Literature DB >> 35573266

The impact of body mass index on the prognostic performance of the Simplified Acute Physiology Score 3: A prospective cohort study.

Isabella B B Ferreira1,2,3,4, Rodrigo C Menezes2,5,6,4, Matheus L Otero7, Thomas A Carmo2,7,3, Gabriel A Agareno7, Gabriel P Telles3, Bruno V B Fahel3, María B Arriaga2,5,6, Kiyoshi F Fukutani2,5, Licurgo Pamplona Neto8, Sydney Agareno8, Kevan M Akrami5,6,9, Nivaldo M Filgueiras Filho1,3,4, Bruno B Andrade2,7,3,5,6.   

Abstract

Objective: To assess the Simplified Acute Physiology Score 3 (SAPS3) prognostic score performance across different body mass index categories.
Methods: A retrospective cohort study in a general ICU in Brazil. A secondary analysis of medical records was performed with clinical and epidemiological data. Patients were stratified according to their body mass index (BMI) category, and a binary logistic regression was then performed to identify factors independently associated with mortality. SAPS3 accuracy was determined using the area under the receiver operating characteristics curve and the Hosmer-Lemeshow test. A modified Kaplan-Meyer plot was employed to evaluate death probability according to BMI. ICU mortality was evaluated as the primary outcome.
Results: A total of 2,179 patients (mean age of 67.9 years and female predominance (53.1%)) were enrolled. SAPS3 was found accurate in all groups except in the underweight (AUC: 0.694 95% CI 0.616-0.773; HL = 0.042). The patients in the underweight group tended to be older, have longer hospital stay, have worse functional status, and have a higher value on prognostic scores. After the adjustments, no statistically significant difference between the BMI groups was noted in relation to mortality, except for the low weight that presented a likelihood of death of 3.50 (95% CI, 1.43-8.58, p = 0.006).
Conclusion: This research showed that SAPS3 had poor accuracy in predicting ICU mortality in underweight patients. This group was shown to be an independent risk factor for worse clinical outcomes.
© 2022 The Author(s).

Entities:  

Keywords:  Body mass index; Intensive care unit; Mortality; Prognosis; Simplified Acute Physiology Score 3

Year:  2022        PMID： 35573266      PMCID： PMC9095890          DOI： 10.1016/j.heliyon.2022.e09188

Source DB:  PubMed          Journal:  Heliyon        ISSN： 2405-8440


Introduction

Healthcare, a dynamically evolving field, involves a broad range of complex variables, as patients characteristics and therapeutic and diagnostic tools change over time. Thus, prognostic scores need to be reassessed frequently to ensure their optimal functionality [1]. Body weight is commonly used in the composition of scores, but the body composition of the population has been changing over recent years; the prevalence of obesity almost tripled between 1975 and 2016 [2]. The World Health Organization (WHO) has reported that obesity is the abnormal or excessive accumulation of body fat that can affect health. The Body mass index (BMI) is one of the recommended tools for its diagnosis [2]. Following the global trend of increasing obesity rates, data collected in Brazil, from 2018 onwards, reveal that 55.7% of the country's adult population is overweight and 19.8% is obese, while the corresponding values in 2006 were 42.6% and 11.8%, respectively [3]. Excess body fat has a well-established association with increased morbidity and mortality in long-term follow-up of out-of-hospital populations. In addition, the increase in the prevalence of obesity in the general population and the burden of comorbidities associated with this disease resulted in an increase in the number of hospitalizations of obese people in intensive care units (ICU) [4]. Despite the obesity epidemic, developing countries present a double burden, in which the obese coexist with a significant population of underweight individuals [5, 6]. Several studies have demonstrated the association of low BMI with all-cause mortality and underlying pathologies in an advanced stage. However, this condition is not considered by most prognostic scores and is not widely studied in the context of ICU [7]. The Simplified Acute Physiology Score 3 (SAPS3) was developed from a multinational database of general ICU patients and is commonly used in Brazilian ICUs, as it has shown good calibration and discrimination in low- and middle-income countries [1, 8]. However, as the country's epidemiological scenario has changed over the years, this study seeks to assess the accuracy of the score in a large cohort of critically ill patients, emphasizing the differences between BMI strata.

Methods

Clinical study design

An observational, analytical cohort study was conducted from August 2015 through July 2018 in a general ICU at Hospital da Cidade in Salvador, Bahia, Brazil. A secondary analysis of admission data stored in the Epimed Monitor system was performed. All patients consecutively admitted to the ICU with the length of stay >24 h were included. Patients <18 years or those with missing data were excluded. Covariates included were age, weight, height, sex, comorbidities, functional capacity, admission diagnosis, length of ICU and hospital stay, physiological and laboratorial data within the first six hours of admission, complications, use of supportive therapy in the ICU, Modified Frailty Index (MFI) [9], the SAPS3 [8], the Charlson Comorbidity Index (CCI) [10]. The patients were stratified based on their BMI values obtained at ICU admission into underweight (BMI <18.5 kg/m2), normal weight (BMI range, 18.5–24.9 kg/m2), overweight (BMI 25–29.9 kg/m2), obese grade I (BMI, 30–34.9 kg/m2) or obese grade II/III (BMI >35 kg/m2) [2]. Our primary outcome was ICU death.

Ethics statement

This article was ethically approved by the Research Ethics Committee of Hospital Ana Nery under number 2,571,265 and CAAE 52892315.1.0000.0045. This same ethics committee approved the waiver of consent to participate in accordance with the regulatory standards of the national health council (N° 466/12), which addresses observational, analytical, or descriptive studies that use the information available in medical records; in which data is analyzed anonymously. The present study was conducted in accordance with the Declaration of Helsinki.

Data analysis

Categorical variables were expressed as frequencies and percentages and analyzed by Fisher's exact test and Z-test. Continuous variables with normal distribution were expressed as means (standard deviation, SD) and means between groups were compared with the one-way analysis of variance (ANOVA) and Tukey's HSD test. Non-normal continuous variables were expressed as median (interquartile range, IQR) and compared with the Mann-Whitney U test and the Kruskal-Wallis test. Normality was assessed by the d'Agostino-Pearson test. All tests results were two-tailed and considered statistically significant for p < 0.05. A binary logistic regression, the backward stepwise method, was used to identify characteristics independently associated with ICU mortality. Finally, the area under the receiver operating characteristic curve (ROC) was determined to assess the discriminative capacity of SAPS3. AUC >0.8 was considered satisfactory. Calibration was assessed using Hosmer-Lemeshow goodness-of-fit test. The data were analyzed with Microsoft Excel suite Office 365, GraphPad Prism version 6.01, and Statistical Package for the Social Sciences, SPSS version 25.0 (IBM, SPSS, USA).

Results

During the study period, 2401 patients were admitted to the ICU. Two hundred and twenty-two subjects were excluded due to missing height, weight, or outcome data or because they did not meet the study inclusion criteria. Finally, 2179 patients were divided into five groups according to their BMI categories (Figure 1). General patient characteristics are provided in Table 1.
Figure 1

Study flowchart.

Table 1

Characteristics of the study population.

