Outcome of COVID-19 in hospitalised immunocompromised patients: An analysis of the WHO ISARIC CCP-UK prospective cohort study.
Outcome of COVID-19 in hospitalised immunocompromised patients: An analysis of the WHO ISARIC CCP-UK prospective cohort study.
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DOI：
10.1371/journal.pmed.1004086
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发表时间：
2023-01
期刊：
影响因子：
15.8
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中科院分区：
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与免疫能力强的患者相比，免疫低下的患者如果感染了冠状病毒2019年病(新冠肺炎)住院，死亡风险可能更高。然而，之前的研究是相互矛盾的。我们的目标是确定免疫功能低下的患者是否面临更大的住院死亡风险，以及这种风险在大流行期间是如何变化的。我们纳入了ISARIC WHO临床特征方案英国前瞻性队列研究中招募的19岁有症状的社区获得性新冠肺炎患者。我们将免疫妥协定义为入院前服用免疫抑制药物、癌症治疗、器官移植、艾滋病毒或先天性免疫缺陷。我们使用Logistic回归来比较两组的死亡风险，调整了年龄、性别、剥夺、种族、接种疫苗和合并疾病。我们使用贝叶斯Logistic回归来探索随时间推移的死亡率。在2020年1月17日至2022年2月28日期间，我们招募了156,552名符合条件的患者，其中21,954名(14%)免疫功能低下。总共有29%(n=6,499)的免疫低下患者和21%(n=28,608)的免疫功能正常的患者在医院死亡。免疫功能低下的患者住院期间死亡率增加(调整后的OR1.44，95%CI[1.39，1.5]，p<；0.001)。并不是所有免疫功能受损的疾病都有相同的风险，例如，接受积极癌症治疗的患者不太可能将他们的护理升级到重症监护(调整后的OR0.77，95%CI[0.77，0.85]，p<；0.001)或机械通气(调整后的OR0.65，95%CI[0.56，0.76]，p<；0.001)。然而，癌症患者死亡的可能性更大(调整后的OR2.0，95%CI[1.87，2.15]，p<；0.001)。分析调整了年龄、性别、社会经济贫困、合并症和疫苗接种状况。随着疫情的发展，免疫低下患者的住院死亡率下降速度慢于免疫能力患者。随着年龄的增长，这一点尤其明显：50岁至69岁的免疫功能低下患者住院死亡率下降的可能性为男性88%，女性83%，80岁患者男性99%，女性98%。这项研究受到入院前缺乏详细药物数据的限制，包括类固醇剂量，这意味着我们可能错误地将一些免疫功能低下的患者归类为免疫能力强的患者。免疫功能低下的患者死于新冠肺炎的风险仍然较高。对于这一患者群体，应继续鼓励采取有针对性的措施，如增加疫苗剂量、单抗和非药物预防干预。ISRCTN 66726260。利用来自世卫组织ISARIC CCP-UK队列的数据，Lance Turtle博士和他的同事报告了新冠肺炎对住院免疫低下患者的结果。在2019年冠状病毒病(新冠肺炎)大流行期间，某些患者群体的死亡率要高得多。老年人和那些有潜在疾病的人死亡的风险更大。随着时间的推移，随着医疗护理的改善，特别是疫苗接种，新冠肺炎的死亡率大幅下降。免疫系统减弱的患者患新冠肺炎的风险也更高。目前尚不清楚，与免疫功能正常的患者相比，是否需要入院的风险增加，或者免疫功能低下的患者一旦住院，他们的死亡风险是否也会增加。我们试图使用世界卫生组织国际严重急性呼吸和新发感染联盟(ISARIC)临床特征协议(CCP)UK数据集，这是一项对英国住院患者进行的前瞻性观察性队列研究，试图确定免疫功能低下的患者入院后死亡风险是否更高。我们的分析表明，免疫系统受损的患者比免疫系统完整的患者在医院死亡的风险更高。即使考虑到其他重要因素，如年龄、性别和慢性病的存在，这种差异仍然存在。在大流行期间，尽管所有患者的死亡风险都降低了，但对免疫能力强的患者来说，风险降低得更多，免疫功能低下的患者的差距也扩大了。与其他有症状的新冠肺炎患者相比，免疫功能低下的患者死亡风险仍然较高。临床医生和政策制定者应该意识到这一患者群体中死亡风险的增加。抗病毒治疗、抗体和非药物干预等有针对性的干预措施应继续用于该患者组。
Immunocompromised patients may be at higher risk of mortality if hospitalised with Coronavirus Disease 2019 (COVID-19) compared with immunocompetent patients. However, previous studies have been contradictory. We aimed to determine whether immunocompromised patients were at greater risk of in-hospital death and how this risk changed over the pandemic. We included patients > = 19 years with symptomatic community-acquired COVID-19 recruited to the ISARIC WHO Clinical Characterisation Protocol UK prospective cohort study. We defined immunocompromise as immunosuppressant medication preadmission, cancer treatment, organ transplant, HIV, or congenital immunodeficiency. We used logistic regression to compare the risk of death in both groups, adjusting for age, sex, deprivation, ethnicity, vaccination, and comorbidities. We used Bayesian logistic regression to explore mortality over time. Between 17 January 2020 and 28 February 2022, we recruited 156,552 eligible patients, of whom 21,954 (14%) were immunocompromised. In total, 29% (n = 6,499) of immunocompromised and 21% (n = 28,608) of immunocompetent patients died in hospital. The odds of in-hospital mortality were elevated for immunocompromised patients (adjusted OR 1.44, 95% CI [1.39, 1.50], p < 0.001). Not all immunocompromising conditions had