近日，柳葉刀發表了最新研究《Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study》（中日友好醫院曹彬教授和武漢市金銀潭醫院陳華教授為通訊作者），研究詳細描述了COVID-19成人住院患者的臨床進程，並對死亡的危險因素進行了分析。
表1. 患者入院時的基線特徵
181例（95％）患者接受了抗生素治療，41例（21％）患者接受了抗病毒治療（洛匹那韋/利托那韋）（表2）。
從發病（入院前）到出院的中位時間為22.0天（IQR 18.0–25.0），發病到死亡的中位時間為18.5天（15.0–22.0）。
單因素分析顯示，糖尿病或冠心病患者的院內死亡率更高。年齡，淋巴細胞減少，白細胞增多，ALT、乳酸脫氫酶、高敏心肌肌鈣蛋白I、肌酸激酶、d-二聚體、血清鐵蛋白、IL-6、凝血酶原時間、肌酐和降鈣素水平升高與死亡存在相關性（表3）。
多因素logistic迴歸模型納入了有完整數據的171例患者（53例死亡患者和118例倖存患者）。結果發現，年齡較大、SOFA（序貫器官衰竭評分）較高、入院時d-二聚體水平超過1μg/ L，與死亡風險增加存在相關性（表3）。廣義線性模型的結果也與上述結果類似（表4）。
表3. 死亡危險因素分析
表4. 廣義線性模型的結果
總結
本研究發現，年齡較大，SOFA評分高和d-二聚體超過1μg/L是COVID-19成年患者死亡的危險因素，這些危險因素可以幫助臨床醫生在早期發現預後較差的患者。
原文鏈接：
https://www.thelancet.com/lancet/article/S0140-6736(20)30566-3
Summary
Background
Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described.
Methods
In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death.
Findings
191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days.
Interpretation
The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future.
Funding
Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.
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