VariableGeneral(n = 2179)Non-survivors(n = 343)Survivors(n = 1836)p-value
Age (years)68 ± 1877 ± 1566 ± 18<0.0001
Gender, female1158 (53.1)172 (50.1)986 (53.7)0.239
BMI25.6 ± 5.723.1 ± 5.526.0 ± 5.6<0.0001
Eutrophic914 (41.9)172 (50.1)742 (40.4)0.001
Underweight171 (7.8)64 (18.7)107 (5.8)<0.0001
Overweight700 (32.1)76 (22.2)624 (34.0)<0.0001
Obese Grade I272 (12.5)21 (6.1)251 (13.7)<0.0001
Obese Grade II/III122 (5.6)10 (2.9)112 (6.1)0.015
Congestive heart failure132 (6.1)16 (4.7)116 (6.3)0.268
Chronic renal failure251 (11.5)45 (13.1)206 (11.2)0.311
Cirrhosis28 (1.3)6 (1.7)22 (1.2)0.430
Cancer302 (13.9)71 (20.7)231 (12.6)<0.0001
Immune deficiency27 (1.2)7 (2.0)20 (1.1)0.177
Diabetes817 (37.5)132 (38.5)685 (37.3)0.716
Coronary Artery Disease241 (11.1)31 (9.0)210 (11.4)0.223
Chronic Atrial Fibrillation137 (6.3)32 (9.3)105 (5.7)0.015
Stroke340 (15.6)77 (22.4)263 (14.3)<0.0001
Dementia125 (5.7)48 (14.0)77 (4.2)<0.0001
Tobacco164 (7.5)19 (5.5)145 (7.9)0.147
Alcoholism119 (5.5)22 (6.4)97 (5.3)0.436
Psychiatric disease169 (7.8)23 (6.7)146 (8.0)0.509
Dyslipidemias201 (9.2)24 (7.0)177 (9.6)0.128
Systolic arterial pressure (mmHg)138 ± 29130 ± 30139 ± 280.846
Diastolic Blood Pressure (mmHg)79 ± 2075 ± 2180 ± 20<0.0001
Mean Arterial Pressure (mmHg)99 ± 2193 ± 22100 ± 20<0.0001
HR (bpm)86 ± 2094 ± 2284 ± 20<0.0001
RR (bpm)20 ± 421 ± 520 ± 4<0.0001
Temperature (°C)36 ± 136 ± 136 ± 10.692
Urea (mmol/L)57 ± 4786 ± 6451 ± 42<0.0001
Creatinine (mg/dL)1.44 ± 21.86 ± 21.36 ± 2<0.0001
Platelets (x103)235 ± 113230 ± 130236 ± 1090.420
Hematocrit (%)34 ± 732 ± 835 ± 7<0.0001
Leukocytes total (x103; /uL)11 ± 1113 ± 711 ± 110.011
 Bands (/uL)176.1 ± 511.6304.6 ± 666.5152.1 ± 473.5<0.0001
 Segmented (x103; /uL)9.26 ± 5.7411.05 ± 6.408.92 ± 5.54<0.0001
 Eosinophils (/uL)123.5 ± 246.5112.6 ± 286.0125.5 ± 238.40.404
 Basophils (/uL)18.6 ± 48.78.58 ± 27.5520.47 ± 51.55<0.0001
 Lymphocytes (x103; /uL)1.69 ± 8.841.27 ± 1.041.77 ± 9.610.360
 Atypical (/uL)9.78 ± 172.828.58 ± 390.266.26 ± 83.380.034
 Monocytes (/uL)562.6 ± 390.2521.38 ± 410.73570.34 ± 385.850.040
Na (mEq/L)139.3 ± 7.11138.86 ± 9.56139.4 ± 6.530.211
K (mEq/L)4.32 ± 0.854.56 ± 1.074.28 ± 0.79<0.0001
Use of vasoactive drug201 (9.2)93 (27.1)108 (5.9)<0.0001
Use of mechanical ventilation347 (15.9)149 (43.4)198 (10.8)<0.0001
C-reactive Protein (mg/L)84.64 ± 69.73136.75 ± 63.4574.37 ± 66.25<0.0001
Length of stay prior to ICU admission (days)2.37 ± 11.314.12 ± 11.202.05 ± 11.300.002
ICU Duration (days)8.04 ± 13.3016.08 ± 24.206.54 ± 9.31<0.0001
ICU readmission200 (9.2)49 (2.2)151 (8.2)<0.0001

Results expressed by number (%), mean ± standard deviation (SD). MAP = Mean arterial pressure; HR = heart rate; RR = Respiratory rate.

Study flowchart. Characteristics of the study population. Results expressed by number (%), mean ± standard deviation (SD). MAP = Mean arterial pressure; HR = heart rate; RR = Respiratory rate. When comparing the BMI groups, the underweight participants had significantly different characteristics. They were older and had a longer length of stay prior to ICU admission and lower mean arterial pressure. A third of this group had an infection as the main diagnosis, in addition to a higher prevalence of comorbidities such as cancer, stroke, and dementia. In contrast, overweight and obese patients had a higher frequency of admissions for surgery and cardiovascular pathologies. No significant difference was observed regarding the need for organic support in ICU (Table 2). There were 343 (15.7%) deaths reported in the ICU during the study period. Especially among the underweight group, there was a higher mortality rate, accompanied by higher scores on the modified Frailty Index (MFI), CCI, and SAPS3 (Table 2). Multiple comparisons between each BMI group are represented in Tables 3 and 4.
Table 2

Comparison between BMI groups.

CharacteristicsUnderweight(n = 171)Normal weight(n = 914)Overweight(n = 700)Obese Grade I(n = 272)Obese Grade II/III(n = 122)p-value
Age (years; mean, SD)76.06 ± 16.3969.48 ± 18.5166.10 ± 16.7364.67 ± 16.1962.40 ± 18.78<0.0001
Gender, female (n, %)98 (57.3)438 (47.9)356 (50.9)176 (64.7)90 (73.8)<0.0001
SAPS3 (mean, SD)54.06 ± 11.4948.52 ± 12.6844.63 ± 11.4943.01 ± 11.8744.02 ± 12.39<0.0001
CCI (mean, SD)2.06 ± 1.901.75 ± 1.841.55 ± 1.681.28 ± 1.631.24 ± 1.50<0.0001
MFI (mean, SD)1.94 ± 1.301.62 ± 1.301.68 ± 1.211.67 ± 1.061.75 ± 1.080.040
Admission Diagnosis (n, %)<0.0001
 Cardiovascular25 (14.6)152 (16.6)160 (22.9)81 (29.8)34 (27.9)
 Respiratory13 (7.6)55 (6.0)40 (5.7)13 (4.8)5 (4.1)
 Neurological22 (12.9)171 (18.7)115 (16.4)41 (15.1)11 (9.0)
 Infectious57 (33.3)184 (20.1)96 (13.7)30 (11.0)25 (20.5)
 Surgical10 (5.8)141 (15.4)143 (20.4)65 (23.9)21 (17.2)
 Other44 (25.7)211 (23.1)146 (20.9)42 (15.4)26 (21.3)
Use of VAD (n, %)21 (12.3)86 (9.4)60 (8.6)27 (9.9)7 (5.7)0.375
Use of MV (n, %)32 (18.7)157 (17.2)110 (15.7)38 (14.0)10 (8.2)0.081
Length of stay prior to ICU (days)4.95 ± 16.702.95 ± 14.581.65 ± 6.281.22 ± 4.771.08 ± 3.470.001
ICU length of stay (days)9.77 ± 12.869.34 ± 15.856.84 ± 10.746.79 ± 12.075.58 ± 5.51<0.0001
Congestive Heart Failure (n, %)11 (6.4)59 (6.5)44 (6.3)13 (4.8)5 (4.1)0.257
Chronic Kidney Disease (n, %)17 (9.9)119 (13.0)82 (11.7)26 (9.6)7 (5.7)0.021
Cirrhosis (n, %)1 (0.6)9 (1.0)14 (2.0)3 (1.1)1 (0.8)0.453
Cancer (n, %)29 (17.0)149 (16.3)90 (12.9)23 (8.5)11 (9.0)0.004
Immunodeficiency (n, %)2 (1.2)17 (1.9)4 (0.6)3 (1.1)1 (0.8)0.056
Diabetes Mellitus (n, %)61 (35.7)315 (34.5)277 (39.6)108 (39.7)56 (45.9)0.003
Coronary Artery Disease (n, %)12 (7.0)86 (9.4)106 (15.1)23 (8.5)14 (11.5)0.098
Stroke (n, %)41 (24.0)157 (17.2)96 (13.7)35 (12.9)11 (9.0)0.002
Dementia (n, %)29 (17.0)60 (6.6)25 (3.6)7 (2.6)4 (3.3)<0.0001
Performance status (n, %)<0.0001
Completely independent113 (66.1)778 (85.1)641 (91.6)245 (90.1)109 (89.3)
Partially independent18 (10.5)65 (7.1)39 (5.6)18 (6.6)8 (6.6)
Fully dependent40 (23.4)71 (7.8)20 (2.9)9 (3.3)5 (4.1)
Clinical and Laboratory (mean, SD)
 Mean arterial pressure (mmHg)91.88 ± 21.2297.45 ± 20.8099.73 ± 20.22102.45 ± 20.71101.32 ± 21.53<0.0001
 Heart rate (bpm)89.70 ± 21.0486.31 ± 20.8384.46 ± 19.5582.57 ± 19.1787.90 ± 21.520.001
 Respiratory rate (ipm)21.21 ± 4.9820.10 ± 4.4320.23 ± 4.3419.83 ± 4.5520.45 ± 4.210.021
 Creatinine (mg/dL)1.40 ± 2.271.49 ± 2.281.52 ± 2.631.26 ± 1.821.08 ± 1.100.249
 Platelets (x103)252.5 ± 136.0239.7 ± 113.7227.3 ± 110.3221.1 ± 76.0259.8 ± 149.30.001
 Hematocrit (%)32.34 ± 6.7534.17 ± 7.5835.20 ± 7.3836.75 ± 6.6536.10 ± 5.94<0.0001
 Na (mEq/L)140.2 ± 8.87138.7 ± 7.68139.7 ± 6.25140.0 ± 6.48139.1 ± 5.400.014
 C Reactive Protein (mg/dL)96.77 ± 64.7391.38 ± 70.1579.53 ± 70.1572.48 ± 67.3573.09 ± 68.99<0.0001
ICU deaths (n, %)64 (37.4)172 (18.8)76 (10.9)21 (7.7)10 (8.2)<0.0001

