Integrating serum ferritin and neutrophil-to-lymphocyte ratio with Sequential Organ Failure Assessment score improves mortality prediction in sepsis

doi:10.5662/wjm.v16.i1.109733

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World Journal of Methodology

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Retrospective Cohort Study

World J Methodol. Mar 20, 2026; 16(1): 109733
Published online Mar 20, 2026. doi: 10.5662/wjm.v16.i1.109733

Table 1 Sequential Organ Failure Assessment score

Organ system	0	1	2	3	4
Respiratory (mmHg)	PaO₂/FiO₂ ≥ 400	PaO₂/FiO₂ < 400	PaO₂/FiO₂ < 300	PaO₂/FiO₂ < 200 and ventilated	PaO₂/FiO₂ < 100 and ventilated
Coagulation (platelets 10³/μL)	Platelets ≥ 150	Platelets < 150	Platelets < 100	Platelets < 50	Platelets < 20
Liver (mg/dL)	Bilirubin < 1.2	Bilirubin 1.2-1.9	Bilirubin 2.0-5.9	Bilirubin 6.0-11.9	Bilirubin ≥ 12.0
Cardiovascular	MAP ≥ 70 mmHg	MAP < 70 mmHg	Dopamine < 5 or dobutamine (any dose)	Dopamine 51-15 or epinephrine ≤ 0.1 or norepinephrine ≤ 0.1	Dopamine > 15 or epinephrine > 0.1 or norepinephrine > 0.1
CNS GCS Score	15	13-14	10-12	6-9	< 6
Renal	Creatinine < 1.2 mg/dL	Creatinine 12-1.9 mg/dL	Creatinine 20-3.4 mg/dL	Creatinine 35-4.9 mg/dL; urine output < 500 mL/day	Creatinine > 5 mg/dL; urine output < 200 mL/day

Catecholamine doses = μg/kg/minute for at least 1 hour; CNS: Central Nervous System; FiO₂: Fraction of inspired oxygen; GCS: Glasgow Coma Scale; MAP: Mean arterial pressure; PaO₂: Partial pressure of oxygen in arterial blood.

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Table 2 Baseline characteristics, n (%)

