RESULT: Results of a retrospective cohort study of 191 inpatients in Wuhan with COVID-19

Authors: Alexandra Freeman
Date added: 13th April 2020, 16:50:11

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813 adult patients were hospitalised in Jinyintan Hospital or Wuhan Pulmonary Hospital with COVID-19 before Jan 31, 2020. After excluding 613 patients that were still hospitalised or not confirmed by SARS-CoV-2 RNA detection as of Jan 31, 2020, and nine inpatients without available key information in their medical records, we included 191 inpatients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) in the final analysis. 54 patients died during hospitalisation and 137 were discharged. The median age of the 191 patients was 56·0 years (IQR 46·0–67·0), ranging from 18 years to 87 years, and most patients were male (table 1). Comorbidities were present in nearly half of patients, with hypertension being the most common comorbidity, followed by diabetes and coronary heart disease (table 1). The most common symptoms on admission were fever and cough, followed by sputum production and fatigue (table 1). Lymphocytopenia occurred in 77 (40%) patients. 181 (95%) patients received antibiotics and 41 (21%) received antivirals (lopinavir/ritonavir; table 2). Systematic corticosteroid and intravenous immunoglobulin use differed significantly between non-survivors and survivors (table 2). The comparison of characteristics, treatment, and outcomes of patients from the two hospitals are shown in the appendix (pp 2–4).

Table 1. Demographic, clinical, laboratory, and radiographic findings of patients on admission



Total (n=191)Non-survivor (n=54)Survivor (n=137)p value
Demographics and clinical characteristics
Age, years56·0 (46·0–67·0)69·0 (63·0–76·0)52·0 (45·0–58·0)
Sex......0·15

Female72 (38%)16 (30%)56 (41%)..

Male119 (62%)38 (70%)81 (59%)..
Exposure history73 (38%)14 (26%)59 (43%)0·028
Current smoker11 (6%)5 (9%)6 (4%)0·21
Comorbidity91 (48%)36 (67%)55 (40%)0·0010

Hypertension58 (30%)26 (48%)32 (23%)0·0008

Diabetes36 (19%)17 (31%)19 (14%)0·0051

Coronary heart disease15 (8%)13 (24%)2 (1%)

Chronic obstructive lung disease6 (3%)4 (7%)2 (1%)0·047

Carcinoma2 (1%)02 (1%)0·37

Chronic kidney disease2 (1%)2 (4%)00·024

Other22 (12%)11 (20%)11 (8%)0·016
Respiratory rate >24 breaths per min56 (29%)34 (63%)22 (16%)
Pulse ≥125 beats per min2 (1%)2 (4%)00·024
Systolic blood pressure 1 (1%)01 (1%)0·53
Fever (temperature ≥37·3°C)180 (94%)51 (94%)129 (94%)0·94
Cough151 (79%)39 (72%)112 (82%)0·15
Sputum44 (23%)14 (26%)30 (22%)0·55
Myalgia29 (15%)8 (15%)21 (15%)0·93
Fatigue44 (23%)15 (28%)29 (21%)0·33
Diarrhoea9 (5%)2 (4%)7 (5%)0·67
Nausea or vomiting7 (4%)3 (6%)4 (3%)0·40
SOFA score2·0 (1·0–4·0)4·5 (4·0–6·0)1·0 (1·0–2·0)
qSOFA score1·0 (0·0–1·0)1·0 (1·0–1·0)0·0 (0·0–1·0)
CURB-65 score0·0 (0·0–2·0)2·0 (1·0–3·0)0·0 (0·0–1·0)

0–1141/188 (75%)16 (30%)125/134 (93%)*

232/188 (17%)23 (43%)9/134 (7%)..

3–515/188 (8%)15 (28%)0/134..
Disease severity status......

General72 (38%)072 (53%)..

Severe66 (35%)12 (22%)54 (39%)..

Critical53 (28%)42 (78%)11 (8%)..
Time from illness onset to hospital admission, days11·0 (8·0–14·0)11·0 (8·0–15·0)11·0 (8·0–13·0)0·53
Laboratory findings
White blood cell count, × 109 per L6·2 (4·5–9·5)9·8 (6·9–13·9)5·2 (4·3–7·7)

32 (17%)5 (9%)27 (20%)*

4–10119 (62%)24 (44%)95 (69%)..

>1040 (21%)25 (46%)15 (11%)..
Lymphocyte count, × 109 per L1·0 (0·6–1·3)0·6 (0·5–0·8)1·1 (0·8–1·5)

77 (40%)41 (76%)36 (26%)
Haemoglobin, g/L128·0 (119·0–140·0)126·0 (115·0–138·0)128·0 (120·0–140·0)0·30
Anaemia29 (15%)14 (26%)15 (11%)0·0094
Platelet count, × 109 per L206·0 (155·0–262·0)165·5 (107·0–229·0)220·0 (168·0–271·0)

13 (7%)11 (20%)2 (1%)
Albumin, g/L32·3 (29·1–35·8)29·1 (26·5–31·3)33·6 (30·6–36·4)
ALT, U/L30·0 (17·0–46·0)40·0 (24·0–51·0)27·0 (15·0–40·0)0·0050

