Phenotype of COVID-19-Associated Hyperinflammation Linked to Escalation of Respiratory Support, Survival

Associations between elevated inflammatory markers and escalation of respiratory support and survival support the existence of a high-risk inflammatory phenotype in patients with coronavirus disease 2019 (COVID-19), according to study results published in Lancet Rheumatology.

The current study enrolled adults with laboratory-confirmed COVID-19 who received inpatient care in March 2020 at participating hospitals in the United Kingdom. Demographic and clinical data were extracted from medical records. Patients were followed-up until discharge or death. The hyperinflammatory COVID-19 phenotype (COV-HI) was defined by a C reactive protein (CRP) concentration >150 mg/L or a ferritin concentration >1500 μg/L. Patients whose CRP concentrations doubled within 24 hours from >50 mg/L were also considered to have COV-HI. The primary outcome was a composite variable including escalated respiratory support and death. Respiratory support was categorized depending on route of administration: oxygen only, noninvasive ventilation, or intubation. Multilevel logistic regression was used to evaluate the effect of hyperinflammation on risk for respiratory support and death.

The study cohort included 269 patients with COVID-19 who were admitted to participating hospitals between March 1 and March 31, 2020. Median patient age was 71 years; 62% were men; 63% were White. At baseline, 90 (33%) patients met the criteria for COV-HI. Compared with patients who did not meet the COV-HI criteria at admission (n=179; 67%), patients with COV-HI had a lower median age (66 [IQR, 57-80 years] vs 71 years [56-83 years], respectively) and a lower median Charlson Comorbidity Index score (1 [0-2] vs 2 [0-3], respectively). A greater percentage of patients with vs without COV-HI died over follow-up (40% vs 26%, respectively).

In addition, meeting the criteria for COV-HI was significantly associated with next-day escalation of respiratory support or death (hazard ratio, 2.24; 95% CI, 1.62-2.87), after adjusting for age, sex, and comorbidities. Among 178 patients who were eligible for respiratory care escalation, 65 (37%) met the criteria for COV-HI at baseline. Among 90 patients who received respiratory care escalation, 67 (74%) met the criteria for COV-HI by the end of follow-up.

These data suggest that elevated inflammatory markers may increase risk for escalated respiratory support or survival in patients with COVID-19.

“Further research into this phenotype could facilitate targeted trials of intervention with immunomodulation and help to identify patients likely to require escalation of care.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Manson JJ, Crooks C, Naja M, et al. COVID-19-associated hyperinflammation and escalation of patient care: a retrospective longitudinal cohort study. Published online August 21, 2020. Lancet Rheumatol. doi:10.1016/S2665-9913(20)30275-7