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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Risk factors of mortality among patients with COVID-19: A hospital-based retrospective study


1 Department of General Medicine, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana, India
2 Department of Respiratory Medicine, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana, India

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Date of Submission22-Jul-2021
Date of Decision31-Jul-2021
Date of Acceptance20-Aug-2021
Date of Web Publication29-Sep-2021
 

  Abstract 


Background: It is not easy to predict either severity or mortality in a patient infected with coronavirus disease 2019 (COVID-19) as the clinical presentation is variable and treatment response varies from person to person, and at the same time, there is a lack of standard treatment protocol. Objective: The objective of this study is to study the risk factors of mortality among patients with COVID-19. Methods: A hospital-based retrospective study was carried out among 299 cases of COVID-19. Hospital records of patients admitted with COVID-19 at the study center from January 2021 to June 2021 were studied. Demographic, clinical, and laboratory variables were studied with respect to mortality. The Chi-square test for proportions and t-test for mean values was applied, and P < 0.05 was considered statistically significant. Results: Those who died were significantly older (55 years vs. 47 years). Gender and vaccine status were not associated with mortality; however, there were only eight cases who took vaccine and all of them recovered. Among clinical variables, SpO2 at admission, severe disease, oxygen dependency, requirement of nasal canula, requirement of noninvasive ventilation, requirement of intubation, and requirement of remdesivir treatment were significantly associated with mortality. Among the CT scan severity score (CTSS), COVID-19 reporting and data system score (CORADS) and laboratory and inflammatory markers, the CTSS, CORADS, d-dimer, C-reactive protein, creatinine, urea, and alkaline phosphatase were significantly associated with mortality. Conclusion: Elderly patients, SpO2 at admission, requirement of oxygen, and other supportive measures as well as inflammatory markers can be used for the early detection of those cases at risk of death. They can be given special care to reduce mortality.

Keywords: Coronavirus disease-2019, mortality, risk factors


How to cite this URL:
Dasari D, Pendurthi AK, Alam KC, Kodithyala PK. Risk factors of mortality among patients with COVID-19: A hospital-based retrospective study. Apollo Med [Epub ahead of print] [cited 2021 Nov 30]. Available from: https://www.apollomedicine.org/preprintarticle.asp?id=327153





  Introduction Top


Novel coronavirus severe acute respiratory syndrome-coronavirus-2 causes coronavirus disease 2019 (COVID-19) pneumonia. It spreads very rapidly. It is impacting the social and economic conditions of the world. The clinical features show a lot of variability. Some cases remain asymptomatic, some present with mild clinical features while some rapidly progress to severe disease and even death. Early stages of the disease are characterized by fever, cough, anosmia, and loss of taste. It can lead to acute failure of lung functions while some cases may land in failure of the multiple organs. Those with preexisting comorbidities and elderly are more susceptible to develop complications. It is not easy to predict either severity or mortality in a patient infected with COVID-19 as the clinical presentation is variable and treatment response varies from person to person, and at the same time, there is a lack of standard treatment protocol.[1],[2],[3]

Preexisting diseases related to vital organs such as heart, lung, and kidney can complicate the disease. The most common complications of COVID-19 include acute respiratory failure, injury to the kidney of acute nature, dysfunction of the liver, damage to the myocardium, and septic shock. Coagulation complications are also commonly seen. Some cases can land into acute cerebrovascular disease and encephalitis.[4],[5],[6]

Studies have shown that there are multiple risk factors that can land a patient into adverse outcome such as organ failure or even death. These are like preexisting diabetes, overweight and obesity, presence of chronic kidney disease, etc., However, in some cases, death can occur suddenly even in the absence of these preexisting conditions or complications. Hence, it is difficult to predict the outcome of the COVID-19.[7],[8],[9]

The situation is complicated by the lack of standard form of treatment protocol for COVID-19. The prognosis of the disease is also not very clear and not properly understood till date. Hence, only way is to identify the risk factors and preexisting conditions in patients with COVID-19. This will help extend early support to such cases and will help to reduce the death rate among these cases. The extensive research from countries from Western Europe, USA, and China have shown that there are some factors which can predict early mortality in patients with COVID-19. These factors are advanced age, being male, presence of hypertension, ground-glass appearance in X-ray chest, lymphopenia, and increased levels of inflammatory markers. However, how far these factors apply to the Indian patients are still not clear as there are few studies on this particular aspect of COVID-19. Indian patients have comorbidities such as diabetes, hypertension, and obesity at an early age (middle age) compared to their Western counterparts.[10]

Hence, more and more research is required on the risk factors of mortality related to COVID-19. Therefore, the present study was conducted to study the risk factors of mortality among patients with COVID-19 at a tertiary care hospital.