Results expressed by number (%), mean ± standard deviation (SD). CCI = Charlson Comorbidity Index, MFI = Modified Frailty Index, ICU = Intensive care unit; VAD = Vasoactive drug; MV = Mechanical ventilation; bpm = beats per minute; incursions per minute.

Table 3

Multiple comparisons between BMI categories.

VariableBMI Reference categoryBMI comparison groupMean difference (95% CI)Error2p-value
AgeUnderweightNormal weight6,58 (2,48; 10,69)1.460.001
Overweight9,97 (5,77; 14,17)1.50.001
Obese grade I11,39 (6,58; 16,2)1.710.001
Obese grade II/III13,66 (7,82; 19,5)2.080.001
Normal weightUnderweight-6,58 (-10,69; -2,48)1.460.001
Overweight3,39 (0,91; 5,86)0.880.001
Obese grade I4,81 (1,41; 8,21)1.210.001
Obese grade II/III7,08 (2,33; 11,83)1.690.001
OverweightUnderweight-9,97 (-14,17; -5,77)1.50.001
Normal weight-3,39 (-5,86; -0,91)0.880.001
Obese grade I1,42 (-2,1; 4,94)1.250.787
Obese grade II/III3,7 (-1,14; 8,53)1.720.2
Obese grade IUnderweight-11,39 (-16,2; -6,58)1.710.001
Normal weight-4,81 (-8,21; -1,41)1.210.001
Overweight-1,42 (-4,94; 2,1)1.250.787
Obese grade II/III2,27 (-3,1; 7,64)1.910.758
Obese grade II/IIIUnderweight-13,66 (-19,5; -7,82)2.080.001
Normal weight-7,08 (-11,83; -2,33)1.690.001
Overweight-3,7 (-8,53; 1,14)1.720.2
Obese grade I-2,27 (-7,64; 3,1)1.910.758
SAPS3UnderweightNormal weight5,55 (2,71; 8,38)1.010.001
Overweight9,43 (6,53; 12,33)1.030.001
Obese grade I10,96 (7,64; 14,28)1.180.001
Obese grade II/III10,04 (6,01; 14,07)1.430.001
Normal weightUnderweight-5,55 (-8,38; -2,71)1.010.001
Overweight3,88 (2,18; 5,59)0.610.001
Obese grade I5,42 (3,07; 7,77)0.840.001
Obese grade II/III4,5 (1,22; 7,77)1.170.001
OverweightUnderweight-9,43 (-12,33; -6,53)1.030.001
Normal weight-3,88 (-5,59; -2,18)0.610.001
Obese grade I1,53 (-0,9; 3,96)0.870.39
Obese grade II/III0,61 (-2,72; 3,95)1.190.986
Obese grade IUnderweight-10,96 (-14,28; -7,64)1.180.001
Normal weight-5,42 (-7,77; -3,07)0.840.001
Overweight-1,53 (-3,96; 0,9)0.870.39
Obese grade II/III-0,92 (-4,63; 2,78)1.320.957
Obese grade II/IIIUnderweight-10,04 (-14,07; -6,01)1.430.001
Normal weight-4,5 (-7,77; -1,22)1.170.001
Overweight-0,61 (-3,95; 2,72)1.190.986
Obese grade I0,92 (-2,78; 4,63)1.320.957
CCIUnderweightNormal weight0,31 (-0,1; 0,72)0.150.205
Overweight0,51 (0,09; 0,93)0.150.006
Obese grade I0,78 (0,29; 1,26)0.170.001
Obese grade II/III0,82 (0,24; 1,4)0.210.001
Normal weightUnderweight-0,31 (-0,72; 0,1)0.150.205
Overweight0,2 (-0,05; 0,45)0.090.153
Obese grade I0,46 (0,12; 0,8)0.120.001
Obese grade II/III0,51 (0,03; 0,98)0.170.022
OverweightUnderweight-0,51 (-0,93; -0,09)0.150.006
Normal weight-0,2 (-0,45; 0,05)0.090.153
Obese grade I0,26 (-0,09; 0,61)0.130.222
Obese grade II/III0,31 (-0,18; 0,79)0.170.38
Obese grade IUnderweight-0,78 (-1,26; -0,29)0.170.001
Normal weight-0,46 (-0,8; -0,12)0.120.001
Overweight-0,26 (-0,61; 0,09)0.130.222
Obese grade II/III0,05 (-0,49; 0,58)0.190.999
Obese grade II/IIIUnderweight-0,82 (-1,4; -0,24)0.210.001
Normal weight-0,51 (-0,98; -0,03)0.170.022
Overweight-0,31 (-0,79; 0,18)0.170.38
Obese grade I-0,05 (-0,58; 0,49)0.190.999
MFIUnderweightNormal weight0,32 (0,03; 0,61)0.010.016
Overweight0,26 (-0,03; 0,56)0.010.091
Obese grade I0,27 (-0,07; 0,61)0.010.168
Obese grade II/III0,2 (-0,22; 0,61)0.010.665
Normal weightUnderweight-0,32 (-0,61; -0,03)0.010.016
Overweight-0,06 (-0,23; 0,12)0.010.893
Obese grade I-0,05 (-0,29; 0,19)0.010.976
Obese grade II/III-0,12 (-0,46; 0,21)0.010.839
OverweightUnderweight-0,26 (-0,56; 0,03)0.010.091
Normal weight0,06 (-0,12; 0,23)0.010.893
Obese grade I0,01 (-0,24; 0,25)0.011
Obese grade II/III-0,07 (-0,41; 0,27)0.010.982
Obese grade IUnderweight-0,27 (-0,61; 0,07)0.010.168
Normal weight0,05 (-0,19; 0,29)0.010.976
Overweight-0,01 (-0,25; 0,24)0.011
Obese grade II/III-0,07 (-0,45; 0,3)0.010.983
Obese grade II/IIIUnderweight-0,2 (-0,61; 0,22)0.010.665
Normal weight0,12 (-0,21; 0,46)0.010.839
Overweight0,07 (-0,27; 0,41)0.010.982
Obese grade I0,07 (-0,3; 0,45)0.010.983
Length of stay prior to ICUUnderweightNormal weight0,43 (-2,67; 3,54)0.940.211
Overweight2,93 (-0,24; 6,11)0.960.006
Obese grade I2,98 (-0,65; 6,61)1.10.007
Obese grade II/III4,19 (-0,22; 8,6)1.340.031
Normal weightUnderweight-0,43 (-3,54; 2,67)0.940.211
Overweight2,5 (0,63; 4,37)0.570.15
Obese grade I2,55 (-0,02; 5,12)0.790.179
Obese grade II/III3,76 (0,17; 7,34)1.090.422
OverweightUnderweight-2,93 (-6,11; 0,24)0.960.006
Normal weight-2,5 (-4,37; -0,63)0.570.15
Obese grade I0,05 (-2,61; 2,71)0.810.985
Obese grade II/III1,26 (-2,4; 4,91)1.110.986
Obese grade IUnderweight-2,98 (-6,61; 0,65)1.10.007
Normal weight-2,55 (-5,12; 0,02)0.790.179
Overweight-0,05 (-2,71; 2,61)0.810.985
Obese grade II/III1,21 (-2,85; 5,26)1.231
Obese grade II/IIIUnderweight-4,19 (-8,6; 0,22)1.340.031
Normal weight-3,76 (-7,34; -0,17)1.090.422
Overweight-1,26 (-4,91; 2,4)1.110.986
Obese grade I-1,21 (-5,26; 2,85)1.231
ICU length of stayUnderweightNormal weight2 (-0,65; 4,64)1.10.995
Overweight3,3 (0,59; 6)1.130.071
Obese grade I3,72 (0,62; 6,82)1.290.143
Obese grade II/III3,87 (0,11; 7,62)1.570.059
Normal weightUnderweight-2 (-4,64; 0,65)1.10.995
Overweight1,3 (-0,3; 2,9)0.670.002
Obese grade I1,73 (-0,48; 3,93)0.920.043
Obese grade II/III1,87 (-1,19; 4,93)1.280.027
OverweightUnderweight-3,3 (-6; -0,59)1.130.071
Normal weight-1,3 (-2,9; 0,3)0.670.002
Obese grade I0,43 (-1,85; 2,7)0.951
Obese grade II/III0,57 (-2,54; 3,68)1.30.87
Obese grade IUnderweight-3,72 (-6,82; -0,62)1.290.143
Normal weight-1,73 (-3,93; 0,48)0.920.043
Overweight-0,43 (-2,7; 1,85)0.951
Obese grade II/III0,14 (-3,32; 3,6)1.440.919
Obese grade II/IIIUnderweight-3,87 (-7,62; -0,11)1.570.059
Normal weight-1,87 (-4,93; 1,19)1.280.027
Overweight-0,57 (-3,68; 2,54)1.30.87
Obese grade I-0,14 (-3,6; 3,32)1.440.919
Hospital length of stayUnderweightNormal weight1,33 (-3,63; 6,29)1.770.944
Overweight6,5 (1,42; 11,58)1.810.003
Obese grade I7,95 (2,14; 13,76)2.070.001