>4059/189 (31%)26 (48%)33/135 (24%)0·0015
Creatinine >133 μmol/L8/186 (4%)5 (9%)3/132 (2%)0·045
Lactate dehydrogenase, U/L300·0 (234·0–407·0)521·0 (363·0–669·0)253·5 (219·0–318·0)

>245123/184 (67%)53 (98%)70/130 (54%)
Creatine kinase, U/L21·5 (13·0–72·4)39·0 (19·5–151·0)18·0 (12·5–52·1)0·0010

>18522/168 (13%)11/52 (21%)11/116 (9%)0·038
High-sensitivity cardiac troponin I, pg/mL4·1 (2·0–14·1)22·2 (5·6–83·1)3·0 (1·1–5·5)

>2824/145 (17%)23/50 (46%)1/95 (1%)
Prothrombin time, s11·6 (10·6–13·0)12·1 (11·2–13·7)11·4 (10·4–12·6)0·0004

171/182 (94%)47 (87%)124/128 (97%)0·016*

≥1611/182 (6%)7 (13%)4/128 (3%)..
D-dimer, μg/mL0·8 (0·4–3·2)5·2 (1·5–21·1)0·6 (0·3–1·0)

≤0·555/172 (32%)4 (7%)51/118 (43%)*

>0·5 to ≤145/172 (26%)6 (11%)39/118 (33%)..

>172/172 (42%)44 (81%)28/118 (24%)..
Serum ferritin, μg/L722·0 (377·2–1435·3)1435·3 (728·9–2000·0)503·2 (264·0–921·5)

>300102/128 (80%)44/46 (96%)58/82 (71%)0·0008
IL-6, pg/mL7·4 (5·3–10·8)11·0 (7·5–14·4)6·3 (5·0–7·9)
Procalcitonin, ng/mL0·1 (0·1–0·1)0·1 (0·1–0·5)0·1 (0·1–0·1)

114/164 (70%)19/51 (37%)95/113 (84%)*

≥0·1 to 30/164 (18%)16/51 (31%)14/113 (12%)..

≥0·25 to 6/164 (4%)3/51 (6%)3/113 (3%)..

≥0·514/164 (9%)13/51 (25%)1/113 (1%)..
Imaging features
Consolidation112 (59%)40 (74%)72 (53%)0·0065
Ground-glass opacity136 (71%)44 (81%)92 (67%)0·049
Bilateral pulmonary infiltration143 (75%)45 (83%)98 (72%)0·090


Data are median (IQR), n (%), or n/N (%). p values were calculated by Mann-Whitney U test, χ2 test, or Fisher's exact test, as appropriate. SOFA=Sequential Organ Failure Assessment. qSOFA=Quick SOFA. ALT=alanine aminotransferase. IL-6=interleukin-6.


*

χ2 test comparing all subcategories.

Table 2. Treatments and outcomes


Total (n=191)Non-survivor (n=54)Survivor (n=137)p value
Treatments*
Antibiotics181 (95%)53 (98%)128 (93%)0·15
Antiviral treatment41 (21%)12 (22%)29 (21%)0·87
Corticosteroids57 (30%)26 (48%)31 (23%)0·0005
Intravenous immunoglobin46 (24%)36 (67%)10 (7%)
High-flow nasal cannula oxygen therapy41 (21%)33 (61%)8 (6%)
Non-invasive mechanical ventilation26 (14%)24 (44%)2 (1%)
Invasive mechanical ventilation32 (17%)31 (57%)1 (1%)
ECMO3 (2%)3 (6%)00·0054
Renal replacement therapy10 (5%)10 (19%)0
Outcomes
Sepsis112 (59%)54 (100%)58 (42%)
Respiratory failure103 (54%)53 (98%)50 (36%)
ARDS59 (31%)50 (93%)9 (7%)
Heart failure44 (23%)28 (52%)16 (12%)
Septic shock38 (20%)38 (70%)0
Coagulopathy37 (19%)27 (50%)10 (7%)
Acute cardiac injury33 (17%)32 (59%)1 (1%)
Acute kidney injury28 (15%)27 (50%)1 (1%)
Secondary infection28 (15%)27 (50%)1 (1%)
Hypoproteinaemia22 (12%)20 (37%)2 (1%)
Acidosis17 (9%)16 (30%)1 (1%)
ICU admission50 (26%)39 (72%)11 (8%)
ICU length of stay, days8·0 (4·0–12·0)8·0 (4·0–12·0)7·0 (2·0–9·0)0·41
Hospital length of stay, days11·0 (7·0–14·0)7·5 (5·0–11·0)12·0 (9·0–15·0)
Time from illness onset to fever, days1·0 (1·0–1·0)1·0 (1·0–1·0)1·0 (1·0–1·0)0·16
Time from illness onset to cough, days1·0 (1·0–3·0)1·0 (1·0–1·0)1·0 (1·0–4·0)0·30
Time from illness onset to dyspnoea, days7·0 (4·0–9·0)7·0 (4·0–10·0)7·0 (4·0–9·0)0·51
Time from illness onset to sepsis, days9·0 (7·0–13·0)10·0 (7·0–14·0)9·0 (7·0–12·0)0·22
Time from illness onset to ARDS, days12·0 (8·0–15·0)12·0 (8·0–15·0)10·0 (8·0–13·0)0·65
Time from illness onset to ICU admission, days12·0 (8·0–15·0)12·0 (8·0–15·0)11·5 (8·0–14·0)0·88
Time from illness onset to corticosteroids treatment, days12·0 (10·0–16·0)13·0 (10·0–17·0)12·0 (10·0–15·0)0·55
Time from illness onset to death or discharge, days21·0 (17·0–25·0)18·5 (15·0–22·0)22·0 (18·0–25·0)0·0003
Duration of viral shedding after COVID-19 onset, days20·0 (16·0–23·0)18·5 (15·0–22·0)20·0 (17·0–24·0)0·024