  Methods Top


A hospital-based retrospective study was carried out. Hospital records of 299 patients from April 2021 to June 2021 were studied. Since this was a hospital record-based study and we did not use any identifying information of the patients, we did not take Ethics Committee permission/waiver letter.

Demographic information such as age, sex, and vaccine taken or not was recorded.

Information on clinical variables such as blood pressure, oxygen saturation at the time of admission, dependency on oxygen during admission, requirement of nasal canula, requirement of a nonrebreather mask (NRBM), requirement of noninvasive ventilation (NIV), requirement of high flow nasal oxygen (HFNO), requirement of intubation, requirement of remdesivir, COVID-19 reporting and data system score (CORADS), and chest CT scan severity score (CTSS) was obtained from the hospital records.

Severity of COVID-19 was assessed by using the Indian Council of Medical Research criteria: mild if: (“Upper respiratory tract symptoms [ &/or fever] without shortness of breath or hypoxia”). Moderate if: (“Any one of: 1. Respiratory rate >24/min, breathlessness”), and in case they were admitted in intensive care unit or required ventilator they were classified as having severe disease (“Any one of: 1. Respiratory rate >30/min, breathlessness, SpO2 <90% on room air”).[11]

Information on inflammatory markers and other available laboratory variables such as interleukin-6 (IL-6), D-dimer, lactate dehydrogenase (LDH), ferritin, C-reactive protein (CRP), creatinine, alkaline phosphatase (ALP), aspartate transaminase (SGOT), and serum glutamic-pyruvic transaminase (SGPT) were obtained from the hospital records.

The data were entered in the Microsoft Excel sheet and analyzed using proportions and mean values with two standard deviation. The Chi-square test for proportions and t-test for mean values was applied. Two tailed P < 0.05 was taken as statistically significant.


  Results Top


Out of 299 cases, 55 (18.4%) died.

Those who died were found to be significantly older (55 years vs. 47 years). The gender and vaccine status were not associated with mortality; however, there were only eight cases who took vaccine and all of them recovered [Table 1].
Table 1: Association between demographic factors with mortality

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Among the clinical variables, SpO2 at the time of admission, having severe disease, oxygen dependency, requirement of nasal cannula, requirement of NIV, requirement of intubation, and requirement of remdesivir treatment were found to be significantly associated with mortality. Other variables such as blood pressure, NRBM, and HFNO were not associated with mortality [Table 2].
Table 2: Association between clinical variables with mortality

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Among the CTSS, CORADS and laboratory and inflammatory markers, the CTSS, CORADS, d-dimer, CRP, creatinine, urea, and ALP were significantly associated with mortality. Other variables such as IL-6, LDH, ferritin, SGOT, and SGPT were not found to be associated with mortality [Table 3].
Table 3: Association of CT severity score, coronavirus disease-2019 reporting and data system, and laboratory and inflammatory markers with mortality

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  Discussion Top


In the present study, those who died were significantly older (55 years vs. 47 years). Gender and vaccine status were not associated with mortality; however, there were only eight cases who took vaccine and all of them recovered. Among clinical variables, SpO2 at admission, severe disease, oxygen dependency, requirement of nasal canula, requirement of NIV, requirement of intubation, and requirement of remdesivir treatment were significantly associated with mortality. Among the CTSS, CORADS and laboratory and inflammatory markers, the CTSS, CORADS, d-dimer, CRP, creatinine, urea, and ALP were significantly associated with mortality.