Obese grade II/III7,58 (0,53; 14,64)2.510.022
Normal weightUnderweight-1,33 (-6,29; 3,63)1.770.944
Overweight5,17 (2,18; 8,16)1.060.001
Obese grade I6,62 (2,51; 10,74)1.460.001
Obese grade II/III6,25 (0,51; 11,99)2.040.019
OverweightUnderweight-6,5 (-11,58; -1,42)1.810.003
Normal weight-5,17 (-8,16; -2,18)1.060.001
Obese grade I1,45 (-2,8; 5,71)1.510.873
Obese grade II/III1,08 (-4,76; 6,92)2.080.985
Obese grade IUnderweight-7,95 (-13,76; -2,14)2.070.001
Normal weight-6,62 (-10,74; -2,51)1.460.001
Overweight-1,45 (-5,71; 2,8)1.510.873
Obese grade II/III-0,37 (-6,86; 6,11)2.311
Obese grade II/IIIUnderweight-7,58 (-14,64; -0,53)2.510.022
Normal weight-6,25 (-11,99; -0,51)2.040.019
Overweight-1,08 (-6,92; 4,76)2.080.985
Obese grade I0,37 (-6,11; 6,86)2.311
Mean arterial pressureUnderweightNormal weight-5,57 (-10,41; -0,72)1.720.011
Overweight-7,85 (-12,81; -2,89)1.770.001
Obese grade I-10,56 (-16,24; -4,89)2.020.001
Obese grade II/III-9,44 (-16,34; -2,53)2.460.001
Normal weightUnderweight5,57 (0,72; 10,41)1.720.011
Overweight-2,28 (-5,21; 0,65)1.040.185
Obese grade I-5 (-9,01; -0,98)1.430.004
Obese grade II/III-3,87 (-9,49; 1,76)20.3
OverweightUnderweight7,85 (2,89; 12,81)1.770.001
Normal weight2,28 (-0,65; 5,21)1.040.185
Obese grade I-2,72 (-6,87; 1,44)1.480.353
Obese grade II/III-1,59 (-7,31; 4,14)2.040.936
Obese grade IUnderweight10,56 (4,89; 16,24)2.020.001
Normal weight5 (0,98; 9,01)1.430.004
Overweight2,72 (-1,44; 6,87)1.480.353
Obese grade II/III1,13 (-5,23; 7,48)2.260.988
Obese grade II/IIIUnderweight9,44 (2,53; 16,34)2.460.001
Normal weight3,87 (-1,76; 9,49)20.3
Overweight1,59 (-4,14; 7,31)2.040.936
Obese grade I-1,13 (-7,48; 5,23)2.260.988
Heart rateUnderweightNormal weight3,39 (-1,36; 8,14)1.690.262
Overweight5,24 (0,38; 10,11)1.730.021
Obese grade I7,14 (1,57; 12,7)1.980.003
Obese grade II/III1,8 (-4,97; 8,57)2.410.945
Normal weightUnderweight-3,39 (-8,14; 1,36)1.690.262
Overweight1,85 (-1,02; 4,71)1.020.368
Obese grade I3,74 (-0,2; 7,68)1.40.059
Obese grade II/III-1,59 (-7,11; 3,92)1.960.927
OverweightUnderweight-5,24 (-10,11; -0,38)1.730.021
Normal weight-1,85 (-4,71; 1,02)1.020.368
Obese grade I1,9 (-2,18; 5,97)1.450.687
Obese grade II/III-3,44 (-9,05; 2,17)20.421
Obese grade IUnderweight-7,14 (-12,7; -1,57)1.980.003
Normal weight-3,74 (-7,68; 0,2)1.40.059
Overweight-1,9 (-5,97; 2,18)1.450.687
Obese grade II/III-5,34 (-11,56; 0,89)2.220.114
Obese grade II/IIIUnderweight-1,8 (-8,57; 4,97)2.410.945
Normal weight1,59 (-3,92; 7,11)1.960.927
Overweight3,44 (-2,17; 9,05)20.421
Obese grade I5,34 (-0,89; 11,56)2.220.114
Respiratory rateUnderweightNormal weight1,12 (0,07; 2,16)0.370.023
Overweight0,98 (-0,08; 2,05)0.380.073
Obese grade I1,38 (0,16; 2,61)0.440.013
Obese grade II/III0,76 (-0,73; 2,25)0.530.606
Normal weightUnderweight-1,12 (-2,16; -0,07)0.370.023
Overweight-0,13 (-0,76; 0,5)0.220.977
Obese grade I0,27 (-0,6; 1,13)0.310.907
Obese grade II/III-0,36 (-1,57; 0,86)0.430.925
OverweightUnderweight-0,98 (-2,05; 0,08)0.380.073
Normal weight0,13 (-0,5; 0,76)0.220.977
Obese grade I0,4 (-0,5; 1,29)0.320.72
Obese grade II/III-0,22 (-1,46; 1,01)0.440.987
Obese grade IUnderweight-1,38 (-2,61; -0,16)0.440.013
Normal weight-0,27 (-1,13; 0,6)0.310.907
Overweight-0,4 (-1,29; 0,5)0.320.72
Obese grade II/III-0,62 (-2; 0,75)0.490.707
Obese grade II/IIIUnderweight-0,76 (-2,25; 0,73)0.530.606
Normal weight0,36 (-0,86; 1,57)0.430.925
Overweight0,22 (-1,01; 1,46)0.440.987
Obese grade I0,62 (-0,75; 2)0.490.707
TemperatureUnderweightNormal weight-0,13 (-0,38; 0,12)0.090.598
Overweight-0,11 (-0,37; 0,15)0.090.755
Obese grade I-0,14 (-0,44; 0,15)0.10.64
Obese grade II/III-0,11 (-0,46; 0,25)0.130.917
Normal weightUnderweight0,13 (-0,12; 0,38)0.090.598
Overweight0,02 (-0,13; 0,17)0.050.996
Obese grade I-0,02 (-0,22; 0,19)0.071
Obese grade II/III0,02 (-0,27; 0,31)0.11
OverweightUnderweight0,11 (-0,15; 0,37)0.090.755
Normal weight-0,02 (-0,17; 0,13)0.050.996
Obese grade I-0,03 (-0,25; 0,18)0.080.991
Obese grade II/III0 (-0,29; 0,3)0.11
Obese grade IUnderweight0,14 (-0,15; 0,44)0.10.64
Normal weight0,02 (-0,19; 0,22)0.071
Overweight0,03 (-0,18; 0,25)0.080.991
Obese grade II/III0,04 (-0,29; 0,36)0.120.998
Obese grade II/IIIUnderweight0,11 (-0,25; 0,46)0.130.917
Normal weight-0,02 (-0,31; 0,27)0.11
Overweight0 (-0,3; 0,29)0.11
Obese grade I-0,04 (-0,36; 0,29)0.120.998
CreatinineUnderweightNormal weight-0,08 (-0,65; 0,49)0.20.994
Overweight-0,11 (-0,7; 0,47)0.210.983
Obese grade I0,14 (-0,52; 0,81)0.240.974
Obese grade II/III0,32 (-0,48; 1,12)0.280.793
Normal weightUnderweight0,08 (-0,49; 0,65)0.20.994
Overweight-0,03 (-0,37; 0,31)0.120.999
Obese grade I0,23 (-0,24; 0,69)0.170.646
Obese grade II/III0,4 (-0,24; 1,04)0.230.393
OverweightUnderweight0,11 (-0,47; 0,7)0.210.983
Normal weight0,03 (-0,31; 0,37)0.120.999
Obese grade I0,26 (-0,23; 0,74)0.170.565
Obese grade II/III0,43 (-0,22; 1,09)0.230.339
Obese grade IUnderweight-0,14 (-0,81; 0,52)0.240.974
Normal weight-0,23 (-0,69; 0,24)0.170.646
Overweight-0,26 (-0,74; 0,23)0.170.565
Obese grade II/III0,18 (-0,55; 0,9)0.260.96
Obese grade II/IIIUnderweight-0,32 (-1,12; 0,48)0.280.793
Normal weight-0,4 (-1,04; 0,24)0.230.393
Overweight-0,43 (-1,09; 0,22)0.230.339
Obese grade I-0,18 (-0,9; 0,55)0.260.96
PlateletsUnderweightNormal weight12,75 (-14,8; 40,29)9.80.691
Overweight25,15 (-3,07; 53,38)10.040.09
Obese grade I31,41 (-0,81; 63,62)11.460.049
Obese grade II/III-7,35 (-46,3; 31,59)13.860.984
Normal weightUnderweight-12,75 (-40,29; 14,8)9.80.691
Overweight12,41 (-4,11; 28,92)5.880.216
Obese grade I18,66 (-4,01; 41,33)8.070.141
Obese grade II/III-20,1 (-51,61; 11,41)11.210.378
OverweightUnderweight-25,15 (-53,38; 3,07)10.040.09
Normal weight-12,41 (-28,92; 4,11)5.880.216
Obese grade I6,26 (-17,23; 29,75)8.360.945
Obese grade II/III-32,51 (-64,61; -0,4)11.430.036
Obese grade IUnderweight-31,41 (-63,62; 0,81)11.460.049
Normal weight-18,66 (-41,33; 4,01)8.070.141
