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COVID-19-associated hyperinflammation and escalation of patient care: a retrospective longitudinal cohort study

A subset of patients with severe COVID-19 develop a hyperinflammatory syndrome, which might contribute to morbidity and mortality. This study explores a specific phenotype of COVID-19-associated hyperinflammation (COV-HI), and its associations with escalation of respiratory support and survival. In...

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Published in:The Lancet Rheumatology 2020-10, Vol.2 (10), p.e594-e602
Main Authors: Manson, Jessica J, Crooks, Colin, Naja, Meena, Ledlie, Amanda, Goulden, Bethan, Liddle, Trevor, Khan, Emon, Mehta, Puja, Martin-Gutierrez, Lucia, Waddington, Kirsty E, Robinson, George A, Ribeiro Santos, Liliana, McLoughlin, Eve, Snell, Antonia, Adeney, Christopher, Schim van der Loeff, Ina, Baker, Kenneth F, Duncan, Christopher J A, Hanrath, Aidan T, Lendrem, B Clare, De Soyza, Anthony, Peng, Junjie, J'Bari, Hajar, Greenwood, Mandy, Hawkins, Ellie, Peckham, Hannah, Marks, Michael, Rampling, Tommy, Luintel, Akish, Williams, Bryan, Brown, Michael, Singer, Mervyn, West, Joe, Jury, Elizabeth C, Collin, Matthew, Tattersall, Rachel S
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Language:English
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Summary:A subset of patients with severe COVID-19 develop a hyperinflammatory syndrome, which might contribute to morbidity and mortality. This study explores a specific phenotype of COVID-19-associated hyperinflammation (COV-HI), and its associations with escalation of respiratory support and survival. In this retrospective cohort study, we enrolled consecutive inpatients (aged ≥18 years) admitted to University College London Hospitals and Newcastle upon Tyne Hospitals in the UK with PCR-confirmed COVID-19 during the first wave of community-acquired infection. Demographic data, laboratory tests, and clinical status were recorded from the day of admission until death or discharge, with a minimum follow-up time of 28 days. We defined COV-HI as a C-reactive protein concentration greater than 150 mg/L or doubling within 24 h from greater than 50 mg/L, or a ferritin concentration greater than 1500 μg/L. Respiratory support was categorised as oxygen only, non-invasive ventilation, and intubation. Initial and repeated measures of hyperinflammation were evaluated in relation to the next-day risk of death or need for escalation of respiratory support (as a combined endpoint), using a multi-level logistic regression model. We included 269 patients admitted to one of the study hospitals between March 1 and March 31, 2020, among whom 178 (66%) were eligible for escalation of respiratory support and 91 (34%) patients were not eligible. Of the whole cohort, 90 (33%) patients met the COV-HI criteria at admission. Despite having a younger median age and lower median Charlson Comorbidity Index scores, a higher proportion of patients with COV-HI on admission died during follow-up (36 [40%] of 90 patients) compared with the patients without COV-HI on admission (46 [26%] of 179). Among the 178 patients who were eligible for full respiratory support, 65 (37%) met the definition for COV-HI at admission, and 67 (74%) of the 90 patients whose respiratory care was escalated met the criteria by the day of escalation. Meeting the COV-HI criteria was significantly associated with the risk of next-day escalation of respiratory support or death (hazard ratio 2·24 [95% CI 1·62–2·87]) after adjustment for age, sex, and comorbidity. Associations between elevated inflammatory markers, escalation of respiratory support, and survival in people with COVID-19 indicate the existence of a high-risk inflammatory phenotype. COV-HI might be useful to stratify patient groups in trial design. None.
ISSN:2665-9913
2665-9913
DOI:10.1016/S2665-9913(20)30275-7