JOPIC
Journal of Pulmonology and Intensive Care

The JoPIC is an independent-unbiased, peer-reviewed, and open-access journal of current national and international issues and reviews for original clinical and experimental research, interesting case reports, surgical techniques, differential diagnoses, editorial opinions, letters to the editor, and educational papers in pulmonology, thoracic surgery, occupational diseases, allergology, and intensive care medicine.

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Original Article
The lethal dance of Covid-19 with sepsis: predicting mortality using C-reactive protein, red cell distribution width, albumin and their ratios
Abstract
Aims: This study aimed to assess the impact of sepsis or secondary infection on mortality among COVID-19 patients admitted to the intensive care unit (ICU), and to evaluate the prognostic utility of C-reactive protein (CRP), red cell distribution width(RDW), albumin levels, and their derived ratios—CRP/Albumin (CAR), RDW/Albumin (RAR), and CRP×RDW/Albumin (CRAR).
Methods: A retrospective cohort of 471 patients aged 18–75 years, treated between January and May 2021 at XXX XXX City Hospital, was analyzed. Patients were classified into three groups: isolated COVID-19, COVID-19 with sepsis, and COVID-19 with secondary non-sepsis infection. Demographic and clinical characteristics, as well as ICU mortality rates, were compared between survivors and non-survivors. The predictive value of CAR, RAR, and CRAR ratios was statistically evaluated.
Results: Sepsis was associated with significantly higher mortality, age, APACHE II scores, lactate, and procalcitonin levels. Deceased patients had lower albumin levels and higher RDW and RAR values. ROC analysis revealed that RDW and RAR were significant predictors of mortality in the isolated COVID-19 group, while albumin and RAR were significant in the secondary infection group. Although univariate analysis highlighted associations between RAR and CRAR with mortality, multivariate analysis identified age, lactate, and sepsis status as independent predictors; notably, sepsis increased mortality by approximately 2.8-fold.
Conclusion: Sepsis dramatically increases mortality risk in COVID-19 ICU patients. RDW, albumin, and their corresponding ratios offer practical value for risk stratification, but must be interpreted within the context of established risk factors such as age and lactate. These biomarkers can aid prognostication, yet should be validated across larger and multicentric cohorts for wider clinical application.

