic patients were included in the study. RDW-to-RLR was not studied.16

Yang et al. studied the diagnostic and predictive role of neutrophil-to-lymphocyte

ratio (NLR), derived-NLR (d-NLR), and platelet-to-lymphocyte ratio (PLR) in COVID-19

patients and found out that elevated age and NLR can be considered independent

biomarkers for indicating poor clinical outcomes.17

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A more recent study investigated and compared the prognostic impacts of C-

reactive protein, white blood cell (WBC) count, NLR, PLR, RDW biomarkers in laboratory-

confirmed COVID-19 cases. In addition, they explored the most useful diagnostic

biomarkers and optimal cutoff values in COVID-19 patients. Their study comprising a total

of 233 patients showed that CRP, LDH, PLR and NLR levels remained significantly higher

in COVID-19 positive patients, while eosinophil, lymphocyte, and platelet levels were

significantly elevated in COVID-19 negative patients.18

On thorough review of available literature in silico, no study to date has been

shown to use RDW-to-lymphocyte ratio or RLR as biomarker in COVID-19. In other

literatures, however, high RLR has been shown to be associated with disease severity

and poorer prognosis in liver disease19 and carcinoma20.

D. Significance of the Study

This study would shed light for the utilization of a novel hematologic biomarker that

may prove valuable in predicting the clinical outcome of in-hospital SARS-CoV-2 patients.

RDW and lymphocyte, being part of a routine CBC, would be very useful and cost efficient

if proven to have clinical validity in predicting outcomes of critically ill patients. It may

prove beneficial to clinicians because of the simplicity of assessment yet has predictive

and prognostic value thereby adding to the assessment tools in the evaluation of SARS-

CoV-2 patients. Moreover, this research can serve as a springboard of information for

subsequent studies.

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III. RESEARCH QUESTION

Can the novel biomarker RDW-to-lymphocyte (RTL) ratio predict the severity of clinical

outcomes in adult Filipino patients diagnosed with Severe Acute Respiratory Syndrome

Coronavirus-2 (SARS-CoV-2) in a tertiary hospital in Valenzuela City?

IV. OBJECTIVES

Objectives of the Study

To know the predictive value of the novel biomarker RDW-to-lymphocyte (RTL)

ratio for severity of clinical outcomes among adult Filipino patients diagnosed with Severe

Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) in a tertiary hospital in

Valenzuela City.

Specific Objective

1. To characterize the study population dichotomized according to level of RLR in

terms of the following demographic and clinical characteristics:

a. Age

b. Gender

c. BMI

d. Co-morbidities

e. Symptoms

f. Duration between onset of symptoms and admission

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2. To know if there is a significant difference between all-cause death cohort and no-

event cohort in terms of the following laboratory parameters:

a. RDW

b. Lymphocyte

c. RLR

3. To determine the optimal cut-off point for RLR using receiver operating

characteristic (ROC).

4. To determine if there is a significant association between RLR in terms of the

following clinical parameters:

a. All-cause mortality

b. Length of hospital stay

c. Need for mechanical ventilator

5. To determine the sensitivity, specificity, predictive value and likelihood ratio of RLR

for in-hospital mortality.

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V. METHODOLOGY

A. General Schema of the Study:

The primary investigator did a chart review of patients of Valenzuela Medical

Center who have laboratory-confirmed SARS-CoV-2 infection as determined by Reverse

Transcriptase-Polymerase Chain Reaction (RT-PCR). The investigator performed

retrospective cohort approach.

Clinical Outcomes of
SARS-CoV-2 Adult
Determination of Patients:
Red Cell Distribution Optimal Cut-off Point
Width-to-Lymphocyte Using • All-cause mortality
Ratio (RLR) Receiver Operating • Length of hospital
Characteristic (ROC) stay
Analysis • Need for mechanical
ventilator

Figure 1. Conceptual Framework of the Study

Figure 1 above shows the conceptual framework of the study. The study evaluated the

association of RLR with clinical outcomes which include: all-cause mortality, length of hospital

stay and need for mechanical ventilator among SARS-CoV-2 patients. ROC analysis was utilized

to determine the optimal cut-off point of RTL ratio to identify high risk and low risk adult SARS-

CoV-2 patients for all-cause mortality and was evaluated in terms of its accuracy in predicting all-

cause mortality.

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B. Study Duration:

The study covered patients who have laboratory-confirmed SARS-CoV-2 infection

as determined by Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR)

admitted in Valenzuela Medical Center from March 2020 to February 2021.

