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Hipokloremia sebagai prediktor mortalitas di rumah sakit pada pasien COVID-19 sedang-berat dengan gagal jantung

Abstract

Introduction: The clinical presentation of COVID-19 infection is wide, from asymptomatic infection to severe viral pneumonia with acute respiratory distress syndrome (ARDS). COVID-19 was initially thought to be a respiratory disease, but it is now known to have multiorgan involvement. The heart is one of the organs that often manifests clinically, including acute coronary syndrome, arrhythmia, myocarditis and even heart failure. Heart disease, especially heart failure and acute coronary syndrome, is often the reason why COVID-19 patients are treated. Heart failure will activate the renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system (SNS), which has implications for congestion, acid-base and electrolyte disturbances. Most of the electrolyte disturbances in treated COVID-19 patients were hyponatremia (12.4%) and hypochloremia (11.1%). Several studies in patients with worsening heart failure have reported that serum chloride is inversely associated with mortality independent of serum sodium levels, thus suggesting its use as a prognostic marker in heart failure.

Methods: This study is a retrospective cohort study involving 59 moderately severe COVID-19 patients with comorbid heart failure. Secondary data was taken from the registry of patients treated with moderate-severe COVID-19 and heart failure at Harapan Kita Heart Center Hospital. The aim of this study was to determine the role of hypochloremia as a predictor of in-hospital mortality in moderate-severe COVID-19 patients with heart failure. Chloride values were taken on the first day of treatment and divided into 2 categories, low (<98 mmol/L) and normal (³98 mmol/L) based on standard values at Harapan Kita Heart Center Hospital.

Result: The average age in the group who died (62.09 ± 1.61) and the group who survived (57.94 ± 9.44). There were no significant differences found in individual demographic characteristics based on age, gender and body mass index between the two groups (p>0.05). There were significant differences, namely lower serum chloride, lower glomerular filtration rate, shorter length of stay, and lower TAPSE parameters in the group that died compared to those who survived (p<0.05). Other characteristics such as serum sodium levels, diuretic use, and ejection fraction PaO2, PF ratio, and comorbid diabetes were not different between the two groups (p>0.05). Multivariate analysis was carried out to adjust the confounding variables in the study. From this analysis it was found that hypochloremia (adjusted HR 17.61; p = 0.003) was the factor that contributed most to the mortality of moderately severe COVID-19 patients with heart failure in this study.

Conclusion: Hypochloremia is a significant predictor of in-hospital mortality in moderate-severe COVID-19 patients with heart failure.

 

Pendahuluan: Presentasi klinis infeksi COVID-19 sangat luas, dari infeksi tanpa gejala hingga pneumonia virus berat dengan sindroma gangguan pernapasan akut (ARDS). COVID-19 pada awalnya dianggap sebagai penyakit pernapasan, tetapi saat ini diketahui bahwa terdapat keterlibatan multiorgan. Jantung adalah salah satu organ yang sering bermanifestasi secara klinis baik itu terjadi sindroma koroner akut, aritmia, miokarditis dan bahkan gagal jantung. Penyakit jantung terutama gagal jantung dan sindroma koroner akut sering menjadi alasan pasien COVID-19 untuk dirawat. Gagal jantung akan mengaktifasi renin-angiotensin-aldosteron system (RAAS) dan sympatic nervous system (SNS) yang berimplikasi terjadinya kongesti, gangguan asam-basa, dan elektrolit. Gangguan elektrolit pada pasien COVID-19 yang dirawat sebagian besar berupa hyponatremia (12,4%) dan hipoklroremia (11,1%). Beberapa penelitian pada pasien dengan gagal jantung yang memburuk telah melaporkan bahwa klorida serum berbanding terbalik dengan kematian yang tidak bergantung pada kadar natrium serum, oleh karenanya disarankan penggunaannya sebagai penanda prognostik pada gagal jantung.

