Interaction Effect Between Hemoglobin and Hypoxemia on COVID-19 Mortality: an observational study from Bogotá, Colombia

PURPOSE: We aimed to assess the effect of hemoglobin (Hb) concentration and oxygenation index on COVID-19 patients’ mortality risk. PATIENTS AND METHODS: We retrospectively reviewed sociodemographic and clinical characteristics, laboratory findings, and clinical outcomes from patients admitted to a tertiary care hospital in Bogotá, Colombia, from March to July 2020. We assessed exploratory associations between oxygenation index and Hb concentration at admission and clinical outcomes. We used a generalized additive model (GAM) to evaluate the observed nonlinear relations and the classification and regression trees (CART) algorithm to assess the interaction effects. RESULTS: We included 550 patients, of which 52% were male. The median age was 57 years old, and the most frequent comorbidity was hypertension (29%). The median value of SpO(2)/FiO(2) was 424, and the median Hb concentration was 15 g/dL. The mortality was 15.1% (83 patients). Age, sex, and SpO(2)/FiO(2), were independently associated with mortality. We described a nonlinear relationship between Hb concentration and neutrophil-to-lymphocyte ratio with mortality and an interaction effect between SpO(2)/FiO(2) and Hb concentration. Patients with a similar oxygenation index had different mortality likelihoods based upon their Hb at admission. CART showed that patients with SpO(2)/FiO(2) < 324, who were less than 81 years with an NLR >9.9, and Hb > 15 g/dl had the highest mortality risk (91%). Additionally, patients with SpO(2)/FiO(2) > 324 but Hb of < 12 g/dl and a history of hypertension had a higher mortality likelihood (59%). In contrast, patients with SpO(2)/FiO(2) > 324 and Hb of > 12 g/dl had the lowest mortality risk (9%). CONCLUSION: We found that a decreased SpO(2)/FiO(2) increased mortality risk. Extreme values of Hb, either low or high, showed an increase in the likelihood of mortality. However, Hb concentration modified the SpO(2)/FiO(2) effect on mortality; the probability of death in patients with low SpO(2)/FiO(2) increased as Hb increased.