C. Setting:

Valenzuela Medical Center (VMC)

D. Sample Size

A total of 163 patients who were admitted as a case of COVID-19 at VMC were

included in the study of which 90 patients had low RLR level while 73 patients had high

RLR level.

The minimum sample size was calculated to be 65 patients for each group at 95%

confidence level, power of 0.65, 0.05 type I error and Area Under the ROC Curve (AUC)

of 0.6 with allocation ratio of 1.

E. Study Population:

Inclusion Criteria

1. Adult ≥18 years of age at time of enrolment

2. Has laboratory-confirmed SARS-CoV-2 infection as determined by RT-PCR

3. Patients with severity classification of COVID-19 as moderate, severe and critical.

4. Admitted patients with available baseline lymphocyte and RDW and lymphocyte

values on CBC on admission

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Exclusion Criteria

1. Patients who were transferred to another intensive care facility and thus lost to

follow-up

2. Patients who were discharge within 24-h after admittance

3. Patients with incomplete history and laboratory workup;

4. Patients with hemoglobinopathies, bone marrow transplant patients, and those

who received blood transfusion prior to ICU admission.

5. Patients who have received intravenous heparin within 24 hours of enrollment

6. Those who have participated in a therapeutic interventional study in the last 30

days

7. Pregnancy

8. Human immunodeficiency virus infection under highly active antiretroviral therapy

(HAART)

F. Data Sources

A letter addressed to the medical director and other important personnel of the

hospital was submitted asking for permission to extract and utilize the charts of patients

who tested positive for SARS-CoV-2. Potential cases were identified from the list of

patients provided by the Hospital Surveillance Unit. The list of patients was then submitted

to the Records Division for chart extraction and review. In addition, the investigator

checked the date of discharge or expiration from the discharge or mortality logbooks of

the department the patients were admitted to. Hospital numbers and date of discharge or

expiration are important for looking for the charts in the Records Division since the

hospital is not using an electronic way of data keeping of patients’ records. The names of

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the patients who were identified to have fulfilled the inclusion and exclusion criteria were

abstracted.

According to the Interim Guidance on the Clinical Management of Adult Patients

with Suspected or Confirmed COVID-19 Infection version 3.1 released by the Philippine

Society of Microbiology and Infectious Diseases (PSMID) last July 29, 2020, confirmed

cases of COVID-19 are any individual, irrespective of the presence or absence of clinical

signs and symptoms, who is laboratory-confirmed for COVID-19 in a test conducted at

the national reference laboratory, a subnational reference laboratory, and/or officially

accredited laboratory testing facility. The currently recommended test to confirm COVID-

19 infection is an RT-PCR assay, which detects the viral RNA. Using this assay, SARS-

CoV-2 can be detected in nasal or pharyngeal samples, sputum or bronchoalveolar

lavage fluid.

Only patients classified as moderate, severe and critical were included in the study.

The classification was provided by the World Health Organization7 and has then been

adapted by the PSMID as provided in their July 29, 2020 guidelines8.

Consequently, this study defines COVID-19 cases as patients with positive real-

time reverse transcription polymerase chain reaction (RT-PCR) with moderate, severe

and critical classification.

For patients whose initial Complete Blood Count (CBC) result was not found in the

chart, their results were obtained from the hospital’s Hematology Unit of the Laboratory

Department headed by the Department of Pathology.

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 Quilang, M. M., et al. | March 2021

G. Definition of terms:

1. Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2)

patients in the context of the study are those in-hospital patients with laboratory-

confirmed SARS-CoV-2 infection as determined by Reverse Transcriptase-

Polymerase Chain Reaction (RT-PCR).

2. Coronavirus Disease-19 (COVID-19) with mild disease patients are

symptomatic patients presenting with fever, cough, fatigue, anorexia, myalgias;

other non-specific symptoms such as sore throat, nasal congestion, headache,

diarrhea, nausea and vomiting; loss of smell (anosmia) or loss of taste (ageusia)

preceding the onset of respiratory symptoms with NO signs of pneumonia or

hypoxia.

3. COVID-19 with moderate disease patients are patients with clinical signs

of non-severe pneumonia (e.g. fever, cough, dyspnea, respiratory rate (RR) =

21-30 breaths/minute, peripheral capillary oxygen saturation (SpO2) >92% on

room air).

4. COVID-19 with severe disease patients are patients with clinical signs of

severe pneumonia or severe acute respiratory infection as follows: fever, cough,

dyspnea, RR>30 breaths/minute, severe respiratory distress or SpO2 <92% on

room air.

