在新冠疫情期间，D-二聚体、脑钠肽/氨基末端脑钠肽前体以及肌酐是在维持生命治疗的 withholding 和 withdrawing 过程中可靠的决策生物标志物。 （注：这里“withholding”和“withdrawing”在医学语境中可能有特定含义，比如“ withholding”可能是指暂不给予某种治疗措施，“withdrawing”可能是指撤掉已有的治疗措施等，结合语境推测大致意思，准确理解还需结合更专业背景知识）
D-dimer, BNP/NT-pro-BNP, and creatinine are reliable decision-making biomarkers in life-sustaining therapies withholding and withdrawing during COVID-19 outbreak.
作者信息
Smadja David M, Fellous Benjamin A, Bonnet Guillaume, Hauw-Berlemont Caroline, Sutter Willy, Beauvais Agathe, Fauvel Charles, Philippe Aurélien, Weizman Orianne, Mika Delphine, Juvin Philippe, Waldmann Victor, Diehl Jean-Luc, Cohen Ariel, Chocron Richard
机构信息
Université de Paris-Cité, Innovative Therapies in Haemostasis, INSERM, Paris, France.
Hematology Department, AP-HP, Georges Pompidou European Hospital, Paris, France.
出版信息
Front Cardiovasc Med. 2022 Sep 6;9:935333. doi: 10.3389/fcvm.2022.935333. eCollection 2022.
BACKGROUND
The decision for withholding and withdrawing of life-sustaining treatments (LSTs) in COVID-19 patients is currently based on a collegial and mainly clinical assessment. In the context of a global pandemic and overwhelmed health system, the question of LST decision support for COVID-19 patients using prognostic biomarkers arises.
METHODS
In a multicenter study in 24 French hospitals, 2878 COVID-19 patients hospitalized in medical departments from 26 February to 20 April 2020 were included. In a propensity-matched population, we compared the clinical, biological, and management characteristics and survival of patients with and without LST decision using Student's -test, the chi-square test, and the Cox model, respectively.
RESULTS
An LST was decided for 591 COVID-19 patients (20.5%). These 591 patients with LST decision were secondarily matched (1:1) based on age, sex, body mass index, and cancer history with 591 COVID-19 patients with no LST decision. The patients with LST decision had significantly more cardiovascular diseases, such as high blood pressure (72.9 vs. 66.7%, = 0.02), stroke (19.3 vs. 11.1%, < 0.001), renal failure (30.4 vs. 17.4%, < 0.001), and heart disease (22.5 vs. 14.9%, < 0.001). Upon admission, LST patients were more severely attested by a qSOFA score ≥2 (66.5 vs. 58.8%, = 0.03). Biologically, LST patients had significantly higher values of D-dimer, markers of heart failure (BNP and NT-pro-BNP), and renal damage (creatinine) ( < 0.001). Their evolutions were more often unfavorable (in-hospital mortality) than patients with no LST decision (41.5 vs. 10.3%, < 0.001). By combining the three biomarkers (D-dimer, BNP and/or NT-proBNP, and creatinine), the proportion of LST increased significantly with the number of abnormally high biomarkers (24, 41.3, 48.3, and 60%, respectively, for none, one, two, and three high values of biomarkers, trend < 0.01).
CONCLUSION
The concomitant increase in D-dimer, BNP/NT-proBNP, and creatinine during the admission of a COVID-19 patient could represent a reliable and helpful tool for LST decision. Circulating biomarker might potentially provide additional information for LST decision in COVID-19.
背景
目前，对于新冠病毒疾病（COVID-19）患者停止和撤销维持生命治疗（LST）的决定是基于团队协作且主要是临床评估做出的。在全球大流行以及卫生系统不堪重负的背景下，出现了使用预后生物标志物为COVID-19患者的LST决策提供支持的问题。
方法
在法国24家医院开展的一项多中心研究中，纳入了2020年2月26日至4月20日在各医疗科室住院的2878例COVID-19患者。在一个倾向评分匹配的人群中，我们分别使用Student's t检验、卡方检验和Cox模型比较了有和没有LST决策的患者的临床、生物学和管理特征及生存情况。
结果
为591例COVID-19患者（20.5%）做出了LST决定。这591例有LST决策的患者随后根据年龄、性别、体重指数和癌症病史与591例没有LST决策的COVID-19患者进行了1:1匹配。有LST决策的患者患心血管疾病的比例显著更高，如高血压（72.9%对66.7%，P = 0.02）、中风（19.3%对11.1%，P < 0.001）、肾衰竭（30.4%对17.4%，P < 0.001）和心脏病（22.5%对14.9%，P < 0.001）。入院时，LST患者经qSOFA评分≥2证实病情更严重（66.5%对58.8%，P = 0.03）。从生物学角度看，LST患者的D-二聚体、心力衰竭标志物（BNP和NT-pro-BNP）和肾损伤标志物（肌酐）的值显著更高（P < 0.001）。与没有LST决策的患者相比，他们的病情发展更常出现不良情况（院内死亡率）（41.5%对10.3%，P < 0.001）。通过联合三种生物标志物（D-二聚体、BNP和/或NT-proBNP以及肌酐），LST的比例随着生物标志物异常升高的数量显著增加（生物标志物无、一个、两个和三个高值时分别为24%、41.3%、48.3%和60%，趋势P < 0.01）。
结论
COVID-19患者入院期间D-二聚体、BNP/NT-proBNP和肌酐同时升高可能是LST决策的一个可靠且有用的工具。循环生物标志物可能为COVID-19的LST决策提供额外信息。
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