Covid-19: Post-Hospitalization, Patients Struggle With Self Care

Covid-19 survivors do not come away unscathed. Nearly half of patients hospitalized with the virus are left with one or more complications from the disease, especially if they required critical care while hospitalized, according to a new report in The Lancet. Moreover, these residual complications left patients with a lower ability to take care of themselves, and this was “most profound” in patients younger than 50 years old.

“The most common complications in our data were acute kidney injury, and complex respiratory and systemic complications,” Thomas M. Drake MBChB, from the Centre for Medical Informatics, Usher Institute, University of Edinburgh, Scotland and colleagues wrote. “Although our study only looked at complications during the first admission for Covid-19, many of the common complications identified are associated with substantial long-term morbidity.” The study authors also noted that while neurological complications weren’t among the most common in their study, these were “the most strongly associated with reduced ability to self-care.

“Most clinical studies of Covid-19 have focused on associated mortality,” Drake and colleagues wrote. “Mortality is a hard endpoint, easily measured, and of utmost importance. However, its use as a sole outcome in Covid-19 studies might underestimate the detrimental impact of Covid-19, particularly in those who are younger or otherwise healthy…We also observed the differences in number of complications decrease between those who died and those who survived as age increased, suggesting that although young people are less likely to die, they might be proportionally more likely to survive and live with complications.”

In a commentary published with the study, Xiaoying Gu, MD, and Bin Cao, MD, from the National Clinical Research Center for Respiratory Medicine in Beijing, called this finding “notable.”

“Whether this difference in complications on mortality was statistically significant was not examined by the authors. This finding is independent of the presence and number of comorbidities and indicates that attention should also be paid to younger patients who are less likely to die during the acute phase but more likely to live longer with complications in the days after acute or subacute Covid-19,” they wrote.

Drake and colleagues included 80,388 patients in their prospective, multicenter, cohort study that ran from Jan. 17 to Aug. 4, 2020, “to characterize the extent and effect of Covid-19 complications, particularly in those who survive, using the International Severe Acute Respiratory and Emerging Infections Consortium (ISARIC) WHO Clinical Characterisation Protocol UK (CCP-UK). There were 75,276 patients age 19 or older and 73,197, or 97.2%, had complication outcome data available for analysis.

“The primary outcome of this study was the incidence of in-hospital complications, defined as organ-specific diagnoses occurring alone or in addition to any hallmarks of Covid-19 illness. We used multilevel logistic regression and survival models to explore associations between these outcomes and in-hospital complications, age, and pre-existing comorbidities,” Drake and colleagues wrote and also noted that “The mean age of our cohort was 71.1 years (SD 18.7), with 56.0% (41,025 of 73,197) being male and 81.0% (59,289 of 73 197) having at least one comorbidity.”

Among their findings:

• Overall mortality was 31.5%.
• Overall complication rate for those admitted to hospital with Covid-19 was 49.7%, with 36,367 having at least one complications.
• 43.5% of patients who survived (n=21,784) had at least one complications.
• Complications rates were highest in males and people over age 60 — 54.5% (16,579 of 30,416) in males and 48.2% (11,707 of 24,288) in females; age <60 years: 48.8% (5,179 of 10,609) in males and 36.6% (2,814 of 7,689) in females.
• Complications were lowest in patients age 19-29 with no comorbidity.
• Those age 60-69 with two or more comorbidities had the highest rates of complications.
• 26.6% of survivors (13,309 of 50,105) had a more difficult time of self care compared to this ability prior to Covid-19 infection.
• Ability to self care worsened with increasing age, male sex, and those who received critical care support while in hospital.

Specific complications rates (those having at least one in-hospital complication) were:

• 24.3% renal complications.
• 18.4% complex respiratory.
• 16.3 % systemic complications.
• 12.3% cardiovascular.
• 4.3% neurological.
• 10.8% gastrointestinal or liver.

The study authors also noted that acute kidney injury, probable ARDS, liver injury, anemia, and cardiac arrhythmia were the most common organ-specific complications. Acute kidney injury increased with age, and patients aged 60-90 were at the greatest risk. Not surprisingly, patients with chronic kidney disease were at the highest risk of acute kidney injury.

Increasing age also impacted those experiencing cardiac complications and these were most frequent in patients with existing cardiac disease — “19.9% (4,496 of 22,563) developed a cardiac complication compared with 8.9% (4,077 of 45,563) in those without previous cardiac disease,” the study authors noted.

Liver injury affected those younger than age 60, with males being impacted the most, and again “patients with pre-existing moderate or severe liver disease (300 [22.4%] of 1,340) compared with those without liver injury (4,097 [6.2%] of 65,646),” the study authors wrote.

While the complication rates were comparable for White, South Asian, and East Asian ethnic and racial groups, Blacks were more affected by complications compared to Whites—822 (33.1%) of 2,480 versus 12,896 (24.0%) of 53,780, respectively.

Obesity also was a factor for complications for patients with obesity being 1.6 times more likely to have respiratory complications than those who did not have obesity.

“This study has important implications for clinicians. It was not possible for us to causally link complications and consequent poor outcomes,” Drake and colleagues wrote in their conclusion. “However, it is plausible that interventions targeted at preventing in-hospital complications or reducing their impact could plausibly improve outcomes. We found respiratory and cardiovascular complications were associated with greatest severity and acute kidney injury was one of the most common. Treatments such as enhanced monitoring and early treatment for patients for cardiac arrhythmias that might lead to further problems such as stroke or cardiac arrest might, therefore, be useful. Similarly, for acute kidney injury, optimizing fluid balance to ensure adequate renal perfusion in patients with less severe respiratory disease might lessen the impact of acute kidney injury. Our data also present research opportunities for preventing complications that contribute to substantial disability.”

Limitations of their study include its focus on in-hospital complications; predefined complications by study protocol; not capturing the timing of the complications; and because the data were captured from a real-world setting, there were no additional tests for detecting the presence of complications.

1. Nearly half of patients who had been hospitalized with the virus are left with one or more complications from the disease, especially if they required critical care while hospitalized, according to a new report in The Lancet.

2. These residual complications left patients with a lower ability to take care of themselves, and this was “most profound” in patients younger than 50 years old.

Candace Hoffmann, Managing Editor, BreakingMED™

Cat ID: 125

Topic ID: 79,125,730,933,125,926,192,927,151,928,925,934