5. COVID-19 with critical disease patients are patients manifesting with

Acute Respiratory Distress Syndrome (ARDS), sepsis and/or septic shock.

6. Patients with ARDS are those with onset within 1 week of known clinical

insult (pneumonia) or new or worsening respiratory symptoms, progressing

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 Quilang, M. M., et al. | March 2021

infiltrates on chest X-ray or chest CT scan, with respiratory failure not fully

explained by cardiac failure or fluid overload.

7. Patients with Sepsis are those with life-threatening organ dysfunction

caused by a dysregulated host response to suspected or proven infection. Signs

of organ dysfunction include altered mental status, difficult or fast breathing, low

oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold

extremities or low blood pressure, skin mottling, or laboratory evidence of

coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia.

8. Patients with Septic Shock are those with persistent hypotension despite

volume resuscitation, requiring vasopressors to maintain MAP > 65 mmHg and

serum lactate level >2 mmol/L.

9. In-hospital mortality which refers to All-cause mortality is the primary

end point of the study which is the death rate from all causes of death for a

population of SARS-CoV-2 patients in the study time period

10. Red cell distribution width (RDW) is a hematologic test that helps

measure variation in red blood cell volume and size which was used in the study

to determine the utility of RTL in predicting all-cause mortality among SARS-

CoV-2 patients.

11. Lymphocyte count is a hematologic test that determines the number of

lymphocytes in the sample of blood which was used in the study to determine

the utility of RLR in predicting all-cause mortality among SARS-CoV-2 patients.

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 Quilang, M. M., et al. | March 2021

12. Red Cell Distribution (RDW)-to-lymphocyte ratio (RLR) is the

independent variable of the study that was evaluated for its predictive value for

all-cause mortality among SARS-CoV-2 patients.

13. Predictive value refers to the likelihood for determining all-cause mortality

among SARS-CoV-2 patients at based on their RLR.

14. Receiver Operating Characteristic (ROC) curve analysis of RLR defines

the optimal cut-point as the point maximizing the Youden function which is the

difference between true positive rate and false positive rate over all possible cut-

point values. It was constructed by mapping of the sensitivity versus 1-

specificity for all possible values of the cut-point between cases and controls.

H. Data Elements Abstracted:

The medical records of adult in-patients in the discharge file admitted in the

institution who fulfilled the inclusion and exclusion were reviewed. Demographic data,

laboratory values and outcome parameters were extracted for review from the medical

records of the patients. Patients were dichotomized, i.e. the independent variable was

split to form high and low groups based on RLR optimal cut-off points. These were then

compared with respect to their means on the demographic and clinical variables.

Admission or transfer to the institution were verified. Documentation that the

patient was admitted or transferred to the institution was needed. Patients were then

characterized in terms of the following demographic and clinical variables: age, gender,

BMI, co-morbidities, symptoms, and duration between onset of symptoms and admission.

Patients' ages were characterized in terms of the following: early adulthood (22-34 years

27
 Quilang, M. M., et al. | March 2021

of age); early Middle Age (35-44 years of age); late Middle Age (45-64 years of age); and,

late adulthood (65 and older). On the other hand, BMI in kg/m2 was classified as

underweight (<18.5 kg/m2); normal weight (18.5–24.9 kg/m2); overweight (25–29.9

kg/m2); and, obesity (>30 kg/m2). Comorbidities such as hypertension, cardiovascular

disease, diabetes mellitus, malignancy, Chronic obstructive pulmonary disease (COPD),

chronic kidney disease (CKD), respiratory illness, including asthma and others were

evaluated. The following signs and symptoms were recorded: fever, chills, fatigue, sore

throat, coryza, nausea and vomiting, dry cough, myalgia, headache, expectoration,

diarrhea, sore throat, loss of taste, loss of smell, rash, difficulty of breathing and chest

pain.

The initial complete blood count (CBC) results requested upon admission were

retrieved from the medical records of the patients and the laboratory department. CBC

was assessed in all patients at hospital admission. Specifically, the data on routine

hematologic tests such as RDW and lymphocyte count were evaluated and recorded.