Overweight-6,26 (-29,75; 17,23)8.360.945
Obese grade II/III-38,76 (-74,42; -3,1)12.690.019
Obese grade II/IIIUnderweight7,35 (-31,59; 46,3)13.860.984
Normal weight20,1 (-11,41; 51,61)11.210.378
Overweight32,51 (0,4; 64,61)11.430.036
Obese grade I38,76 (3,1; 74,42)12.690.019
HematocritUnderweightNormal weight-1,83 (-3,6; -0,06)0.630.031
Overweight-2,86 (-4,68; -1,04)0.650.001
Obese grade I-4,41 (-6,48; -2,34)0.740.001
Obese grade II/III-3,75 (-6,26; -1,25)0.890.001
Normal weightUnderweight1,83 (0,06; 3,6)0.630.031
Overweight-1,03 (-2,09; 0,03)0.380.051
Obese grade I-2,58 (-4,04; -1,12)0.520.001
Obese grade II/III-1,92 (-3,95; 0,1)0.720.059
OverweightUnderweight2,86 (1,04; 4,68)0.650.001
Normal weight1,03 (-0,03; 2,09)0.380.051
Obese grade I-1,55 (-3,06; -0,04)0.540.032
Obese grade II/III-0,89 (-2,96; 1,17)0.740.742
Obese grade IUnderweight4,41 (2,34; 6,48)0.740.001
Normal weight2,58 (1,12; 4,04)0.520.001
Overweight1,55 (0,04; 3,06)0.540.032
Obese grade II/III0,66 (-1,64; 2,95)0.820.929
Obese grade II/IIIUnderweight3,75 (1,25; 6,26)0.890.001
Normal weight1,92 (-0,1; 3,95)0.720.059
Overweight0,89 (-1,17; 2,96)0.740.742
Obese grade I-0,66 (-2,95; 1,64)0.820.929
LeukocytesUnderweightNormal weight0,55 (-2,18; 3,28)0.970.98
Overweight0,53 (-2,27; 3,32)0.990.984
Obese grade I0,84 (-2,35; 4,03)1.140.946
Obese grade II/III-0,48 (-4,34; 3,37)1.370.997
Normal weightUnderweight-0,55 (-3,28; 2,18)0.970.98
Overweight-0,02 (-1,66; 1,62)0.581
Obese grade I0,3 (-1,95; 2,54)0.80.996
Obese grade II/III-1,03 (-4,15; 2,09)1.110.886
OverweightUnderweight-0,53 (-3,32; 2,27)0.990.984
Normal weight0,02 (-1,62; 1,66)0.581
Obese grade I0,32 (-2,01; 2,64)0.830.996
Obese grade II/III-1,01 (-4,19; 2,17)1.130.899
Obese grade IUnderweight-0,84 (-4,03; 2,35)1.140.946
Normal weight-0,3 (-2,54; 1,95)0.80.996
Overweight-0,32 (-2,64; 2,01)0.830.996
Obese grade II/III-1,33 (-4,86; 2,21)1.260.829
Obese grade II/IIIUnderweight0,48 (-3,37; 4,34)1.370.997
Normal weight1,03 (-2,09; 4,15)1.110.886
Overweight1,01 (-2,17; 4,19)1.130.899
Obese grade I1,33 (-2,21; 4,86)1.260.829
Segmented neutrophilsUnderweightNormal weight498,96 (-898,42; 1896,34)497.270.854
Overweight1178,21 (-253,81; 2610,23)509.590.141
Obese grade I1036,11 (-597,74; 2669,96)581.420.384
Obese grade II/III-244,51 (-2219,86; 1730,84)702.940.997
Normal weightUnderweight-498,96 (-1896,34; 898,42)497.270.854
Overweight679,25 (-159,73; 1518,23)298.560.153
Obese grade I537,15 (-612,92; 1687,22)409.260.683
Obese grade II/III-743,47 (-2341,97; 855,02)568.840.687
OverweightUnderweight-1178,21 (-2610,23; 253,81)509.590.141
Normal weight-679,25 (-1518,23; 159,73)298.560.153
Obese grade I-142,1 (-1334,02; 1049,82)424.150.997
Obese grade II/III-1422,72 (-3051,59; 206,14)579.640.102
Obese grade IUnderweight-1036,11 (-2669,96; 597,74)581.420.384
Normal weight-537,15 (-1687,22; 612,92)409.260.683
Overweight142,1 (-1049,82; 1334,02)424.150.997
Obese grade II/III-1280,62 (-3089,49; 528,24)643.70.271
Obese grade II/IIIUnderweight244,51 (-1730,84; 2219,86)702.940.997
Normal weight743,47 (-855,02; 2341,97)568.840.687
Overweight1422,72 (-206,14; 3051,59)579.640.102
Obese grade I1280,62 (-528,24; 3089,49)643.70.271
Band neutrophilsUnderweightNormal weight75,96 (-48,73; 200,65)44.370.427
Overweight105,63 (-22,15; 233,41)45.470.138
Obese grade I140,73 (-5,06; 286,52)51.880.052
Obese grade II/III66,52 (-109,75; 242,78)62.720.827
Normal weightUnderweight-75,96 (-200,65; 48,73)44.370.427
Overweight29,67 (-45,19; 104,54)26.640.799
Obese grade I64,77 (-37,85; 167,39)36.520.389
Obese grade II/III-9,44 (-152,08; 133,19)50.761
OverweightUnderweight-105,63 (-233,41; 22,15)45.470.138
Normal weight-29,67 (-104,54; 45,19)26.640.799
Obese grade I35,1 (-71,26; 141,45)37.850.886
Obese grade II/III-39,12 (-184,46; 106,23)51.720.943
Obese grade IUnderweight-140,73 (-286,52; 5,06)51.880.052
Normal weight-64,77 (-167,39; 37,85)36.520.389
Overweight-35,1 (-141,45; 71,26)37.850.886
Obese grade II/III-74,21 (-235,62; 87,19)57.440.696
Obese grade II/IIIUnderweight-66,52 (-242,78; 109,75)62.720.827
Normal weight9,44 (-133,19; 152,08)50.761
Overweight39,12 (-106,23; 184,46)51.720.943
Obese grade I74,21 (-87,19; 235,62)57.440.696
LymphocytesUnderweightNormal weight-28,93 (-2185,57; 2127,71)767.451
Overweight-796,2 (-3006,3; 1413,9)786.480.85
Obese grade I-360,33 (-2881,92; 2161,25)897.320.995
Obese grade II/III-274,81 (-3323,44; 2773,83)1084.880.999
Normal weightUnderweight28,93 (-2127,71; 2185,57)767.451
Overweight-767,27 (-2062,09; 527,56)460.770.456
Obese grade I-331,4 (-2106,35; 1443,55)631.630.985
Obese grade II/III-245,88 (-2712,9; 2221,15)877.910.999
OverweightUnderweight796,2 (-1413,9; 3006,3)786.480.85
Normal weight767,27 (-527,56; 2062,09)460.770.456
Obese grade I435,87 (-1403,67; 2275,4)654.610.964
Obese grade II/III521,39 (-1992,5; 3035,29)894.590.978
Obese grade IUnderweight360,33 (-2161,25; 2881,92)897.320.995
Normal weight331,4 (-1443,55; 2106,35)631.630.985
Overweight-435,87 (-2275,4; 1403,67)654.610.964
Obese grade II/III85,53 (-2706,16; 2877,22)993.441
Obese grade II/IIIUnderweight274,81 (-2773,83; 3323,44)1084.880.999
Normal weight245,88 (-2221,15; 2712,9)877.910.999
Overweight-521,39 (-3035,29; 1992,5)894.590.978
Obese grade I-85,53 (-2877,22; 2706,16)993.441
Atypical lymphocytesUnderweightNormal weight-4,12 (-46,25; 38,01)14.990.999
Overweight-3,93 (-47,11; 39,25)15.370.999
Obese grade I-33,62 (-82,87; 15,64)17.530.308
Obese grade II/III0,12 (-59,43; 59,67)21.191
Normal weightUnderweight4,12 (-38,01; 46,25)14.990.999
Overweight0,19 (-25,12; 25,51)9.011
Obese grade I-29,5 (-64,17; 5,18)12.340.118
Obese grade II/III4,24 (-43,95; 52,43)17.150.999
OverweightUnderweight3,93 (-39,25; 47,11)15.370.999
Normal weight-0,19 (-25,51; 25,12)9.011
Obese grade I-29,69 (-65,63; 6,25)12.790.138
Obese grade II/III4,05 (-45,07; 53,16)17.480.999
Obese grade IUnderweight33,62 (-15,64; 82,87)17.530.308
