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The correlation of neutrophil-to-lymphocyte ratio (NLR) and monocytes-to-lymphocytes ratio (MLR) with disease severity in hospitalized patients with Coronavirus disease 2019 (COVID-19)

  • Suhartono Suhartono ,
  • Indra Wijaya ,
  • Nadjwa Zamalek Dalimoenthe ,


Background: Early intervention of cases with potential progression to severe disease is essential to improve survival probability in Coronavirus disease 2019 (COVID-19). Systemic inflammation plays an essential role in the process of disease aggravation. This study aimed to assess the correlation of systemic inflammatory response related biomarkers neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR) on time to admission with the disease severity of inpatients with COVID-19.

Methods: We performed a retrospective study using secondary data from medical records of inpatients with COVID-19 at Murni Teguh Memorial Hospital, Medan, Indonesia, from June 1 to September 30, 2020. The demographic data were collected from the medical record and the hematologic parameter from the laboratory. NLR and MLR were calculated by dividing the absolute neutrophils and monocytes counts by the absolute lymphocyte counts. The data were tabulated and analyzed by univariate and bivariate analysis with a significance level of p<0.05.

Results: Study subjects consisted of 55 non-severe cases and 40 severe cases. The median NLR and MLR of severe and non-severe groups were 7.65 vs 2.92 (p<0.001) and 0.46 vs 0.25 (p=0.013). The correlation coefficients of NLR and MLR with disease severity were 0.564 (p<0.001) and 0.257 (p=0.012). The AUC of ROC analysis was 0.830 (cut-off:>4.81;p<0.001) in NLR and 0.650 (cut-off:>0.31; p=0.013) in MLR to predict the severe disease.

Conclusion: NLR and MLR had a significant positive correlation with the disease severity. NLR is better than MLR in predicting severe disease in hospitalized patients with COVID-19. 