Finally, the RLR was computed based on the following formula:

𝐑𝐞𝐝 𝐜𝐞𝐥𝐥 𝐝𝐢𝐬𝐭𝐫𝐢𝐛𝐮𝐭𝐢𝐨𝐧 𝐰𝐢𝐝𝐭𝐡

𝐑𝐞𝐝 𝐜𝐞𝐥𝐥 𝐝𝐢𝐬𝐭𝐫𝐢𝐛𝐮𝐭𝐢𝐨𝐧 𝐰𝐢𝐝𝐭𝐡 𝐭𝐨 𝐋𝐲𝐦𝐩𝐡𝐨𝐜𝐲𝐭𝐞 𝐫𝐚𝐭𝐢𝐨 =
𝐋𝐲𝐦𝐩𝐡𝐨𝐜𝐲𝐭𝐞 𝐂𝐨𝐮𝐧𝐭

I. Outcomes of interest:

In-hospital mortality, or the all-cause mortality, is the primary endpoint of the study.

This refers to all of the deaths that occur in the study population regardless of the cause.

The total number of deaths was recorded accordingly. The study population was reported

as follows: (1) all-cause death and (2) no event.

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 Quilang, M. M., et al. | March 2021

An in-patient stay is when a patient is formally admitted to a hospital. The average

length of hospital stay was used as secondary endpoint of the study. It refers to the

average number of days stayed by all inpatients from the day the patient was admitted

until the day of discharge or expiration.

The need for mechanical ventilation is defined as being ventilated mechanically

through an endotracheal tube or a tracheostomy. Patients who were ventilated on

admission but who were subsequently extubated within 24-h after admission were

categorized in the non-ventilated, because these patients were, in general, patients that

were quickly weaned.

J. Statistical Methods:

Data was encoded in MS Excel by the researcher. Stata MP version 14 software

was used for data processing and analysis. Continuous data was presented as

mean/standard deviation (SD) or median/interquartile range (IQR) depending on data

distribution. Categorical data was presented as frequency and percentages. Continuous

variables were compared using independent t test or Mann Whitey U test. Categorical

variables were analyzed using Chi square test or Fisher’s exact test. P values ≤0.05 was

considered as statistically significant. Charts and graphs were created using MS Excel.

Finally, the cut off to determine the high and low RDW-to-Lymphocyte ratio was derived

from ROC curve analysis provided by easyROC: a web-tool for ROC curve analysis (ver.

1.3) which was accessed from http://www.biosoft.hacettepe.edu.tr/easyROC/.

A receiver operating characteristic (ROC) curve was applied to determine a cut-off

point of the panel that could best predict the occurrence of death. The receiver operator

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 Quilang, M. M., et al. | March 2021

characteristic (ROC) curve shows the tradeoff between sensitivity and specificity as one

changes the cut-off values for positivity. The sensitivity versus 1-specificity plot in ROC

space is called ROC curve. The higher discriminant capacity of the test corresponds with

the ROC curve.8 The two cohorts dichotomized based from the derived optimum cut-off

point was compared in terms of the following clinical outcomes: all-cause mortality, length

of hospital stay and need for mechanical ventilator.

The prognostic and predictive value of RLR was based on the computation of

sensitivity, specificity, likelihood ratio and predictive value with corresponding 95%

confidence interval. Sensitivity, also called the true positive rate, measures the proportion

of positives that are correctly identified. This means that they are both positive for the

outcome and positive with the diagnostic test.

Specificity or true negative rate measures the proportion of negatives that are

correctly identified as such. In the context of this study, these are the proportion of patients

negative for the result and negative for the diagnostic tests.

The following formula was adopted for sensitivity and specificity:

Sensitivity or True Positive Rate (TPR)

𝑇𝑃 𝑇𝑃
𝑻𝑷𝑹 = =
𝑃 𝑇𝑃 + 𝐹𝑁

Specificity or True Negative Rate

𝑇𝑁 𝑇𝑁
𝑺𝑷𝑪 = =
𝑁 𝑇𝑁 + 𝐹𝑃

Where: TP = True Positive

TN = True Negative

FP = False Positive

FN = False Negative

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 Quilang, M. M., et al. | March 2021

Furthermore, the positive and negative predictive values are the proportions of

positive and negative results that are true positive and true negative results.

Precision or positive predictive value (PPV)

𝑇𝑃
𝑃𝑃𝑉 =
𝑇𝑃 + 𝐹𝑃

Negative predictive value (NPV)

!"
𝑁𝑃𝑉 = !"#$"

K. Confidentiality:

The master list of patients was kept by the primary investigator with the excel file

of patients’ data protected by a password. Backup file of the excel file will only be sent to

the primary investigator, the statistician, and the primary investigator’s research adviser

if needed. The investigator shall not use data and records for any purpose other than

conducting the study.

