近日，柳叶刀发表了最新研究《Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study》（中日友好医院曹彬教授和武汉市金银潭医院陈华教授为通讯作者），研究详细描述了COVID-19成人住院患者的临床进程，并对死亡的危险因素进行了分析。
表1. 患者入院时的基线特征
181例（95％）患者接受了抗生素治疗，41例（21％）患者接受了抗病毒治疗（洛匹那韦/利托那韦）（表2）。
从发病（入院前）到出院的中位时间为22.0天（IQR 18.0–25.0），发病到死亡的中位时间为18.5天（15.0–22.0）。
单因素分析显示，糖尿病或冠心病患者的院内死亡率更高。年龄，淋巴细胞减少，白细胞增多，ALT、乳酸脱氢酶、高敏心肌肌钙蛋白I、肌酸激酶、d-二聚体、血清铁蛋白、IL-6、凝血酶原时间、肌酐和降钙素水平升高与死亡存在相关性（表3）。
多因素logistic回归模型纳入了有完整数据的171例患者（53例死亡患者和118例幸存患者）。结果发现，年龄较大、SOFA（序贯器官衰竭评分）较高、入院时d-二聚体水平超过1μg/ L，与死亡风险增加存在相关性（表3）。广义线性模型的结果也与上述结果类似（表4）。
表3. 死亡危险因素分析
表4. 广义线性模型的结果
总结
本研究发现，年龄较大，SOFA评分高和d-二聚体超过1μg/L是COVID-19成年患者死亡的危险因素，这些危险因素可以帮助临床医生在早期发现预后较差的患者。
原文链接：
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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