Normal weight29,5 (-5,18; 64,17)12.340.118
Overweight29,69 (-6,25; 65,63)12.790.138
Obese grade II/III33,74 (-20,8; 88,27)19.410.41
Obese grade II/IIIUnderweight-0,12 (-59,67; 59,43)21.191
Normal weight-4,24 (-52,43; 43,95)17.150.999
Overweight-4,05 (-53,16; 45,07)17.480.999
Obese grade I-33,74 (-88,27; 20,8)19.410.41
MonocytesUnderweightNormal weight-47,81 (-142,96; 47,33)33.860.62
Overweight-16,02 (-113,52; 81,48)34.70.991
Obese grade I-40,29 (-151,53; 70,96)39.590.847
Obese grade II/III-96,22 (-230,71; 38,28)47.860.261
Normal weightUnderweight47,81 (-47,33; 142,96)33.860.62
Overweight31,8 (-25,33; 88,92)20.330.521
Obese grade I7,53 (-70,77; 85,83)27.860.999
Obese grade II/III-48,4 (-157,24; 60,43)38.730.722
OverweightUnderweight16,02 (-81,48; 113,52)34.70.991
Normal weight-31,8 (-88,92; 25,33)20.330.521
Obese grade I-24,27 (-105,42; 56,89)28.880.918
Obese grade II/III-80,2 (-191,1; 30,7)39.470.251
Obese grade IUnderweight40,29 (-70,96; 151,53)39.590.847
Normal weight-7,53 (-85,83; 70,77)27.860.999
Overweight24,27 (-56,89; 105,42)28.880.918
Obese grade II/III-55,93 (-179,09; 67,23)43.830.706
Obese grade II/IIIUnderweight96,22 (-38,28; 230,71)47.860.261
Normal weight48,4 (-60,43; 157,24)38.730.722
Overweight80,2 (-30,7; 191,1)39.470.251
Obese grade I55,93 (-67,23; 179,09)43.830.706
BasophilsUnderweightNormal weight-1,16 (-13,03; 10,71)4.220.999
Overweight-9 (-21,16; 3,17)4.330.23
Obese grade I-6,38 (-20,26; 7,5)4.940.697
Obese grade II/III-9,9 (-26,68; 6,88)5.970.46
Normal weightUnderweight1,16 (-10,71; 13,03)4.220.999
Overweight-7,84 (-14,96; -0,71)2.540.017
Obese grade I-5,21 (-14,98; 4,56)3.480.563
Obese grade II/III-8,74 (-22,32; 4,84)4.830.369
OverweightUnderweight9 (-3,17; 21,16)4.330.23
Normal weight7,84 (0,71; 14,96)2.540.017
Obese grade I2,62 (-7,5; 12,75)3.60.95
Obese grade II/III-0,9 (-14,74; 12,94)4.921
Obese grade IUnderweight6,38 (-7,5; 20,26)4.940.697
Normal weight5,21 (-4,56; 14,98)3.480.563
Overweight-2,62 (-12,75; 7,5)3.60.95
Obese grade II/III-3,53 (-18,89; 11,84)5.470.968
Obese grade II/IIIUnderweight9,9 (-6,88; 26,68)5.970.46
Normal weight8,74 (-4,84; 22,32)4.830.369
Overweight0,9 (-12,94; 14,74)4.921
Obese grade I3,53 (-11,84; 18,89)5.470.968
EosinophilsUnderweightNormal weight42,95 (-17,15; 103,05)21.390.262
Overweight35,87 (-25,72; 97,46)21.920.474
Obese grade I54,64 (-15,63; 124,91)25.010.186
Obese grade II/III69,19 (-15,77; 154,14)30.230.149
Normal weightUnderweight-42,95 (-103,05; 17,15)21.390.262
Overweight-7,08 (-43,16; 29,01)12.840.982
Obese grade I11,68 (-37,78; 61,15)17.60.964
Obese grade II/III26,23 (-42,52; 94,98)24.470.821
OverweightUnderweight-35,87 (-97,46; 25,72)21.920.474
Normal weight7,08 (-29,01; 43,16)12.840.982
Obese grade I18,76 (-32,5; 70,03)18.240.842
Obese grade II/III33,31 (-36,75; 103,37)24.930.669
Obese grade IUnderweight-54,64 (-124,91; 15,63)25.010.186
Normal weight-11,68 (-61,15; 37,78)17.60.964
Overweight-18,76 (-70,03; 32,5)18.240.842
Obese grade II/III14,55 (-63,25; 92,35)27.680.985
Obese grade II/IIIUnderweight-69,19 (-154,14; 15,77)30.230.149
Normal weight-26,23 (-94,98; 42,52)24.470.821
Overweight-33,31 (-103,37; 36,75)24.930.669
Obese grade I-14,55 (-92,35; 63,25)27.680.985
NaUnderweightNormal weight1,47 (-0,28; 3,22)0.620.128
Overweight0,47 (-1,32; 2,26)0.640.948
Obese grade I0,2 (-1,86; 2,25)0.730.999
Obese grade II/III1,04 (-1,43; 3,51)0.880.761
Normal weightUnderweight-1,47 (-3,22; 0,28)0.620.128
Overweight-1 (-2,05; 0,05)0.370.056
Obese grade I-1,27 (-2,72; 0,18)0.520.099
Obese grade II/III-0,43 (-2,42; 1,56)0.710.974
OverweightUnderweight-0,47 (-2,26; 1,32)0.640.948
Normal weight1 (-0,05; 2,05)0.370.056
Obese grade I-0,27 (-1,77; 1,23)0.530.987
Obese grade II/III0,57 (-1,46; 2,6)0.720.934
Obese grade IUnderweight-0,2 (-2,25; 1,86)0.730.999
Normal weight1,27 (-0,18; 2,72)0.520.099
Overweight0,27 (-1,23; 1,77)0.530.987
Obese grade II/III0,84 (-1,42; 3,1)0.810.835
Obese grade II/IIIUnderweight-1,04 (-3,51; 1,43)0.880.761
Normal weight0,43 (-1,56; 2,42)0.710.974
Overweight-0,57 (-2,6; 1,46)0.720.934
Obese grade I-0,84 (-3,1; 1,42)0.810.835
KUnderweightNormal weight0,01 (-0,2; 0,22)0.081
Overweight0,05 (-0,17; 0,27)0.080.966
Obese grade I0,11 (-0,14; 0,36)0.090.707
Obese grade II/III-0,03 (-0,33; 0,27)0.110.998
Normal weightUnderweight-0,01 (-0,22; 0,2)0.081
Overweight0,04 (-0,08; 0,17)0.040.881
Obese grade I0,1 (-0,07; 0,28)0.060.444
Obese grade II/III-0,04 (-0,28; 0,2)0.090.99
OverweightUnderweight-0,05 (-0,27; 0,17)0.080.966
Normal weight-0,04 (-0,17; 0,08)0.040.881
Obese grade I0,06 (-0,12; 0,24)0.060.869
Obese grade II/III-0,08 (-0,33; 0,16)0.090.879
Obese grade IUnderweight-0,11 (-0,36; 0,14)0.090.707
Normal weight-0,1 (-0,28; 0,07)0.060.444
Overweight-0,06 (-0,24; 0,12)0.060.869
Obese grade II/III-0,14 (-0,42; 0,13)0.10.569
Obese grade II/IIIUnderweight0,03 (-0,27; 0,33)0.110.998
Normal weight0,04 (-0,2; 0,28)0.090.99
Overweight0,08 (-0,16; 0,33)0.090.879
Obese grade I0,14 (-0,13; 0,42)0.10.569
C Reactive ProteinUnderweightNormal weight5,4 (-11,94; 22,74)6.170.906
Overweight17,24 (-0,54; 35,02)6.330.051
Obese grade I24,29 (4,09; 44,49)7.190.007
Obese grade II/III23,69 (-1,14; 48,52)8.840.057
Normal weightUnderweight-5,4 (-22,74; 11,94)6.170.906
Overweight11,84 (1,49; 22,19)3.680.012
Obese grade I18,89 (4,79; 33)5.020.002
Obese grade II/III18,29 (-1,9; 38,48)7.180.081
OverweightUnderweight-17,24 (-35,02; 0,54)6.330.051
Normal weight-11,84 (-22,19; -1,49)3.680.012
Obese grade I7,05 (-7,59; 21,69)5.210.657
Obese grade II/III6,45 (-14,12; 27,01)7.320.904
Obese grade IUnderweight-24,29 (-44,49; -4,09)7.190.007
Normal weight-18,89 (-33; -4,79)5.020.002
Overweight-7,05 (-21,69; 7,59)5.210.657
Obese grade II/III-0,61 (-23,29; 22,08)8.071
Obese grade II/IIIUnderweight-23,69 (-48,52; 1,14)8.840.057
Normal weight-18,29 (-38,48; 1,9)7.180.081
Overweight-6,45 (-27,01; 14,12)7.320.904
Obese grade I0,61 (-22,08; 23,29)8.071