L. Regulatory and Ethical Consideration:

The study protocol was submitted to the adviser and technical review board of the

Department of Internal Medicine of the institution prior to Institutional Review Board (IRB)

submission. Ethics approval was obtained before study commencement. This hospital-

based retrospective study was conducted following the principles outlined in the

Declaration of Helsinki and approved by the IRB.

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 Quilang, M. M., et al. | March 2021

VI. RESULTS
A. Demographics

A total of 163 patients who were admitted as a case of COVID-19 at VMC were

included in the study of which 90 patients had low RLR level while 73 patients had high

RLR level. Table 1 below presents the demographic and clinical characteristics of the

study population. Patients are predominantly males in the late middle age (45-64 years

old) across cohort. Both age and gender are not associated with levels of RLR. In terms

of BMI, the following are the frequency and percentage of underweight (<18.5 kg/m2);

normal weight (18.5-24.9 kg/m2); overweight (25-29.9 kg/m2); and obesity (>30 kg/m2) for

low RLR cohort and high RLR cohort: 13 (14.44%) and 22 (30.14%); 57 (63.33%) and 38

(52.05%); 18 (20%) and 6 (8.22%); 2 (2.22%) and 0 (0%) respectively. Higher BMI is

associated with lower RLR.

Table 1. Demographic and baseline characteristics of the study population

Low RLR High RLR
Variables N=90 N=73 P value
N/Mean %/SD N/Mean %/SD
Age (Years)
Early Adulthood
18 20.00% 12 16.44% 0.884
(22-34 yrs. old)
Early Middle Age
13 14.44% 11 15.07%
(35-44 yrs. old)
Late Middle Age
35 38.89% 27 36.99%
(45-64 yrs. old)
Late Adulthood
24 26.67% 23 31.51%
(³65 yrs. old)
Gender
Male 49 54.44% 42 57.53% 0.692
Female 41 45.56% 31 42.47%
Body mass index (kg/m2)
Underweight
13 14.44% 22 30.14% 0.019
(<18.5 kg/m2)
Normal weight
57 63.33% 38 52.05%
(18.5–24.9 kg/m2)
Overweight
18 20.00% 6 8.22%
(25–29.9 kg/m2)
Obesity 2 2.22% 0 0.00%

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 Quilang, M. M., et al. | March 2021

(>30 kg/m2)
Comorbidities
None 23 25.56% 16 21.92% 0.315

Hypertension 54 60.00% 37 50.68%

Cardiovascular
53 58.89% 38 52.05%
disease
Diabetes Mellitus 28 31.11% 21 28.77%

Malignancy 1 1.11% 5 6.85%

COPD 2 2.22% 0 0.00%

Chronic kidney
9 10.00% 13 17.81%
disease
Respiratory illness,
14 15.56% 14 19.18%
including asthma
Others 1 1.11% 0 0.00%
Symptoms
Fever 39 43.33% 27 36.99% 0.984

Chills 2 2.22% 1 1.37%

Fatigue 7 7.78% 8 10.96%

Sore throat 3 3.33% 2 2.74%

Coryza 1 1.11% 2 2.74%

Nausea and
12 13.33% 11 15.07%
Vomiting
Dry Cough 29 32.22% 15 20.55%

Myalgia 14 15.56% 11 15.07%

Headache 3 3.33% 3 4.11%

Expectoration 22 24.44% 18 24.66%

Diarrhea 6 6.67% 3 4.11%

Sore throat 0 0.00% 0 0.00%

Loss of taste 0 0.00% 0 0.00%

Loss of smell 0 0.00% 0 0.00%

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 Quilang, M. M., et al. | March 2021

Rash 0 0.00% 0 0.00%

Difficulty of
62 68.89% 47 64.38%
breathing
Chest pain 16 17.78% 14 19.18%
Duration between
onset of symptoms 6.19 4.77 5.77 6.43 0.632
and admission

The two most common comorbidities of the study population are hypertension and

cardiovascular disease with the following frequency and percentage: 54 (60.00%) and 37

(50.68%) for low RLR cohort; and 53 (58.89%) and 38 (52.05%) for high RLR cohort

respectively. Co-morbidity is not associated with RLR. In terms of symptomatology,

majority of patients experienced difficulty of breathing and fever that prompted consult

with the following frequency and percentage for low and high RLR cohorts: 62 (68.89%)

and 47 (64.38%); and 39 (43.33%) and 27 (36.99%) respectively. Symptoms of patients

are not associated with RLR. Lastly, the duration between onset of symptoms and

admission did not vary significantly across cohorts (P=0.632).