Keywords : COVID-19, sepsis, mortality, CAR, RAR, CRAR

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1. Mahdi BM, Almukhtar M. Role of vaccines against COVID-19 pandemic. SLAS Discovery. 2023;28(8):355-357. doi:10.1016/j.slasd.2023. 07.002
2. Xie NN, Zhang WC, Chen J, Tian FB, Song JX. Clinical characteristics, diagnosis, and therapeutics of COVID-19: a review. Curr Med Sci. 2023; 43(6):1066-1074. doi:10.1007/s11596-023-2797-3
3. HenryBM,BenoitJL,BenoitS, et al. Red blood cell distribution width (RDW) predicts COVID-19 severity: a prospective, observational study from the Cincinnati SARS-CoV-2 emergency department cohort. Diagnostics (Basel). 2020;10(9):618. doi:10.3390/diagnostics10090618
4. Bouayed MZ, Laaribi I, Chatar CEM, et al. C-reactive protein (CRP): a poor prognostic biomarker in COVID-19. Front Immunol. 2022;14(13): 1040024. doi:10.3389/fimmu.2022.1040024
5. SuleimanAS,IslamMA,AkterMS,et al. A meta-meta-analysis of co-infection, secondary infections, and antimicrobial resistance in COVID-19 patients. J Infect Public Health.2023;16(10):1562-1590. doi: 10.1016/j.jiph.2023.07.005
6. Langford BJ, So M, Raybardhan S, et al. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clin Microbiol Infect. 2020;26:1622-1629. doi:10. 1016/j.cmi.2020.07.016
7. Ghahramani S, Tabrizi R, Lankarani KB, et al. Laboratory features of severe vs. non-severe COVID-19 patients Asian populations: systematic review and meta-analysis. Eur J Med Res. 2020;25(1):30. doi:10.1186/s40001-020-00432-3
8. DanartiR,LimantaraNV,RiniDLU, et al.Cutaneous manifestation in COVID-19: a lesson over 2 years into the pandemic. Clin Med Res. 2023; 21(1):36-45. doi:10.3121/cmr.2023.1598
9. Karimi A, Shobeiri P, Kulasinghe A, Rezaei N. Novel systemic inflammation markers to predict COVID-19 prognosis. Front Immunol. 2021;12:741061. doi:10.3389/fimmu.2021.741061
10. Yao Z, Zhang Y, Wu H. Regulation of C-reactive protein conformation in inflammation. Inflamm Res. 2019; 68:815-823. doi:10.1007/s00011-019-01269-1
11. Ho KM, Lee KY, Dobb GJ, Webb SA. C-reactive protein concentration as a predictor of in-hospital mortality after ICU discharge: a prospective cohort study. Int Care Med. 2008;34:481-487. doi:10.1007/s00134-007-0928-0
12. Rathore SS, Oberoi S, Iqbal K, et al. Prognostic value of novel serum biomarkers, including C-reactive protein to albumin ratio and fibrinogen to albumin ratio, in COVID-19 disease: a meta-analysis. Rev Med Virol. 2022:e2390. doi:10.1002/rmv.2390
13. KalabinA,ManiVR,ValdiviesoSC,DonaldsonB. Does C-reactive protein/albumin ratio have prognostic value in patients with COVID-19. J Infect Developing Countries.2021;15(8):1086-1093. doi:10. 3855/jidc.14826
14. Li Y, Li H, Song C, et al. Early prediction of diseaseprogression in patients with severe COVID-19 using C-reactive protein to albumin ratio. Disease Markers.2021;2021:6304189. doi:10.1155/2021/6304189
15. RamachandranP,GajendranM,PerisettiA,et al. Red blood cell distribution width in hospitalized COVID-19 patients. Front Med. 2022;7(8):582403. doi:10.3389/fmed.2021.582403
16. Mutlu NM, Peket TT, Soyal OB, et al. Red cell distribution width in diagnosis of brain death. Transplantation Proceedings. 2019;51(7):2189-2191. doi:10.1016/j.transproceed.2019.04.072
17. HongWS,RudasA,BellEJ,ChiangJN.Association of red blood cell distribution width with hospital admission and in-hospital mortality across all-cause adult emergency department visits. JAMIA Open. 2023; 6(3):ooad053. doi:10.1093/jamiaopen/ooad053
18. Chandler CM, Reid MC, Cherian S, Daniel E SabathDE, Edlefsen KL. Comparison of blood counts and markers of inflammation and coagulation in patients with and without COVID-19 presenting to the Emergency Department in Seattle, WA. Am J Clin Pathol. 2021;156(2): 185-197. doi:10.1093/ajcp/aqab052
19. Ertekin B, Acar T. The relationship between prognosis and red cell distribution width (RDW) and RDW-albumin ratio (RAR) in patients with severe COVID-19 disease. Int J General Med. 2022:15:8637-8645. doi:10.2147/IJGM.S392453
20. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021;49(11):e1063-e1143. doi:10.1097/CCM. 0000000000005337
21. Zhu Y, Sharma L, Chang D. Pathophysiology and clinical management of coronavirus disease (COVID-19): a mini-review. Front Immunol. 2023;14:1116131. doi:10.3389/fimmu.2023.1116131
22. Bloria SD,Chauhan R,SarnaR,Gombar S,Jindal S. Comparison of APACHE II and APACHE IV score as predictors of mortality in patients with septic shock in intensive care unit: a prospective observational study. J Anaesthesiol Clin Pharmacol.2023;39(3):355-359. doi:10.4103/joacp.joacp_380_21
23. Budak F, Korkmaz Ş. General evaluation regarding the COVID-19 pandemic process: the example of Turkey. J Social Res Management. 2020;1:62-79. doi:10.35375/sayod.738657
24. Belinskaia DA, Voronina PA, Shmurak VI, Jenkins RO, Goncharov NV. Serum albumin in health and disease: esterase, antioxidant, transporting and signaling properties. Int J Molecular Sci. 2021;22(19): 10318. doi:10.3390/ijms221910318
25. Saravi B, Goebel U, Hassenzahl LO, et al. Capillary leak and endothelial permeability in critically ill patients: a current overview. Intens Care Med Experimental. 2023;11(1):96. doi:10.1186/s40635-023-00582-8
26. Aziz M, Fatima R, Lee-Smith W, Assaly R. The relationship between low serum albumin and severe COVID-19: a systematic review and meta-analysis. Crit Care. 2020;24:255. doi:10.1186/s13054-020-02995-3
27. Kalın BS, Solmaz İ. Prognostic role of red cell distribution width/albumin ratio and lactate dehydrogenase level in COVID-19 patients. Ege J Med. 2022;61(1):38-43. doi:10.19161/etd.1085634
28. Yılmaz N, Tosun F, Cömert E, Duran M, Tuna VD. The relationship of CRP/albumin ratio level and prognosis in pregnant COVID-19. Nigerian J Clin Practice. 2022;25(10):1745-1750. doi:10.4103/njcp.njcp_ 244_22
29. Uzum Y, Turkkan E. Predictivity of CRP, albumin, and CRP to albumin ratio on the development of intensive care requirement, mortality, and disease severity in COVID-19. Cureus. 2023;15(1):e33600. doi:10.7759/cureus.33600
30. Kim MH, Ahn JY, Song JE, et al. The C-reactive protein/albumin ratio as an independent predictor of mortality in patients with severe sepsis or septic shock treated with early goal-directed therapy. PLoS ONE. 2015;10(7):e0132109. doi:10.1371/journal.pone.0132109
31. Shan X, Li Z, Jiang J, et al. Prognostic value of red blood cell distribution width to albumin ratio for predicting mortality in adult patients meeting sepsis-3 criteria in intensive care units. BMC Anesthesiol. 2024; 24(1):208. doi:10.1186/s12871-024-02585-8
32. YooJW, JuS, LeeSJ, ChoYJ, LeeJD, KimHC. Red cell distribution width/albumin ratio is associated with 60-day mortality in patients with acute respiratory distress syndrome. Infect Dis.2020;52(4):266-270. doi:10.1080/23744235.2020.1717599
33. Jandaghian S, Vaezi A, Manteghinejad A, et al. Red blood cell distribution width (RDW) as a predictor of in-hospital mortality in COVID-19 patients; a cross sectional study. Arch Academic Emerg Med. 2021;9(1):e67. doi:10.22037/aaem.v9i1.1325
Article available in :
Volume 3, Issue 4, 2025
Page : 94-101
https://doi.org/10.51271/JOPIC-0067
Article Information
Received : 01 Kas 2025
Accepted : 19 Kas 2025
Published : 29 Kas 2025
Corresponding Author :

Semih Aydemir: Department of Anesthesiology and Reanimation, Yıldırım Beyazıt University Yenimahalle Training and Research Hospital, Ankara, Turkiye

[email protected]
Citation : Has Selmi N, Şengel N, Balkız Soyal Ö, et al. The lethal dance of COVID-19 with sepsis: predicting mortality using C-reactive protein, red cell distribution width, albumin and their ratios. J Pulmonol Intens Care. 2025;3(4):94-101.

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