Metode: Studi ini adalah studi kohort retrospektif yang melibatkan 59 pasien COVID-19 sedang berat dengan komorbid gagal jantung. Data sekunder diambil dari registri pasien yang dirawat dengan COVID-19 sedang-berat dan gagal jantung di Rumah Sakit Pusat Jantung Harapan Kita. Tujuan dari penelitian ini adalah untuk mengetahui peranan hipokloremia sebagai prediktor mortalitas di Rumah Sakit pada pasien COVID-19 sedang-berat dengan gagal jantung. Nilai klorida diambil saat hari pertama perawatan dan dibagi menjadi 2 kategori, rendah (<98 mmol/L) dan normal (³98 mmol/L) berdasarkan nilai standar di Rumah Sakit Pusat Jantung Harapan Kita.

Hasil penelitian: Rata-rata usia pada kelompok yang meninggal (62,09 ± 1,61) dan kelompok yang bertahan hidup (57,94 ± 9,44). Tidak ditemukan adanya perbedaan yang bermakna pada karakteristik demografi individu berdasarkan usia, jenis kelamin, dan indeks massa tubuh antara kedua kelompok (p>0,05). Terdapat perbedaan yang bermakna yaitu serum klorida yang lebih rendah, laju filtrasi glomerulus yang lebih rendah, lama rawat yang lebih singkat, dan parameter tricuspid annular systolic excursion (TAPSE) yang lebih rendah pada kelompok yang meninggal dibandingkan dengan bertahan hidup (p<0,05). Karakteristik lain seperti kadar serum natrium, penggunaan diuretik, dan fraksi ejeksi PaO2, PF rasio, dan komorbid diabetes yang tidak berbeda diantara kedua kelompok (p>0,05). Analisis multivariat dilakukan untuk melakukan adjustment terhadap variabel perancu yang ada dalam penelitian, dari analisis ini ditemukan bahwa kondisi hipokloremia (adjusted HR 17,61; p =0,003)  merupakan faktor yang paling berperan terahdap mortalitas dari pasien COVID 19 derajat sedang berat dengan gagal jantung dalam penelitian ini.

Simpulan: Hipoklremia sebagai prediktor yang signifikan untuk mortalitas di Rumah Sakit pada pasien COVID-19 sedang-berat dengan gagal jantung.