B. Difference between In-hospital Mortality and No Event

Table 2. Comparison of In-hospital Mortality Cohort and No Event Groups according to

Hematologic Parameters
In-hospital
No Event
Mortality
Variables N=72 P-Value
N=91

Mean SD1 Mean SD

Red cell distribution width (%) 14.166 2.176 13.544 2.057 0.065

Lymphocyte count (%) 12.841 8.917 15.397 7.989 0.059

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 Quilang, M. M., et al. | March 2021

Red cell distribution width-to-

1.644 0.979 1.301 1.049 0.033
lymphocyte ratio (RLR)
1 – Standard Deviation (SD)
Table 2 above compares in-hospital mortality group and no event groups according to

hematologic parameters. The mean (±SD) RDW and lymphocyte count of in-hospital mortality

group and no event group were as follows: 14.166 (SD±2.176) and 13.544 (SD±2.057); and

12.841 (SD±8.917) and 15.397 (SD±7.989) respectively. There is no significant difference across

groups in terms of RDW and lymphocyte count; however, the mean RLR in the in-hospital group

1.644±0.979 is significantly higher compared to no event group 1.301±1.049.

C. Cut-off Point for Red Cell Distribution Width (RDL)-to-Lymphocyte Ratio (RLR)
The identification of the optimal cut-point value of RLR requires a simultaneous

assessment of sensitivity and specificity. Figure 1 below shows the Receiver Operating

Characteristic (ROC) curve analysis of RLR constructed by mapping of the sensitivity

versus 1- specificity for all possible values of the cut-point between cases and controls.

The optimal cut-off point of RLR was determined to be 1.238 (with optimal criterion of

0.319) which is the point that best discriminates patients at high risk for in hospital

mortality in terms of both sensitivity and specificity.

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 Quilang, M. M., et al. | March 2021

Figure 1. Receiver Operating Characteristic (ROC) Curve of RLR

D. Association of Red Cell Distribution Width (RDL)-to-Lymphocyte Ratio (RLR) and

Different Clinical Parameters

Table 3. Association of RLR and Clinical Outcomes of COVID-19 Patients

Low RLR High RLR

Variables N=90 N=73 P-Value

Frequency Percentage Frequency Percentage

Need for mechanical

43 47.78% 64 87.67 < 0.001
ventilator

In-hospital mortality 37 41.11% 54 73.97% < 0.001

Length of Hospital
stay (mean days ± 11.90 11.43 6.60 7.98 0.001
SD)

Table 3 above shows the association of RLR and clinical outcomes of COVID-19

patients. The frequency of patients needing mechanical ventilator and in-hospital mortality

were as follows: 43 (47.78%) and 37 (41.11%) for the low RLR cohort and 64 (87.67%)

and 54 (73.97%) for the high RLR cohort. Both need for mechanical ventilator and in-

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 Quilang, M. M., et al. | March 2021

hospital mortality were significantly associated with high RLR. On the other hand, the

mean length of hospital stay of low RLR cohort (11.90 days ±11.43) was significantly

higher than those with high RLR (6.60 days ±7.98).

E. Performance Measures of RLR in Predicting In-hospital Mortality

Table 4. Performance Measures of RLR in Predicting In-hospital Mortality

95% Confidence Interval
Parameters Value
Upper Limit Lower Limit
Sensitivity 59.30% 48.50% 69.50%
Specificity 72.60% 60.90% 82.40%
Positive Predictive Value 73.00% 61.40% 80.80%
Negative Predictive Value 58.90% 48.10% 71.70%
Positive Likelihood Ratio 2.166 1.437 3.265
Negative Likelihood Ratio 0.560 0.421 0.745

Table 4 shows the performance measures of RLR in predicting in-hospital

mortality. The sensitivity, specificity, positive predictive value, negative predictive value,

positive likelihood ratio and negative likelihood ratio of RLR for in-hospital mortality was

as follows: 59.30% (95% CI=48.50-69.50%); 72.60% (95% CI=60.90-82.40%); 73.00%

(95% CI=61.40-80.80%); 58.90% (95% CI=48.10-71.70%); 2.166 (95% CI=1.437-3.265);

0.560 (95% CI=0.421-0.745) respectively.

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 Quilang, M. M., et al. | March 2021

VII. DISCUSSION

Survival rates among people hospitalized with COVID-19 has improved, but rising

cases is causing the total number of deaths to increase. Predictors of early mortality,

however, have been less intensively addressed thus far. Consequently, more refined

prognostication of poor outcome including death is especially needed in the management

of COVID-19. This is clinically important since such knowledge would impact on

management decisions, which can range from recognizing the need for intensified

monitoring to withdrawal from maximal therapy. A prognostic biomarker helps indicate

how a disease may develop in an individual when a disorder is already diagnosed.