Bonferroni post hoc analysis was used, after ANOVA, to compare the study variables between each BMI category. In bold are the variables with statistical significance (p < 0.05).

Table 4

Differences in proportions between each BMI category.

VariablesUnderweightNormal weightOverweightObese grade IObese grade II/III
GenderFemale98a, b (57, 31%)438b (47, 92%)356b (50, 86%)176a, c (64, 71%)90c (73, 77%)
Male73a, b (42, 69%)476b (52, 08%)344b (49, 14%)96a, c (35, 29%)32c (26, 23%)
Admission DiagnosisCardiovascular25a, b (14, 62%)152b (16, 63%)160a, c (22, 86%)81c (29, 78%)34a, c (27, 87%)
Respiratory13a (7, 6%)55a (6, 02%)40a (5, 71%)13a (4, 78%)5a (4, 1%)
NeurologicalNeurological22a (12, 87%)171a (18, 71%)115a (16, 43%)41a (15, 07%)11a (9, 02%)
Infectious57a (33, 33%)184b (20, 13%)96c (13, 71%)30c (11, 03%)25a, b, c (20, 49%)
Surgical10a (5, 85%)141b (15, 43%)143b, c (20, 43%)65c (23, 9%)21b, c (17, 21%)
Other44a (25, 73%)211a (23, 09%)146a (20, 86%)42a (15, 44%)26a (21, 31%)
Use of VADYes21a (12, 28%)86a (9, 41%)60a (8, 57%)27a (9, 93%)7a (5, 74%)
No150a (87, 72%)828a (90, 59%)640a (91, 43%)245a (90, 07%)115a (94, 26%)
Use of MVYes32a (18, 71%)157a (17, 18%)110a (15, 71%)38a (13, 97%)10a (8, 2%)
No139a (81, 29%)757a (82, 82%)590a (84, 29%)234a (86, 03%)112a (91, 8%)
Congestive Heart FailureYes11a (6, 43%)59a (6, 46%)44a (6, 29%)13a (4, 78%)5a (4, 1%)
No160a (93, 57%)855a (93, 54%)656a (93, 71%)259a (95, 22%)117a (95, 9%)
Chronic Renal FailureYes17a (9, 94%)119a (13, 02%)82a (11, 71%)26a (9, 56%)7a (5, 74%)
No154a (90, 06%)795a (86, 98%)618a (88, 29%)246a (90, 44%)115a (94, 26%)
CirrhosisYes1a (0, 58%)9a (0, 98%)14a (2%)3a (1, 1%)1a (0, 82%)
No170a (99, 42%)905a (99, 02%)686a (98%)269a (98, 9%)121a (99, 18%)
CancerYes29a, b (16, 96%)149b (16, 3%)90a, b (12, 86%)23a (8, 46%)11a, b (9, 02%)
No142a, b (83, 04%)765b (83, 7%)610a, b (87, 14%)249a (91, 54%)111a, b (90, 98%)
ImmunodeficientYes2a (1, 17%)17a (1, 86%)4a (0, 57%)3a (1, 1%)1a (0, 82%)
No169a (98, 83%)897a (98, 14%)696a (99, 43%)269a (98, 9%)121a (99, 18%)
Diabetes MellitusYes61a (35, 67%)315a (34, 46%)277a (39, 57%)108a (39, 71%)56a (45, 9%)
No110a (64, 33%)599a (65, 54%)423a (60, 43%)164a (60, 29%)66a (54, 1%)
Coronary Artery DiseaseYes12a, b (7, 02%)86b (9, 41%)106a (15, 14%)23a, b (8, 46%)14a, b (11, 48%)
No159a, b (92, 98%)828b (90, 59%)594a (84, 86%)249a, b (91, 54%)108a, b (88, 52%)
StrokeYes41a (23, 98%)157a, b (17, 18%)96b (13, 71%)35b (12, 87%)11b (9, 02%)
No130a (76, 02%)757a, b (82, 82%)604b (86, 29%)237b (87, 13%)111b (90, 98%)
DementiaYes29a (16, 96%)60b (6, 56%)25b (3, 57%)7b (2, 57%)4b (3, 28%)
No142a (83, 04%)854b (93, 44%)675b (96, 43%)265b (97, 43%)118b (96, 72%)
Performance statusCompletely ​independent113a (66, 08%)778b (85, 12%)641c (91, 57%)245b, c (90, 07%)109b, c (89, 34%)
Partially ​independent18a (10, 53%)65a (7, 11%)39a (5, 57%)18a (6, 62%)8a (6, 56%)
Fully ​dependent40a (23, 39%)71b (7, 77%)20c (2, 86%)9b, c (3, 31%)5b, c (4, 1%)
ICU deathsYes64a (37, 43%)172b (18, 82%)76c (10, 86%)21c (7, 72%)10c (8, 2%)
No107a (62, 57%)742b (81, 18%)624c (89, 14%)251c (92, 28%)112c (91, 8%)
ICU readmissionYes20a, b (11, 7%)105b (11, 49%)51a (7, 29%)14a (5, 15%)10a, b (8, 2%)
No151a, b (88, 3%)809b (88, 51%)649a (92, 71%)258a (94, 85%)112a, b (91, 8%)