the same risk, for example, patients on active cancer treatment were less likely to have their care escalated to intensive care (adjusted OR 0.77, 95% CI [0.7, 0.85], p < 0.001) or ventilation (adjusted OR 0.65, 95% CI [0.56, 0.76], p < 0.001). However, cancer patients were more likely to die (adjusted OR 2.0, 95% CI [1.87, 2.15], p < 0.001). Analyses were adjusted for age, sex, socioeconomic deprivation, comorbidities, and vaccination status. As the pandemic progressed, in-hospital mortality reduced more slowly for immunocompromised patients than for immunocompetent patients. This was particularly evident with increasing age: the probability of the reduction in hospital mortality being less for immunocompromised patients aged 50 to 69 years was 88% for men and 83% for women, and for those >80 years was 99% for men and 98% for women. The study is limited by a lack of detailed drug data prior to admission, including steroid doses, meaning that we may have incorrectly categorised some immunocompromised patients as immunocompetent. Immunocompromised patients remain at elevated risk of death from COVID-19. Targeted measures such as additional vaccine doses, monoclonal antibodies, and nonpharmaceutical preventive interventions should be continually encouraged for this patient group. ISRCTN 66726260. Using data from the WHO ISARIC CCP-UK cohort, Dr. Lance Turtle and colleagues report on the outcome of COVID-19 in immunocompromised patients that are hospitalised. Throughout the Coronavirus Disease 2019 (COVID-19) pandemic, mortality has been much higher in certain groups of patients. Older people and those with underlying medical conditions have been at greater risk of death. Over time, with improvements in medical care and especially vaccination, mortality from COVID-19 has reduced dramatically. Patients with a weakened immune system are also at higher risk from COVID-19. It is not clear whether there is an increased risk of needing admission to hospital, or whether once immunocompromised patients are in hospital their risk of death is also increased, compared with immunocompetent patients. We sought to determine whether the risk of death was higher in immunocompromised patients after admission to hospital, using the WHO International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Clinical Characterisation Protocol (CCP) UK dataset, a prospective observational cohort study of hospitalised patients in the United Kingdom. Our analysis showed that patients who are immunocompromised have a higher risk of death in hospital than patients with intact immune systems. This difference remained even accounting for other important factors such as age, sex, and the presence of chronic conditions. Over the course of the pandemic, although the risk of death for all patients has decreased, the risk has decreased much more for immunocompetent patients and the gap has widened for immunocompromised patients. Immunocompromised patients remain at increased risk of death compared with other patients admitted with symptomatic COVID-19. Clinicians and policy makers should be aware of the increased risk of death in this patient group. Targeted interventions such as antiviral treatments, antibodies, and nonpharmaceutical interventions should continue to be used in this patient group.
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