Characteristic	All patients (n = 1954)	Survivors (n = 1426)	Deaths (n = 528)	P value
Demographics
Age, years (mean ± SD)	61.6 ± 15.3	59.4 ± 15.2	67.7 ± 13.7	< 0.001
Sex				0.364
Male	1082 (55.4)	778 (54.6)	304 (57.6)
Female	872 (44.6)	648 (45.4)	224 (42.4)
BMI, kg/m² (mean ± SD)	28.3 ± 7.9	28.5 ± 8.0	27.8 ± 7.7	0.107
Comorbidities
Charlson comorbidity index (mean ± SD)	2.2 ± 2.2	2.0 ± 2.1	2.8 ± 2.4	< 0.001
Hypertension	823 (42.1)	566 (39.7)	257 (48.7)	< 0.001
Diabetes mellitus	517 (26.5)	362 (25.4)	155 (29.4)	0.079
COPD	304 (15.6)	198 (13.9)	106 (20.1)	0.001
Chronic kidney disease	386 (19.8)	247 (17.3)	139 (26.3)	< 0.001
Chronic liver disease	215 (11.0)	137 (9.6)	78 (14.8)	0.001
Malignancy	293 (15.0)	177 (12.4)	116 (22.0)	< 0.001
Source of infection¹				0.019
a: Pulmonary	809 (41.4)	565 (39.6)	244 (46.2)
b: Urinary	421 (21.5)	333 (23.4)	88 (16.7)
c: Abdominal	389 (19.9)	288 (20.2)	101 (19.1)
d: Bloodstream	215 (11.0)	147 (10.3)	68 (12.9)
e: Other/unknown	120 (6.1)	93 (6.5)	27 (5.1)
Clinical parameters at admission
Systolic BP, mmHg (mean ± SD)	118.7 ± 24.5	121.8 ± 22.9	110.4 ± 26.7	< 0.001
MAP, mmHg (mean ± SD)	78.5 ± 16.0	80.6 ± 14.9	73.0 ± 17.2	< 0.001
Heart rate, bpm (mean ± SD)	101.3 ± 21.8	100.1 ± 20.9	104.5 ± 23.7	< 0.001
Respiratory rate, breaths/min (mean ± SD)	22.8 ± 6.2	22.0 ± 5.8	24.9 ± 6.7	< 0.001
Temperature, °C (mean ± SD)	37.3 ± 1.1	37.4 ± 1.0	37.0 ± 1.2	< 0.001
SpO₂, % (mean ± SD)	94.8 ± 4.7	95.4 ± 4.2	93.2 ± 5.5	< 0.001
Laboratory values
Ferritin (mean ± SD) (ng/mL)	1480.9 ± 2912.1	1196.4 ± 2423.8	2223.5 ± 3766.6	< 0.001
NLR (mean ± SD)	31.6 ± 95.3	24.7 ± 85.6	50.1 ± 114.4	< 0.001
Hemoglobin, g/dL (mean ± SD)	11.2 ± 2.3	11.4 ± 2.2	10.6 ± 2.3	< 0.001
WBC count, × 10³/μL (mean ± SD)	15.8 ± 11.2	15.2 ± 10.6	17.3 ± 12.4	< 0.001
Platelet count, × 10³/μL (mean ± SD)	217.3 ± 119.0	228.9 ± 119.8	186.8 ± 111.2	< 0.001
Creatinine, mg/dL (mean ± SD)	1.7 ± 1.5	1.5 ± 1.3	2.1 ± 1.8	< 0.001
Total bilirubin, mg/dL (mean ± SD)	1.4 ± 2.5	1.2 ± 2.1	2.0 ± 3.2	< 0.001
Lactate, mmol/L (mean ± SD)	2.9 ± 2.4	2.4 ± 1.8	4.1 ± 3.2	< 0.001
Interventions
Invasive ventilation	782 (40.0)	483 (33.9)	299 (56.6)	< 0.001
Vasopressor use	897 (45.9)	560 (39.3)	337 (63.8)	< 0.001
Dialysis	326 (16.7)	198 (13.9)	128 (24.2)	< 0.001
Outcomes
ICU stay duration, days (mean ± SD)	6.3 ± 7.8	5.9 ± 7.2	7.4 ± 9.1	0.001
Hospital stay duration, days (mean ± SD)	14.2 ± 13.4	15.8 ± 13.7	10.1 ± 11.5	< 0.001

¹P values represent overall comparison across categories using the χ² test.

BMI: Body mass index; BP: Blood pressure; COPD: Chronic obstructive pulmonary disease; ICU: Intensive care unit; IQR: Interquartile range; MAP: Mean arterial pressure; NLR: Neutrophil-lymphocyte ratio; SpO_2: Peripheral oxygen saturation; SD: Standard deviation; WBC: White blood cell.

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Table 3 Distribution of patients and mortality by ferritin and neutrophil-lymphocyte ratio quartiles, n (%)

