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Combination of fibrosis-4 score and D-dimer: a practical approach to identify poor outcome in COVID-19
Fernanda Manhães Pozzobon1,2, Ronir Raggio Luiz3,4, Júlia Gomes Parente1
1Department of Internal Medicine, Barra D'Or Hospital, Rede D'Or São Luiz, Rio de Janeiro.
Insights
The sequential use of Fibrosis-4 (FIB-4) score and D-dimer (DD) effectively identifies high-risk coronavirus disease 2019 (COVID-19) patients. This strategy aids in predicting mortality and can reduce unnecessary D-dimer testing.
Area of Science:
- Clinical Medicine
- Infectious Diseases
- Hematology
Background:
- Fibrosis-4 (FIB-4) score and D-dimer (DD) are prognostic markers for COVID-19.
- Precise cutoff points and combined usage for COVID-19 outcomes require further investigation.
Purpose of the Study:
- To evaluate the individual and combined performance of FIB-4 and DD in predicting COVID-19 patient outcomes.
- To establish optimal cutoff points for FIB-4 and DD in predicting in-hospital mortality.
Main Methods:
- Analysis of hospitalized COVID-19 patients (n=518) from March to December 2020.
- Evaluation of clinical and laboratory data, including FIB-4 and DD levels.
- Development of a sequential diagnostic strategy using FIB-4 followed by DD to predict mortality.
Main Results:
- FIB-4 demonstrated superior performance over DD in predicting mortality (AUC 0.76 vs. 0.65).
- Optimal cutoffs were FIB-4 ≥1.76 and DD ≥2000 ng/ml, associated with significantly higher mortality.
- Sequential testing identified a high-risk subgroup (48% mortality) with 98% sensitivity for mortality prediction.
Conclusions:
- Sequential application of FIB-4 and DD is a robust strategy for identifying high-risk COVID-19 patients upon admission.
- This approach can optimize diagnostic testing by minimizing unnecessary DD measurements in low-risk individuals identified by FIB-4.
Aim:
Fibrosis-4 (FIB-4) score and D-dimer (DD) have emerged as prognostic markers in coronavirus disease 2019 (COVID-19). However, precise cutoff points remain undefined, and their combined use has been scarcely studied. We aimed to analyze FIB-4 and DD performance, individually and combined, to predict outcomes among COVID-19 patients.
Methods:
From March to December 2020, hospitalized COVID-19 patients were evaluated based on clinical and laboratory tests from their first day of hospitalization. Primary outcome was inhospital mortality, and secondary outcomes included hospital stay length, ICU admission and duration, need for hemodialysis, ventilatory support, and extent of lung involvement. Optimal FIB-4 and DD cutoff points to predict mortality were established to maximize sensitivity and specificity. A sequential diagnostic strategy using both markers was subsequently evaluated.
Results:
Among 518 patients (61 ± 16 years, 64% men), the inhospital mortality rate was 18%. FIB-4 outperformed DD in predicting mortality (area under the receiver operating characteristic curve: 0.76 vs. 0.65, P = 0.003) and was chosen as the first step in sequential analysis. Mortality was higher in patients with FIB-4 ≥1.76 vs. FIB-4 <1.76 (26 vs. 5%, P < 0.001) and DD ≥2000 ng/ml vs. DD <2000 ng/ml (38 vs. 16%, P < 0.001). Using FIB-4 as a screening test (cutoff = 1.76, 90% sensitivity) followed by DD (cutoff = 2000 ng/ml; 90% specificity) identified a subgroup with higher mortality when compared with FIB-4 alone (48 vs. 26%, P < 0.001), missing the identification of only 2% of deaths.
Conclusion:
Sequential use of FIB-4 and DD represents a comprehensive strategy to identify high-risk COVID-19 patients at hospital admission, potentially minimizing unnecessary DD tests in those deemed low-risk by FIB-4.
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