Quantifying biomarkers at multiple levels and integrating multiple biomarkers for

prognostication lead to more accurate predictions.21 In this study, the utility of RLR was

explored to discriminate high-risk from low-risk patients in terms of in-hospital mortality.

The use of novel biomarker such as RLR in the clinical environment not only impacts the

risk of adverse outcomes for patients, but the use of this can also affect clinical practice.

In this current study, high RLR has been shown to be significantly associated with

high BMI. According to Tanaka et al., lymphocytes may be reduced in human obesity,

and that this may be related, at least in part, to the elevated TNF-alpha production.

Blastogenic responses to phytohemagglutinin or concanavalin A of T cells, CD3(+),

CD4(+), CD8(+), CD4(+) CD45RO(+), and TCR alpha beta T cells were significantly

diminished in obese subjects. Consequently, this has an impact in the RLR.22 In a meta-

analysis, Chang et al. reported that BMI was found to be higher in patients with severe

disease than in those with mild or moderate disease. Furthermore, Elevated BMI was

associated with invasive mechanical ventilation (IMV) use (MD 4.1, 95% CI, 2.1–6.1; p

<.0001) in Western countries, and this result was consistent across studies.23 Other

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 Quilang, M. M., et al. | March 2021

demographic and clinical variables, however, such as age, gender, co-morbidities,

symptoms, and duration between onset of symptoms and admission were not associated

with RLR.

Data showed that RDW and lymphocyte count did not vary significantly across

groups. However, RLR measured at upon admission of expired patients was significantly

higher compared to patient who were subsequently discharged as improved from COVID-

19. However, in the study conducted by Foy et al., they found out that RDW during

hospitalization were associated with significantly higher mortality risk for patients with

SARS-CoV-2 infection.10 According to Huang et al., lymphopenia is associated with poor

outcome in patients with COVID-19.24 This is the first study to the best of our knowledge

to investigate the relationship between COVID-19 mortality and RLR. In this current study,

high RLR was associated with need for mechanical ventilation, in-hospital mortality and

lower length of hospital stay. We could attribute the lower length in hospital stay to the

increase in mortality, hence shorter hospital stay, in this cohort.

The approach for the identification of the optimal cut-off point value in ROC

analysis was based on the area under the ROC curve (AUC), sensitivity, and specificity

values. The method defines the optimal cut-point as the point maximizing the Youden

function which is the difference between true positive rate and false positive rate over all

possible cut-point values. At an optimal cut-off point of 1.238 derived from ROC analysis,

the specificity of RLR was noted to be 72.60% (95% CI=60.90-82.40%). This means that

RLR will correctly return a low result for 72.60% of COVID-19 patients who would survive,

but will return a false-positive result for 27.4% of the COVID-19 patients who would expire

and should have tested with low RLR. With a sensitivity of 59.30% (95% CI=48.50-

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 Quilang, M. M., et al. | March 2021

69.50%), RLR will correctly return a high value for 59.30% of COVID-19 patients who

would expire, but will return a false-negative for 40.70% of COVID-19 patients who have

survived and should have tested with high RLR.

Moreover, RLR has a positive predictive value of 73% (95% CI=61.40-80.80%)

and negative predictive value of 58.90% (95% CI=48.10-71.70%). This means that if

COVID-19 patient screens with high RLR, there is a 73% probability that the patient would

expire. On the other hand, if a COVID-19 patient screens with low RLR, there is 58.9%

probability that the patient would survive. Finally, the positive and negative likelihood

ratios indicate that the results generate small but sometimes important shifts in

probability.

The RLR is an inexpensive and easily calculated index that can potentially predict

mortality of COVID-19 patients. The combined information provided by RDW and

lymphocyte count assessment may be a better prognostic predictor than RDW at

admission or lymphopenia alone.

VIII. LIMITATIONS OF THE STUDY

The major limitation of this study is its retrospective nature hence, this study would

have to rely on the accuracy of bookkeeping of the Records Division. Moreover, the

number of patients studied is small despite the great homogeneity of the groups

evaluated.

Because the time of initial infection was unavailable, these results are not specific

to any disease progression time points. In addition, the socioeconomic status of patients

was unavailable, and the potential association of mortality risk with socioeconomic status

could not be assessed.