References

  1. Worldometer. Worldometer’s COVID-19 data 2022 [cited 2022 13 February 2022]. Available from: https://www.worldometers.info/coronavirus/country/indonesia/.
  2. Batah SS, Fabro AT. Pulmonary pathology of ARDS in COVID-19: A pathological review for clinicians. Respir Med. 2021;176:106239.
  3. Huang C, Wang Y, Li X et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506.
  4. Wang D, Hu B, Hu C. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020;323:1061–1069.
  5. Italia L, Tomasoni D, Bisegna S et al. COVID-19 and heart failure: from epidemiology during the pandemic to myocardial injury, myocarditis, and heart failure sequelae. Front. Cardiovasc. Med. 2021;8:713650
  6. Zou F, Qian Z, Wang Y. Cardiac injury and COVID-19: a systematic review and meta-analysis. Elsevier. 2020;3(4):386-394.
  7. Petrilli CM, Jones SA, Yang J. Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study. BMJ. 2020;369:m1966. doi: 10.1136/bmj.m1966
  8. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area. JAMA. (2020) 323:2052–9. doi: 10.1001/jama.2020.6775.
  9. Alvarez-Garcia J, Lee S, Gupta A, et al. Prognostic impact of prior heart failure in patients hospitalizedwith COVID-19. J Am Coll Cardiol. 2020;76:2334–48. doi:10.1016/j.jacc.2020.09.549.
  10. Tomasoni D, Inciardi RM, Lombardi CM, et al. Impact of heart failure on the clinical course and outcomes of patients hospitalized for COVID-19. Results of the Cardio-COVID-Italy multicentre study. Eur J Heart Fail. 2020;22:2238–47. doi: 10.1002/ejhf.2052
  11. Bader F, Manla Y, Atallah B, Starling RC. Heart failure and COVID-19. Heart Fail Rev. 2021;26:1-10
  12. Inciardi RM, Adamo M, Lupi L, et al. Characteristics and outcomes of patients hospitalized for COVID- 19 and cardiac disease in Northern Italy. Eur Heart J. 2020;41:1821–9. doi:10.1093/eurheartj/ehaa388
  13. Pourfridoni M, Abbasnia SM, Shafaei F et al. Fluid and electrolyte disturbances in COVID-19 and their complications. BioMed Research International. 2021;6667047:1-5
  14. Malieckal DA, Uppal NN, Jia HN et al. Electrolyte abnormalities in patiens hospitalized with COVID-19. Clinical Kidney Journal. 2021;14(6):1704-1707.
  15. Kazory A, Ronco C. Emergency of chloride as an overlooked cardiorenal connector in heart failure. Blood Purif. 2020;49:219-221
  16. Grodin JL, Simon J, Hachamovitch R et al. Prognostic role of serum chloride levels in acute decompensated heart failure. JACC. 2015;66:6-11.
  17. Kondo T, Yamada T, Tamaki S. Serial change in serum chloride during hospitalization could predict heart failure death in acute decompensated heart failure patients. Circ J. 2018; 82(4):1041-1050.
  18. Carvalho HD, Richard MC, Chouihed T at al. Electrolyte imbalance in COVID-19 patiens admitted to the emergency department: a case-control study. Internal and Emergency Medicine. 2021;16:1945-50.
  19. Zandijk AJL, Norel V, Margje R et al. Chloride in heart failure: the neglected electrolyte. JACC: Heart Failure. 2021;9(12);904-915.
  20. Carter B, Ramsay EA, Short R, Goodison S, Lumsden J, Khan A, Braude P, Vilches-Moraga A, Quinn TJ, McCarthy K, Hewitt J, Myint PK; COPE Study. Prognostic value of estimated glomerular filtration rate in hospitalised older patients (over 65) with COVID-19: a multicentre, European, observational cohort study. BMC Geriatr. 2022;22(1):119. doi: 10.1186/s12877-022-02782-5.
  21. Mirijelo A, Piscitelli P, Matthaeis AD et al. Low eGFR is strong predictor of worse outcome in hospitalized COVID-19 patients. J Clin Med. 2021;10(22): 5224-31.
  22. Paternoster G, Bertini P, Innelli P et al. Right ventricular dysfunction in patients with COVID-19: a systematic review and meta-analysis. Journal of Cardiothoracic and Vascular Anesthesia. 2021;35:3319-3324.
  23. Corica B, Marra AM, Basili S, Cangemi R, Cittadini A, Proietti M, et al. Prevalence of right ventricular dysfunction and impact on all-cause death in hospitalized patients with COVID-19: a systematic review and meta-analysis. Sci Rep. 2021;11(1):17774.
  24. Seo M, Watanabe T, Yamada T et al. Prognostic significance of serum chloride level in heart failurepatients with preserved ejection fraction. ESC Heart Failure. 2022;9:1444-1453.
  25. Wu Y, Hou B, Liu J, Chen Y, Zhong P. Risk factors associated with long-term hospitalization in patients with COVID-19: a singl- centered retrospective study. Frontiers in Medicine. 2020; 7:315-319.
  26. Valga F, Monzon T, Vega-Diaz N et al. Hypocloremia is associated with a greater incidence of pneumonia in chronic hemodialysis patients with COVID-19: a center experience. 2020;10(2):1-3. https://doi.org/10.1016/j.nefro.2022.02.001
  27. Kirthi AAAK, Yasmin AAADA, Artha IMJR, Bhargah A. Hipertensi sebagai prediktor kejadian kardiovaskular mayor pada pasien infark miokard akut pada tahun 2018 di RSUP Sanglah Denpasar, Bali-Indonesia. Intisari Sains Medis. 2019;10(3):530-536. Available from: https://isainsmedis.id/index.php/ism/article/view/443

How to Cite

Darma, I. K. S. S., Widyantoro, B. ., & Juzar, D. A. . (2023). Hipokloremia sebagai prediktor mortalitas di rumah sakit pada pasien COVID-19 sedang-berat dengan gagal jantung. Intisari Sains Medis, 14(3), 986–992. https://doi.org/10.15562/ism.v14i3.1852

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I Kadek Susila Surya Darma
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Bambang Widyantoro
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Dafsah Arifa Juzar
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