  1. Jin Y, Yang H, Ji W, Wu W, Chen S, Zhang W, Duan G. Virology, epidemiology, pathogenesis, and control of COVID-19. Viruses. 2020; 12 (4): 372; doi: 10.3390/v12040372.
  2. World Health Organization?. Clinical management of COVID-19: interim guidance, May 27 2020. World Health Organization.
  3. Harapan H, Itoh N, Yufika A, Winardi W, Keam S, Te H, et al. Coronavirus disease 2019 (COVID-19): A literature review. J Infect Public Health. 2020; 13(5): 667-673.
  4. Sun Q, Qiu H, Huang M, Yi Y. Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province. Ann Intensive Care. 2020;10 (1): 33. doi: 10.1186/s13613-020-00650-2
  5. Russell CD, Parajuli A, Gale HJ, Bulteel NS, Schuetz P, Jager CPC, Loonen AJM, et al. The utility of peripheral blood leucocyte ratios as biomarkers in infectious diseases: A systematic review and meta-analysis. J Infect. 2019; 78 (5): 339-348
  6. Huang Y, Liu A, Liang L, Jiang J, Luo H, Deng W, et al. Diagnostic value of blood parameters for community-acquired pneumonia. Int Immunopharmacol. 2018; 64:10-15.
  7. Sun S, Cai X, Wang H, He G, Lin Y, Lu B, et al. Abnormalities of peripheral blood system in patients with COVID-19 in Wenzhou, China. Clin Chim Acta. 2020; 507:174-180.
  8. Zhu Z, Cai T, Fan L, Lou K, Hua X, Huang Z, et al. Clinical value of immune-inflammatory parameters to assess the severity of coronavirus disease 2019. Int J Infect Dis. 2020; 95: 332-339.
  9. Yang AP, Liu JP, Tao WQ, Li HM. The diagnostic and predictive role of NLR, d-NLR and PLR in COVID-19 patients. Int Immunopharmacol. 2020; 84: 106504.
  10. Ou M, Zhu J, Ji P, Li H, Zhong Z, Li B et al. Risk factors of severe cases with COVID-19: a meta-analysis. Epidemiol Infect. 2020; 148(175):1–11.
  11. Domingues R, Lippi A, Setz C, Outeiro TF, Krisko A. SARS-CoV-2, immunosenescence and inflammaging: partners in the COVID-19 crime. Aging. 2020; 12(18): 18778-18789.
  12. Ding X, Yu Y, Lu B, Huo J, Chen M, Kang Y et al. Dynamic profile and clinical implications of hematological parameters in hospitalized patients with coronavirus disease 2019. Clin Chem Lab Med. 2020; 58(8): 1365-1371.
  13. Pradhan A, Olsson P. Sex differences in severity and mortality from COVID-19 : are males more vulnerable?. Biol Sex Differ. 2020; 11: 53
  14. Qin C, Zhou L, Hu Z, Yang S, Tao Y, Xie C, et al. Dysregulation of immune response in patients with coronavirus 2019 (COVID-19) in Wuhan, China. Clin Infect Dis. 2020; 234-239.
  15. Xie L, Wu Q, Lin Q, Liu X, Lin W, Hae S, et al. Dysfunction of adaptive immunity is related to severity of COVID-19: a retrospective study. Ther Adv Respir Dis. 2020; 14:1-15.
  16. Wang D, Li R, Wang J, Jiang Q, Gao C, Yang J et al. Correlation analysis between disease severity and clinical and biochemical characteristics of 143 cases of COVID-19 in Wuhan, China: a descriptive study. BMC Infect Dis. 2020; 20(1): 519-528.
  17. Newton AH, Cardani A, Braciale TJ. The host immune response in respiratory virus infection: balancing virus clearance and immunopathology. Semin Immunopathol. 2016; 38:471-482.
  18. Hajghorbani T, Zafari P, Masoumi T, Rajabinejad M, Jafari SR. The role of dysregulated immune responses in COVID-19 pathogenesis. Virus Res. 2020; 290: doi: 198197. 10.1016/j.virusres.2020.198197
  19. Garcia LF. Immune response, inflammation, and the clinical spectrum of COVID-19. Front Immunol. 2020; 11: 144-68.
  20. Peng J, Qi D, Yuan G, Deng X, Mei Y, Feng L et al. Diagnostic value of peripheral hematologic markers for coronavirus disease 2019 (COVID-19): a multicenter, cross-sectional study. J Clin Lab Anal. 2020; 34 (10): e23475. doi: 10.1002/jcla.23475.
  21. Vabret N, Britton GJ, Gruber C, Hegde S, Kim J, Kuksin M, et al. Immunology of COVID-19: Current state of the science. Immunity. 2020;52(6):910-941.
  22. Zeng F, Huang Y, Guo Y, Yin M, Chen X, Xiao L, et al. Association of inflammation marker with the severity of COVID-19: a meta-analysis. Int J Infect Dis. 2020; 96:467-474.
  23. Praveen T, Desai D, Soneja M, Wig N. Immune dysregulation in COVID-19 and its therapeutic implication. J Clin Sci Res. 2020; 9: 37-41.
  24. Vasco GP, Ortega AR, Carralo MM, Gonzales C, Santacruz AR, Cortijo LG, Fernandez G. Clinical characteristics and outcomes among hospitalized adults with severe COVID-19 admitted to a tertiary medical center and receiving antiviral, antimalarials, glucocorticoids, or immunomodulation with tocilizumab or cyclosporine: a retrospective observational study (COQUIMA cohort). EClinicalMedicine. 2020: 100591.

How to Cite

Suhartono, S., Wijaya, I., & Dalimoenthe, N. Z. (2021). The correlation of neutrophil-to-lymphocyte ratio (NLR) and monocytes-to-lymphocytes ratio (MLR) with disease severity in hospitalized patients with Coronavirus disease 2019 (COVID-19). Bali Medical Journal, 10(2), 653–658.




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Suhartono Suhartono
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Indra Wijaya
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Nadjwa Zamalek Dalimoenthe
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