Jain et al.[10] studied 425 cases and observed that mortality rate was 5.17% which is low compared to present study (18.4%). They found that advanced age, being male, shortness of breath, oxygen saturation <93%, increased respiratory rate, and comorbidities such as diabetes, hypertension, and coronary artery disease were significantly associated mortality. We also found that advanced age and less oxygen saturation were significant factors; however, gender was not associated factor and other factors were not studied. Among laboratory markers, they noted that lymphopenia, CRP, ferritin, and LDH were significantly associated with mortality; on the other hand, we noted that CRP was associated but not the ferritin and LDH in the present study.

Marimuthu et al.[12] carried out a review of 854 case records retrospectively in South India. They observed that elderly, males, symptoms such as fever, cough, breathlessness; addictions like smoking, alcohol; and presence of comorbidities were significantly associated with mortality. When compared to the present study, elderly was at more risk of mortality but gender was not associated with mortality. We did not study comorbidities and addictions.

Bhandari et al.[13] assessed the 522 cases at Jaipur. They found that the significant risk factors of mortality were the presence of multiple comorbid condition, being male, elderly, and presence of clinical manifestations of COVID-19. We also observed that increased age was a significant risk factor of mortality.

Gupta et al.[14] carried out a prospective observational study of 200 cases of COVID-19. They found that the significant risk factors of mortality were advanced age, longer duration of symptoms, leukocytosis, high SOFA score, requirement for ventilator support, raised levels of creatinine, and raised levels of AST. We also noted that advanced age, high CTSS, high CORADS, and increased creatinine were the significant risk factors of mortality among patients with COVID-19.

Mohandas et al.[15] included 3345 cases in their study and found that age more than 50 years, presence of comorbidities such as diabetes, hypertension, coronary heart disease, and chronic kidney disease were significantly associated with mortality. We did not study the presence of comorbidities but we did find that advanced age was a significant risk factor along with some laboratory and inflammatory markers.

Albitar et al.[16] retrospectively studied 828 cases using open access individual level worldwide data and analyzed the data using the univariate and multivariate techniques. They noted that most of the cases were males from Asia. Older age, being male, presence of hypertension, diabetes, and being from America were the important risk factors of mortality among COVID-19 patients. We also found that older age was associated with mortality significantly.

Mahendra et al.[17] included 560 cases of severe pneumonia from their retrospective hospital record-based study that out of 4012 admitted cases of COVID-19. They found a mortality rate of 54.64% in severe cases while it was only 5% among the mild and moderate cases. This is similar to the present study findings where we found that the mortality rate was 96.4% in severe cases compared to only 3.6% in mild and moderate cases. They found that SpO2/FiO2 <400, age more than 50 years, symptoms lasting for more than 4 days, increased levels of serum ferritin, increased rate of respiration, presence of preexisting diseases and not using remdesivir were independently associated with mortality. We also found that decrease SpO2 at admission time, advanced age, and requirement of remdesivir were significant risk factors for mortality. However, we found that ferritin was not associated with mortality. Other factors were not studied in the present study.

Mehraeen et al.[18] carried out a systematic review in which they included 114 studies involving 310,494 cases of COVID-19 from worldwide. They studied association between 72 parameters with mortality rates. They found that older age, presence of diabetes, and hypertension were significantly associated with mortality, but on multivariate analysis, only diabetes was found to be indecently associated with mortality. The author concluded that further studies are needed to find more factors associated with mortality.


  Conclusion Top


Elderly patients, SpO2 at admission, requirement of oxygen, and other supportive measures as well as inflammatory markers can be used for the early detection of those cases at risk of death. They can be given special care to reduce mortality. All those who took vaccine recovered. Even though only eight took vaccine as per present data and it is difficult to comment on this particular aspect using only eight cases, vaccine is known to prevent the severe form of disease and mortality.

Declaration of patient consent form

Since this was a hospital record-based study and we did not use any identifying information of the patients, we did not use the patient consent form.

Acknowledgment

Nil.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Prashanth Kumar Kodithyala,
Department of Respiratory Medicine, Malla Reddy Institute of Medical Sciences, Suraram, Quthbullapur Municipality, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_83_21




 
 
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    -  Dasari D
    -  Pendurthi AK
    -  Alam KC
    -  Kodithyala PK


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