Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study
Open accessAbstract
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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Aging, obesity and inflammation-related diseases such as diabetes and cardiovascular diseases are risk factors for the severity of COVID-19.
“Of note, aging, obesity and inflammation-related diseases such as diabetes and cardiovascular diseases have been shown to be risk factors for the severity of COVID-19 (293, 371–373).”
From IL-6 in inflammation, autoimmunity and cancer (2021) · cites this paper as [293]
The Discussion identifies older age as a risk factor for in-hospital death among adults hospitalised with COVID-19. Table 1 in the Results shows diabetes and coronary heart disease were more common among non-survivors than survivors, but it does not establish them as independent risk factors for disease severity. The paper does not report obesity as a risk factor. (LLM, conf=0.88)
Experimental — accuracy not yet measuredBlood IL-6 level is highly correlated with COVID-19 disease mortality.
“Among the elevated inflammatory mediators, the blood IL-6 level is highly correlated with the disease mortality (293, 338) and predicts the need for mechanical ventilation (339).”
From IL-6 in inflammation, autoimmunity and cancer (2021) · cites this paper as [293]
COVID-19 mortality rises with increasing age and with comorbidities.
“While the virus affects people of all ages, data have consistently shown that mortality is higher with increasing age and comorbidities [[3], [4], [5], [6]].”
Neutralizing antibody levels correlate with viral load and are higher in more severe disease and in older versus younger adults.
“The magnitude of these NAb responses appear to correlate with viral load, with higher responses reported in patients with more severe disease, and in older adults compared with younger adults26–29.”
From Immunological mechanisms of vaccine-induced protection against COVID-19 in humans (2021) · cites this paper as [27]
Among patients who developed severe disease, median time to dyspnea was 5 to 8 days, median time to ARDS was 8 to 12 days, and median time to intensive care unit admission was 10 to 12 days after symptom onset.
“Additional studies found that, among patients who developed severe disease, the median time to dyspnea was 5 to 8 days, the median time to ARDS was 8 to 12 days, and the median time to intensive care unit admission was 10 to 12 days after symptom onset (68–70).”
From Lung epithelial and endothelial damage, loss of tissue repair, inhibition of fibrinolysis, and cellular senescence in fatal COVID-19 (2021) · cites this paper as [70]
In severe COVID-19, ARDS usually begins around day 12 after symptom onset, when viral shedding is mostly resolved, and death or recovery follows about 7-12 days later.
“The onset of ARDS in severe cases typically occurs around day 12 post-symptom onset44,57, when viral shedding appears to be mostly resolved58, followed by death or recovery around 7-12 days later44,57.”
From SARS-CoV-2, COVID-19 and the aging immune system (2021) · cites this paper as [44]
Pro-thrombotic coagulopathy, high D-dimer, venous thromboembolism, arterial thromboses and fibrin-based occlusion of small vessels are associated with severe COVID-19.
“Pro-thrombotic coagulopathy, high levels of D-dimer, venous thromboembolism, arterial thromboses, and fibrin-based occlusion of small blood vessels have all been associated with cases of severe COVID-197,44,49,93-99.”
From SARS-CoV-2, COVID-19 and the aging immune system (2021) · cites this paper as [44]
Most associations observed between baseline characteristics and mortality or intubation were consistent with prior epidemiological studies.
“However, most associations observed between baseline characteristics and mortality or intubation are in line with prior epidemiological studies [17,19].”
From Association between antidepressant use and reduced risk of intubation or death in hospitalized patients with COVID-19: results from an observational study (2021) · cites this paper as [19]
In COVID-19 patients, elevated ferritin levels were related to disease severity, development of acute respiratory distress syndrome, and death.
“In COVID-19 patients, elevated ferritin levels were related to disease severity, development of acute respiratory distress syndrome (ARDS) and death [5,7,8].”
From Prevalence and Predictive Value of Anemia and Dysregulated Iron Homeostasis in Patients with COVID-19 Infection (2020) · cites this paper as [5]
Guidelines for management of surgical patients during the SARS-CoV-2 pandemic are based solely on expert opinion.
“Guidelines have been published for the management of surgical patients during the SARS-CoV-2 pandemic,9, 10, 11 but they are based solely on expert opinion.”
From Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study (2020) · cites this paper as [10]
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- Authors
- Zhou, F., Yu, T., Du, R., Fan, G., Liu, Y., Liu, Z., Xiang, J., Wang, Y., Song, B., Gu, X., Guan, L., Wei, Y., Li, H., Wu, X., Xu, J., Tu, S., Zhang, Y., Chen, H., & Cao, B.
- Affiliations
- Chinese Academy of Medical Sciences & Peking Union Medical College (CN)
- Jinyintan Hospital (CN)
- Wuhan Pulmonary Hospital (CN)
- Capital Medical University (CN)
- Tsinghua University (CN)
- Corresponding author
- Chen, Hua
- ORCID
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2020-03
- Volume
- 395
- Issue
- 10229
- Pages
- 1054-1062
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC7270627
- OpenAlex
- W3009885589
- Cited by
- 27,263
- References
- 33
- Citations by year
- 2026: 409 · 2025: 791 · 2024: 1528 · 2023: 2790 · 2022: 4524 · 2021: 7747 · 2020: 9427 · 2019: 13 · 2018: 2 · 2017: 1 · 2014: 1 · 2012: 3
- FWCI
- 778.36
- Type
- journal article
- Language
- en
- Update notices
- erratum (2020-03-28)
- Open access
- bronze
- doi.org
- Locations
- The Lancet (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- DSPACE System - Metalibrary (University of the Coast) (submittedVersion, public-domain)
- reponame:Expeditio Repositorio Institucional UJTL
- Funders
- University of Oxford
- Chinese Academy of Medical Sciences (CIFMS 2018-I2M-1-003, 2018-I2M-1-003)
- Peking Union Medical College
- National Key Research and Development Program of China (2018YFC1200100, 2018YFC1200102)
- Topics
- Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
- Health Sciences › Medicine › Infectious Diseases › SARS-CoV-2 and COVID-19 Research
- Health Sciences › Medicine › Neurology › Long-Term Effects of COVID-19
- Keywords
- COVID-19 pandemic, SARS-CoV-2, in-hospital mortality, risk factors, clinical course, viral shedding, SOFA score, D-dimer, comorbidities, hypertension, age, hospitalized adults, Wuhan outbreak, mortality prediction model, prognostic factors, organ failure, coagulopathy, cytokine storm, cytokine release syndrome
- MeSH terms
- Betacoronavirus, COVID-19, SARS-CoV-2, COVID-19 Testing, Adolescent, Adult, Age Factors, Aged, Aged, 80 and over, Cardiovascular Diseases, China, Female, Fibrin Fibrinogen Degradation Products, Humans, Hypertension, Male, Middle Aged, Mortality, Patient Care Planning, Patient Isolation, Pneumonia, Viral, Prognosis, Retrospective Studies, Risk Factors, Cohort Studies, Comorbidity, Coronavirus Infections, Disease Progression, Risk Assessment, Clinical Laboratory Techniques, Diabetes Complications, Young Adult, Pandemics, Organ Dysfunction Scores
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