Characterisation of ferritin–lymphocyte ratio in COVID-19

Alexander Liu, Robert Hammond, Kenneth Chan, Chukwugozie Chukwuenweniwe, Rebecca Johnson, Duaa Khair, Eleanor Duck, Oluwaseun Olubodun, Kristian Barwick, Winston Banya, James Stirrup, Peter D. Donnelly, Juan C. Kaski, Anthony R. M. Coates*

*Corresponding author for this work

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Introduction: The ferritin–lymphocyte ratio (FLR) is a novel inflammatory biomarker for the assessment of acute COVID-19 patients. However, the prognostic value of FLR for predicting adverse clinical outcomes in COVID-19 remains unclear, which hinders its clinical translation. Methods: We characterised the prognostic value of FLR in COVID-19 patients, as compared to established inflammatory markers. Results: In 217 study patients (69 years [IQR: 55–82]; 60% males), FLR was weakly correlated with CRP (R = 0.108, p = 0.115) and white cell count (R = −0.144; p = 0.034). On ROC analysis, an FLR cut-off of 286 achieved a sensitivity of 86% and a specificity of 30% for predicting inpatient mortality (AUC 0.60, 95% CI: 0.53–0.67). The negative predictive values of FLR for ruling out mortality, non-invasive ventilation requirement and critical illness (intubation and/or ICU admission) were 86%, 85% and 93%, respectively. FLR performed similarly to CRP (AUC 0.60 vs. 0.64; p = 0.375) for predicting mortality, but worse than CRP for predicting non-fatal outcomes (all p < 0.05). On Kaplan–Meier analysis, COVID-19 patients with FLR values > 286 had worse inpatient survival than patients with FLR ≤ 286, p = 0.041. Conclusions: FLR has prognostic value in COVID-19 patients, and appears unrelated to other inflammatory markers such as CRP and WCC. FLR exhibits high sensitivity and negative predictive values for adverse clinical outcomes in COVID-19, and may be a good “rule-out” test. Further work is needed to improve the sensitivity of FLR and validate its role in prospective studies for guiding clinical management.
Original languageEnglish
Article number2819
Number of pages12
Issue number10
Publication statusPublished - 18 Oct 2023


  • Coronavirus disease 19
  • Ferritin–lymphocyte ratio
  • Inflammatory biomarkers
  • Risk stratification
  • C-reactive protein
  • White cell count
  • COVID-19


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