Data are median (IQR) or n (%). p values were calculated by Mann-Whitney U test, χ2 test, or Fisher's exact test, as appropriate. ECMO=extracorporeal membrane oxygenation. ARDS=acute respiratory distress syndrome. ICU=intensive care unit. COVID-19=coronavirus disease 2019.


*

Ordered by escalating scale of respiratory support.

Detectable until death.

The median time from illness onset (ie, before admission) to discharge was 22·0 days (IQR 18·0–25·0), whereas the median time to death was 18·5 days (15·0–22·0; table 2). 32 patients required invasive mechanical ventilation, of whom 31 (97%) died. The median time from illness onset to invasive mechanical ventilation was 14·5 days (12·0–19·0). Extracorporeal membrane oxygenation was used in three patients, none of whom survived. Sepsis was the most frequently observed complication, followed by respiratory failure, ARDS, heart failure, and septic shock (table 2). Half of non-survivors experienced a secondary infection, and ventilator-associated pneumonia occurred in ten (31%) of 32 patients requiring invasive mechanical ventilation. The frequency of complications were higher in non-survivors than survivors (table 2).

In univariable analysis, odds of in-hospital death was higher in patients with diabetes or coronary heart disease (table 3). Age, lymphopenia, leucocytosis, and elevated ALT, lactate dehydrogenase, high-sensitivity cardiac troponin I, creatine kinase, d-dimer, serum ferritin, IL-6, prothrombin time, creatinine, and procalcitonin were also associated with death (table 3).

Table 3. Risk factors associated with in-hospital death



Univariable OR (95% CI)p valueMultivariable OR (95% CI)p value
Demographics and clinical characteristics
Age, years*1·14 (1·09–1·18)1·10 (1·03–1·17)0·0043
Female sex (vs male)0·61 (0·31–1·20)0·15....
Current smoker (vs non-smoker)2·23 (0·65–7·63)0·20....
Comorbidity present (vs not present)

Chronic obstructive lung disease5·40 (0·96–30·40)0·056....

Coronary heart disease21·40 (4·64–98·76)2·14 (0·26–17·79)0·48

Diabetes2·85 (1·35–6·05)0·0062....

Hypertension3·05 (1·57–5·92)0·0010....
Respiratory rate, breaths per min

≤241 (ref)......

>248·89 (4·34–18·19)....
SOFA score6·14 (3·48–10·85)5·65 (2·61–12·23)
qSOFA score12·00 (5·06–28·43)....
Laboratory findings
White blood cell count, × 109 per L

0·73 (0·26–2·10)0·56....

4–101 (ref)......

>106·60 (3·02–14·41)....
Lymphocyte count, × 109 per L*0·02 (0·01–0·08)0·19 (0·02–1·62)0·13
ALT, U/L

≤401 (ref)......

>402·87 (1·48–5·57)0·0018....
Creatinine, μmol/L

≤1331 (ref)......

>1334·39 (1·01–19·06)0·048....
Lactate dehydrogenase, U/L

≤2451 (ref)......

>24545·43 (6·10–338·44)0·0002....
Creatine kinase, U/L

≤1851 (ref)......

>1852·56 (1·03–6·36)0·043....
High-sensitivity cardiac troponin I, pg/mL

≤281 (ref)......

>2880·07 (10·34–620·36)....
D-dimer, μg/mL

≤0·51 (ref)..1 (ref)..

> 0·51·96 (0·52–7·43)0·322·14 (0·21–21·39)0·52

> 120·04 (6·52–61·56)18·42 (2·64–128·55)0·0033
Prothrombin time, s

1 (ref)......

≥164·62 (1·29–16·50)0·019....
Serum ferritin, μg/L

≤3001 (ref)......

>3009·10 (2·04–40·58)0·0038....
IL-6, pg/mL*1·12 (1·03–1·23)0·0080....
Procalcitonin, ng/mL*13·75 (1·81–104·40)0·011....


OR=odds ratio. SOFA=Sequential Organ Failure Assessment. qSOFA=Quick SOFA. ALT=alanine aminotransferase. IL-6=interleukin-6.


*

Per 1 unit increase.





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