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 Quilang, M. M., et al. | March 2021

Another yet important limitation would be the current problem of increasing number

of different SARS-CoV-2 variants that may behave differently from each other, i.e. one

being highly infectious from the others. With all the mutations going on, we may be facing

a more deadly type of variant that will greatly affect our current knowledge of the

pathogenesis and clinical course of outcome of COVID-19. With COVID-19, we’re still

learning and our current knowledge is still evolving.

IX. CONCLUSION

The following conclusions were drawn based from the findings of the study:

1. RLR is significantly associated with BMI (P=0.019) but not with age, gender, co-

morbidities, symptoms, and duration between onset of symptoms and admission;

2. There is a significant difference between RLR in the in-hospital mortality group and no

event group (P=0.033); however, RDW and lymphocyte count did not vary significantly

across cohorts;

3. High RLR is significantly associated with the need for mechanical ventilation

(p<0.001), higher in-hospital mortality (p<0.001), and shorter length of hospital stay

(p=0.001)

4. The optimal cut-off point of RLR was determined to be 1.238 (with optimal criterion of

0.319); with a sensitivity, specificity, positive predictive value, negative predictive

value, positive likelihood ratio and negative likelihood ratio as follows: 59.30% (95%

CI = 48.50-69.50%); 72.60% (95% CI = 60.90-82.40%); 73.00% (95% CI = 61.40-

80.80%); 58.90% (95% CI = 48.10-71.70%); 2.166 (95% CI = 1.437-3.265); 0.560

(95% CI = 0.421-0.745) respectively.

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 Quilang, M. M., et al. | March 2021

X. RECOMMENDATIONS

It is recommended that this study be re-created in different centers to include a

larger number of participants with different geographic locations. This will further include

a wider range of population groups to increase generalizability of the study.

Moreover, different SARS-CoV-2 variants should eventually be taken into

consideration in future studies.

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 Quilang, M. M., et al. | March 2021

APPENDICES

APPENDIX A: Letter of Intent to do chart review

November 23, 2020

MARIA ESTRELLA B. LITAM, MD, MBA-H, FPPS, FPIDSP

Medical Center Chief II
Valenzuela Medical Center
Padrigal St., Karuhatan, Valenzuela, 1441

THRU:

ESTELLA E. JAVIER, MD, FPOGS

Hospital Training Officer

MA EILEEN R. SIANGHIO, MD, FPAFP

Head, Surveillance Unit

LUISITO D. CELESTINO, MD, FPSP, RPh

Head, Department of Laboratory and Pathology

ESPERANZA K. CAMACHO, MGM

Head, Hospital Information Management Department

MARILEN A. HACHERO, RTRP, MMHoA

Chief Respiratory Therapist

Dear Ma’am;

Good day!

I am Mayoline M. Quilang, a Third year resident of the Department of Internal Medicine. As part of the requirements of the
residents, we have to submit a clinical research output. The department has continuously pushed the residents to choose a research
that is timely and relevant hence, I have chosen to conduct a study entitled “Clinical Utility of Red Cell Distribution Width-to-Lymphocyte
(RTL) Ratio in Predicting Severity of Outcomes among Adult Filipino Patients Diagnosed with Severe Acute Respiratory Syndrome
Coronavirus-2 (SARS-CoV-2) in a Tertiary Hospital in Valenzuela City.” The study aims to review the clinical validity of Red Cell
Distribution Width-to-Lymphocyte (RTL) Ratio as a potential new biomarker in predicting the severity of clinical outcomes of patients
with Coronavirus Disease-19 (COVID-19).

In this regard, I would like to ask permission from your good office to allow me to tap the different departments of our
institution so I can review the records and list of patients considered to be COVID-19 positive based on nasopharyngeal/oral swab
from March 2020 onwards. From the hospital records, I am going to extract the patients’ demographic and clinical details aside from
their diagnostic results. I promise to limit the use of the patients’ data for this study alone and to maintain confidentiality at all times.

Hoping for you positive response.

Thank you and more power!

Respectfully yours,

Mayoline Medrano Quilang, MD

Third Year Resident
Department of Internal Medicine

Noted by:

Michelle Marie Q. Pipo, MD

Internal Medicine Research Coordinator
Co-author

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APPENDIX B: Data Collection Form

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APPENDIX C: Gantt Chart

WEEK
ACTIVITY
1 2 3 4
Data Gathering
Analysis of data
Completion of paper

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APPENDIX D: Budget Allocation

Price Quantity Subtotal

Paper for printing Php 150 per ream 2 reams Php 300
Printing of protocols Php 1.50 per page 200 pages Php 300
and final paper
OVERALL TOTAL Php 600

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