13 The model was adjusted for elevated CRP using a level of ≥40 mg/L, in addition to: patient age group (<65, 65–79, ≥80 years old), sex, diabetes (yes/no), hypertension (yes/no), coronary artery disease (yes/no) and kidney disease. To assess differing thresholds for CRP as a prognostic factor of outcome, a series of mixed-effects multivariable Cox proportional hazards models for time to mortality were fit, in a method consistent with the COPE study primary analysis. Secondary analysis: prognostic modelling analysis The aim of this study is to examine the distribution of CRP at hospital admission, and objectives are to: (i) assess CRP as a prognostic bimodal or trimodal distribution (ii) propose and compare the categorization of CRP as a prognostic marker to either a linear or a log-linear measure of CRP. The use of CRP as a biomarker in COVID-19 may present a quick and accessible tool in clinical management, trigger longer periods of enhanced observation, provide information around likely disease progression and assist with early therapeutic, ventilation and palliative care discussions. Whilst CRP has been argued as an important marker of disease progression in COVID-19, 6, its distribution has never been explored to understand whether distinct patterns exist in a heterogeneous population. 10, 11 Although using CRP in a continuous manner may offer an improved understanding of the contribution of CRP within each analysis, it does not allow CRP to be used by clinical teams to guide management of patients with COVID-19. 9 The studies adjusted for admission CRP as a covariate to account for baseline disease severity have assumed a linear or natural logarithm transformation relationship with outcome. 7 A lower cut-off of ≥20.44 mg/L was used as a threshold for related lung injury, 8 and >32.5 mg/L was found to offer 80% predictive power for a person needing mechanical ventilation. In addition to a binary threshold, CRP has been examined in a trichotomized model with the two thresholds at ≥40 mg/L and ≥100 mg/L. 6 Most these studies used CRP with a binary threshold proposed values to predict inpatient mortality varied from ≥10 mg/L to ≥76 mg/L. In a recent systematic review, 10 of the 22 included COVID-19 prognostic models treated CRP either as a factor or covariate. However, debate remains over the utility of CRP as a prognostic marker for patients admitted to hospital with COVID-19. 4 In COVID-19, a CRP level of ≥4 mg/L has been shown to be useful for triaging suspected cases when comparing polymerase chain reaction (PCR)-positive patients versus negative controls who have presented to a fever clinic with respiratory symptoms or a high temperature. 3 The profile of this biomarker has made CRP useful and routinely available in clinical medicine for diagnostics.ĬRP can be used to assist with differentiation between viral and bacterial infections, for example, influenza produces a mean CRP level of 25.65 mg/L versus bacterial pneumonia which produces a mean CRP level of 135.96 mg/L (95% CI 99.38 to 172.54 mg/L). Crucially, it may be elevated before a patients’ vital signs are affected or leukocytes are raised. 3 Secretion begins 4–10 h after an inflammatory insult and peaks at 48 h, with a short half-life of 19 h. ![]() ![]() 1, 2 CRP is a non-specific acute phase protein that is produced by hepatocytes and elevated in acute infection or inflammation. Elevated levels of serum C-reactive protein (CRP) have been observed in patients with COVID-19 and used to assist with triage, diagnostics and prognostication.
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