Category	Total (n = 1954)	In-hospital mortality	30-day mortality	Median survival, days (95%CI)
Ferritin quartiles
Q1 (< 277 ng/mL)	488 (25.0)	87 (17.8)	104 (21.3)	87.8 (40.6-NR)
Q2 (277-651 ng/mL)	490 (25.1)	91 (18.6)	100 (20.4)	89.8 (58.9-NR)
Q3 (> 651 ng/mL)	976 (49.9)	290 (29.7)	324 (33.2)	44.4 (36.0-58.4)
NLR quartiles
Q1 (< 6.8)	484 (24.8)	78 (16.1)	94 (19.4)	92.3 (53.7-NR)
Q2 (6.8-12.4)	504 (25.8)	87 (17.3)	98 (19.4)	91.4 (50.3-NR)
Q3 (> 12.4)	966 (49.4)	303 (31.4)	336 (34.8)	41.7 (32.8-55.2)
Combined ferritin & NLR
Both in Q1	225 (11.5)	23 (10.2)	29 (12.9)	NR (78.6-NR)
Both in Q2	247 (12.6)	36 (14.6)	42 (17.0)	98.7 (62.4-NR)
Mixed quartiles	755 (38.6)	173 (22.9)	192 (25.4)	65.3 (48.9-85.6)
Both in Q3	727 (37.2)	236 (32.5)	265 (36.5)	37.2 (29.4-46.8)

CI: Confidence interval; NLR: Neutrophil-lymphocyte ratio; NR: Not reported.

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Table 4 Cox proportional analysis

Variable	Unadjusted HR (95%CI)	P value	Adjusted HR (95%CI)¹	P value
Ferritin quartiles
Q3 (highest)	Reference	-	Reference	-
Q1 (lowest)	0.58 (0.47-0.73)	< 0.001	0.71 (0.57-0.90)	0.005
Q2 (middle)	0.59 (0.47-0.74)	< 0.001	0.70 (0.55-0.88)	0.002
NLR quartiles
Q3 (highest)	Reference	-	Reference	-
Q1 (lowest)	0.65 (0.52-0.80)	< 0.001	0.73 (0.59-0.91)	0.006
Q2 (middle)	0.60 (0.48-0.74)	< 0.001	0.63 (0.50-0.78)	< 0.001
Combined ferritin & NLR
Both in Q3 (highest)	Reference	-	Reference	-
Both in Q1 (lowest)	0.42 (0.32-0.55)	< 0.001	0.56 (0.42-0.74)	< 0.001
Mixed quartiles	0.65 (0.53-0.80)	< 0.001	0.74 (0.60-0.91)	0.005
Charlson comorbidity index
Per 1-point increase	1.03 (1.00-1.07)	0.048	1.03 (0.99-1.06)	0.161
Age
Per 1-year increase	1.01 (1.01-1.02)	< 0.001	1.02 (1.01-1.02)	< 0.001
Sex
Male	Reference	-	Reference	-
Female	1.08 (0.91-1.29)	0.364	1.11 (0.93-1.32)	0.258
Continuous variables
NLR (per unit)	1.00 (1.00-1.00)	0.072	1.00 (1.00-1.00)	0.908
Ferritin (per unit)	1.00 (1.00-1.00)	< 0.001	1.00 (1.00-1.00)	< 0.001

¹Adjusted model includes sex, age, neutrophil-lymphocyte ratio quartiles, ferritin quartiles, and Charlson comorbidity index.

CI: Confidence interval; HR: Hazard ratio; NLR: Neutrophil-lymphocyte ratio.

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Table 5 Area under operating characteristic curve for all predictive models

Model	Apparent AUROC (95%CI)	Corrected AUROC	P value
SOFA alone	0.602 (0.574-0.630)	0.595	Reference
SOFA + ferritin	0.655 (0.627-0.628)	0.649	< 0.0001
SOFA + ferritin + NLR	0.656 (0.629-0.683)	0.649	< 0.0001

AUROC: Area under operating characteristic curve; CI: Confidence interval; NLR: Neutrophil-lymphocyte ratio; SOFA: Sequential Organ Failure Assessment.

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Citation: Patel N, Patel V, Murugan Y, Patel K, Varma V, Surani S. Integrating serum ferritin and neutrophil-to-lymphocyte ratio with Sequential Organ Failure Assessment score improves mortality prediction in sepsis. World J Methodol 2026; 16(1): 109733
URL: https://www.wjgnet.com/2222-0682/full/v16/i1/109733.htm
DOI: https://dx.doi.org/10.5662/wjm.v16.i1.109733