Clinical outcomes of COVID-19 in Wuhan, China: a large cohort study
Clinical outcomes of COVID-19 in Wuhan, China: a large cohort study
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DOI：
10.1186/s13613-020-00706-3
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发表时间：
2020-07-31
影响因子：
8.1
通讯作者：
Chen, Dechang
中科院分区：
文献类型：
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作者：
Liu, Jiao;Zhang, Sheng;Chen, Dechang
自2019年12月以来，由严重急性呼吸道综合征冠状病毒2型（SARS-Cov-2）引起的2019冠状病毒病（COVID-19）疫情最初出现在中国武汉，目前已蔓延至全球。已描述COVID-19患者的临床特征。然而，导致重症COVID-19患者住院期间病情恶化和预后不良的风险因素尚未得到很好的确定。方法在这项回顾性、单中心队列研究中，纳入了2019年12月29日至2020年2月28日武汉市传染病医院1190例经实验室确诊的COVID-19成人住院患者（≥ 18岁），并确定了结局（出院或死亡）。最终随访日期为2020年3月2日。从电子病历中提取临床数据，包括特征、实验室和影像学信息以及治疗，并进行比较。采用多变量logistic回归模型探讨与院内恶化和死亡相关的潜在预测因素。结果共纳入确诊COVID-19患者1190例。他们的中位年龄为57岁（四分位距47-67岁）。261名患者（22%）在入院后出现严重疾病。多因素Logistic回归分析显示，SOFA评分越高，（OR 1.32，95% CI 1.22-1.43，每次评分增加，恶化p < 0.001，OR 1.30，95% CI 1.11-1.53，每次评分增加，死亡p = 0.001），淋巴细胞减少症入院时病情恶化的OR值为1.81，95%CI为1.13- 2.89，p = 0.013;死亡的OR值为4.44，95%CI为1.26- 15.87，p = 0.021），是住院期间病情由不严重恶化为严重及严重患者死亡的独立危险因素。入院时D-二聚体大于1 μ g/L（OR 3.28，95%CI 1.19- 9.04，p = 0.021），白细胞减少（OR 5.10，95% CI 1.25-20.78），血小板减少症（OR 8.37，95%CI 2.04-34.44）和糖尿病史（OR 11.16，95%CI 1.87- 66.57，p = 0.008）也与重症COVID-19患者的院内死亡风险较高相关。与非幸存者相比，观察到重度疾病幸存者从疾病发作到无创机械通气的时间间隔更短（10.5天，IQR 9.25-11.0 vs. 16.0天，IQR 11.0-19.0天，p = 0.030）。糖皮质激素治疗增加了病情由不严重进展为严重的风险（OR 3.79，95%CI 2.39- 6.01，p < 0.001）。抗病毒药物尤其是奥司他韦或更昔洛韦的应用与重症患者死亡风险降低相关（OR 0.17，95%CI 0.05- 0.64，p < 0.001）。结论入院时SOFA评分高、淋巴细胞减少可预测非重症患者在院内发生重症。入院时D-二聚体升高、白细胞减少、血小板减少和糖尿病是COVID-19重症患者院内死亡的独立危险因素。给予奥司他韦或更昔洛韦可能有利于降低重症患者的死亡率。
Background Since December 2019, an outbreak of Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) initially emerged in Wuhan, China, and has spread worldwide now. Clinical features of patients with COVID-19 have been described. However, risk factors leading to in-hospital deterioration and poor prognosis in COVID-19 patients with severe disease have not been well identified. Methods In this retrospective, single-center cohort study, 1190 adult inpatients (>= 18 years old) with laboratory-confirmed COVID-19 and determined outcomes (discharged or died) were included from Wuhan Infectious Disease Hospital from December 29, 2019 to February 28, 2020. The final follow-up date was March 2, 2020. Clinical data including characteristics, laboratory and imaging information as well as treatments were extracted from electronic medical records and compared. A multivariable logistic regression model was used to explore the potential predictors associated with in-hospital deterioration and death. Results 1190 patients with confirmed COVID-19 were included. Their median age was 57 years (interquartile range 47-67 years). Two hundred and sixty-one patients (22%) developed a severe illness after admission. Multivariable logistic regression demonstrated that higher SOFA score (OR 1.32, 95% CI 1.22-1.43, per score increase,p < 0.001 for deterioration and OR 1.30, 95% CI 1.11-1.53, per score increase,p = 0.001 for death), lymphocytopenia (OR 1.81, 95% CI 1.13-2.89p = 0.013 for deterioration; OR 4.44, 95% CI 1.26-15.87,p = 0.021 for death) on admission were independent risk factors for in-hospital deterioration from not severe to severe disease and for death in severe patients. On admission D-dimer greater than 1 mu g/L (OR 3.28, 95% CI 1.19-9.04,p = 0.021), leukocytopenia (OR 5.10, 95% CI 1.25-20.78), thrombocytopenia (OR 8.37, 95% CI 2.04-34.44) and history of diabetes (OR 11.16, 95% CI 1.87-66.57,p = 0.008) were also associated with higher risks of in-hospital death in severe COVID-19 patients. Shorter time interval from illness onset to non-invasive mechanical ventilation in the survivors with severe disease was observed compared with non-survivors (10.5 days, IQR 9.25-11.0 vs. 16.0 days, IQR 11.0-19.0 days,p = 0.030). Treatment with glucocorticoids increased the risk of progression from not severe to severe disease (OR 3.79, 95% CI 2.39-6.01,p < 0.001). Administration of antiviral drugs especially oseltamivir or ganciclovir is associated with a decreased risk of death in severe patients (OR 0.17, 95% CI 0.05-0.64,p < 0.001). Conclusions High SOFA score and lymphocytopenia on admission could predict that not severe patients would develop severe disease in-hospital. On admission elevated D-dimer, leukocytopenia, thrombocytopenia and diabetes were independent risk factors of in-hospital death in severe patients with COVID-19. Administration of oseltamivir or ganciclovir might be beneficial for reducing mortality in severe patients.