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Cidade JP, de Souza Dantas VC, de Figueiredo Thompson A, de Miranda RCCC, Mamfrim R, Caroli H, Escudini G, Oliveira N, Castro T, Póvoa P. Identification of Distinct Clinical Phenotypes of Critically Ill COVID-19 Patients: Results from a Cohort Observational Study. J Clin Med 2023; 12:jcm12083035. [PMID: 37109370 PMCID: PMC10144996 DOI: 10.3390/jcm12083035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/06/2023] [Accepted: 04/20/2023] [Indexed: 04/29/2023] Open
Abstract
Purpose: COVID-19 presents complex pathophysiology, and evidence collected points towards an intricate interaction between viral-dependent and individual immunological mechanisms. Identifying phenotypes through clinical and biological markers may provide a better understanding of the subjacent mechanisms and an early patient-tailored characterization of illness severity. Methods: A multicenter prospective cohort study was performed in 5 hospitals in Portugal and Brazil for one year between 2020-2021. All adult patients with an Intensive Care Unit admission with SARS-CoV-2 pneumonia were eligible. COVID-19 was diagnosed using clinical and radiologic criteria with a SARS-CoV-2 positive RT-PCR test. A two-step hierarchical cluster analysis was made using several class-defining variables. Results: 814 patients were included. The cluster analysis revealed a three-class model, allowing for the definition of three distinct COVID-19 phenotypes: 407 patients in phenotype A, 244 patients in phenotype B, and 163 patients in phenotype C. Patients included in phenotype A were significantly older, with higher baseline inflammatory biomarkers profile, and a significantly higher requirement of organ support and mortality rate. Phenotypes B and C demonstrated some overlapping clinical characteristics but different outcomes. Phenotype C patients presented a lower mortality rate, with consistently lower C-reactive protein, but higher procalcitonin and interleukin-6 serum levels, describing an immunological profile significantly different from phenotype B. Conclusions: Severe COVID-19 patients exhibit three different clinical phenotypes with distinct profiles and outcomes. Their identification could have an impact on patients' care, justifying different therapy responses and inconsistencies identified across different randomized control trial results.
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Affiliation(s)
- José Pedro Cidade
- Intensive Care Unit 4, Department of Intensive Care São Francisco Xavier Hospital, CHLO, Lisbon, 1449-005 Lisbon, Portugal
- Nova Medical School, Clinical Medicine, CHRC, New University of Lisbon, 1169-056 Lisbon, Portugal
| | | | | | | | | | | | | | | | - Taiza Castro
- Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro 22281-100, Brazil
| | - Pedro Póvoa
- Intensive Care Unit 4, Department of Intensive Care São Francisco Xavier Hospital, CHLO, Lisbon, 1449-005 Lisbon, Portugal
- Nova Medical School, Clinical Medicine, CHRC, New University of Lisbon, 1169-056 Lisbon, Portugal
- Center for Clinical Epidemiology, Research Unit of Clinical Epidemiology, OUH Odense University Hospital, 5000 Odense C, Denmark
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Souza-Dantas VC, Dal-Pizzol F, Tomasi CD, Spector N, Soares M, Bozza FA, Póvoa P, Salluh JIF. Identification of distinct clinical phenotypes in mechanically ventilated patients with acute brain dysfunction using cluster analysis. Medicine (Baltimore) 2020; 99:e20041. [PMID: 32358385 PMCID: PMC7440320 DOI: 10.1097/md.0000000000020041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 02/10/2020] [Accepted: 03/24/2020] [Indexed: 11/25/2022] Open
Abstract
Acute brain dysfunction (ABD) is a frequent and severe syndrome occurring in critically ill patients and early identification of high-risk patients is paramount. In the present analysis, we propose a clinically applicable model for early phenotype identification of ABD at the bedside in mechanically ventilated patients, improving the recognition of patients with prolonged ABD.Prospective cohort with 629 mechanically ventilated patients in two medical-surgical intensive care units at academic centers. We applied cluster analysis to identify phenotypes using clinical and biological data. We then tested the association of phenotypes and its respective clinical outcomes. We performed a validation on a new cohort of patients select on subsequent patients admitted to the participants intensive care units.A model with 3 phenotypes best described the study population. A 4-variable model including medical admission, sepsis diagnosis, simplified acute physiologic score II and basal serum C-reactive protein (CRP) accurately classified each phenotype (area under curve 0.82; 95% CI, 0.79-0.86). Phenotype A had the shorter duration of ABD (median, 1 day), while phenotypes B and C had progressively longer duration of ABD (median, 3 and 6 days, respectively; P < .0001). There was an association between the duration of ABD and the baseline CRP levels and simplified acute physiology score II score (sensitivity and specificity of 80%). To increase the sensitivity of the model, we added CRP kinetics. By day 1, a CRP < 1.0 times the initial level was associated with a shorter duration of ABD (specificity 0.98).A model based on widely available clinical variables could provide phenotypes associated with the duration of ABD. Phenotypes with longer duration of ABD (phenotypes B and C) are characterized by more severe inflammation and by significantly worse clinical outcomes.
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Affiliation(s)
- Vicente Cés Souza-Dantas
- School of Medicine, Universidade Federal do Rio de Janeiro, Rua Professor Paulo Rocco 255, Cidade universitária, Rio de Janeiro
| | - Felipe Dal-Pizzol
- Laboratório de Fisiopatologia Experimental, Programa de pós-graduação em ciências da saúde, Universidade do Extremo Sul Catarinense, Avenida Universitária
- Intensive Care Unit, São José Hospital
- São José Hospital Research Center, Rua Coronel Pedro Benedet
| | - Cristiane D. Tomasi
- Laboratório de Fisiopatologia Experimental, Programa de pós-graduação em ciências da saúde, Universidade do Extremo Sul Catarinense, Avenida Universitária
- Intensive Care Unit, São José Hospital
- São José Hospital Research Center, Rua Coronel Pedro Benedet
- Núcleo de Estudos e Pesquisas em Integralidade e Saúde – NEPIS
- Programa de Pós-Graduação em Saúde Coletiva, Universidade do Extremo Sul Catarinense, Avenida Universitária 1105, Criciúma, SC
| | - Nelson Spector
- School of Medicine, Universidade Federal do Rio de Janeiro, Rua Professor Paulo Rocco 255, Cidade universitária, Rio de Janeiro
| | - Márcio Soares
- D’or Institute for Research and Education, Rua Diniz Cordeiro 30, Botafogo
- Postgraduation Program, Instituto Nacional de Câncer, Praça Cruz Vermelha 23, Centro
| | - Fernando A. Bozza
- D’or Institute for Research and Education, Rua Diniz Cordeiro 30, Botafogo
- National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, Centro Hospitalar de Lisboa Ocidental, São Francisco Xavier Hospital, Estrada Forte do Alto Duque, Lisbon
- NOVA Medical School, CEDOC, New University of Lisbon, Campo Mártires da Pátria 130, Lisbon, Portugal
| | - Jorge I. F. Salluh
- D’or Institute for Research and Education, Rua Diniz Cordeiro 30, Botafogo
- Postgraduation Program, Instituto Nacional de Câncer, Praça Cruz Vermelha 23, Centro
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