Z-test with Bonferroni correction of clinical and epidemiological characteristics between BMI groups. In Bold, variables with significant difference (p < 0.05). Each subscript letter denotes a subset whose columns proportions do not differ significantly from each other.

Comparison between BMI groups. Results expressed by number (%), mean ± standard deviation (SD). CCI = Charlson Comorbidity Index, MFI = Modified Frailty Index, ICU = Intensive care unit; VAD = Vasoactive drug; MV = Mechanical ventilation; bpm = beats per minute; incursions per minute. Multiple comparisons between BMI categories. Bonferroni post hoc analysis was used, after ANOVA, to compare the study variables between each BMI category. In bold are the variables with statistical significance (p < 0.05). Differences in proportions between each BMI category. Z-test with Bonferroni correction of clinical and epidemiological characteristics between BMI groups. In Bold, variables with significant difference (p < 0.05). Each subscript letter denotes a subset whose columns proportions do not differ significantly from each other. The ability of SAPS3 to predict intra-unit mortality was assessed for each BMI group. Its accuracy was excellent in all groups except in the underweight group, with an AUC of 0.69 (95% CI 0.61–0.77; p < 0.001), reflecting a significantly decreased sensitivity in its performance and Hosmer-Lemeshow goodness of fit test significance of 0.042 (Figure 2). A model including BMI and SAPS3 showed an association of the two variables with mortality, however, with poor goodness-of-fit (Hosmer-Lemeshow p-value: 0.102), suggesting incompleteness of the model (Table 5).
Figure 2

Performance of SAPS3 Mortality Prediction According to BMI Category. The area under the receiver operating characteristics curve was calculated for each BMI stratum. SAPS3 performance was adequate in all BMI groups except for the underweight group, in which a significantly poor discriminant function was observed. P-value for all curves <0.001.

Table 5

Binary logistic regression of BMI and SAPS3 association with mortality.

ParametersBS.E.Exp (B)95% C.I. for EXP(B)P-value
Saps3Points0,1170,0071,124(1,109–1,14)0,0001
BMI-0,070,0140,932(0,908–0,958)0,0001
Constant-6,0360,5140,002
Performance of SAPS3 Mortality Prediction According to BMI Category. The area under the receiver operating characteristics curve was calculated for each BMI stratum. SAPS3 performance was adequate in all BMI groups except for the underweight group, in which a significantly poor discriminant function was observed. P-value for all curves <0.001. Univariable analysis showed a significantly higher probability of death (OR 3.71; 95% CI 2.65–5.18), for underweight patients, in contrast to overweight, obese, and obese II/III (Figure 3). A binary regression model was performed to assess factors that could confound the assessment of mortality. The highest chance of death persisted in the underweight group, with an OR of 3.50 (95% CI 1.43–8.58, p = 0.006), while the overweight and obese groups were no longer associated with mortality. The need for mechanical ventilation or vasopressors on admission (OR 3.11 [95% CI, 4.90–8.24, p < 0.0001] and OR 2.69 [95% CI, 1.74–4 .18, p < 0.0001], respectively), were the variables that represented the highest independent risk in our model (Figure 3). Greater dependence on performing daily activities was also an independent predictor of mortality in our population (OR: 2.84 [95%CI: 1.76–4.57]). The model presented good fit with a Hosmer-Lemeshow goodness-of-fit p-value of 0.102. No difference was observed between the BMI groups for the use of these supports. Moreover, when evaluated as a continuous variable, the BMI presented statistical significance on both the univariate and multivariate analysis with a decrease of 0.04% in the odds of mortality for each additional 1 kg/m2 (Figure 4).
Figure 3

Risk assessment model for intra-unit mortality. The white prism represents the OR in the univariate analysis, while the black prism represents the OR after adjustment in the binary logistic regression. The variables that presented statistical significance at the end of the binary logistic regression were represented. CRP (C-reactive protein); K (potassium level); MV (mechanical ventilation); VAD (vasopressor drug).

Figure 4

Death Probability According to BMI. A modified Kaplan-Meier curve to estimate the probability of death by BMI level. For every 1 additional kg/m2, there is a 0.04% reduction in the probability of death.

Risk assessment model for intra-unit mortality. The white prism represents the OR in the univariate analysis, while the black prism represents the OR after adjustment in the binary logistic regression. The variables that presented statistical significance at the end of the binary logistic regression were represented. CRP (C-reactive protein); K (potassium level); MV (mechanical ventilation); VAD (vasopressor drug). Death Probability According to BMI. A modified Kaplan-Meier curve to estimate the probability of death by BMI level. For every 1 additional kg/m2, there is a 0.04% reduction in the probability of death.

Discussion

While SAPS3 performed well in the obese, overweight, and normal weight groups, there was a significant lack of accuracy in underweight patients. Similarly, Deliberato et al. demonstrated that the performance of others severity scores was inconsistent across BMI categories [11]. We assume that the clinical differences observed between the groups may impact the performance of the score; therefore, it should be accessed and readjusted. Binary logistic regression of BMI and SAPS3 association with mortality. We found clinically significant differences between the BMI groups in our study that may be compromising SAPS3 predictive performance in patients with low weight. These patients were older and had a higher burden of comorbidities that were independently associated with worse outcomes. Overweight and obese patients had a higher prevalence of diabetes and a lower mean SAPS3 score. The absence of significance between the creatinine values according to BMI groups may be associated with the presence of acute kidney injury at admission in underweight patients, since a lower proportion of lean mass is expected in this group [12]. In earlier studies, even after adjusting for significant comorbidities, low weight showed an association with mortality [13, 14, 15, 16]. However, in the current study, obese and overweight patients showed no protective factors, despite findings on previous research [17, 18, 19]. Studies exploring the effect of BMI on ICU outcomes have reported controversial results. Three meta-analyses have already demonstrated a J-shaped relationship between BMI and mortality, with overweight and moderate obesity being protective when compared to a normal BMI [18, 19]. This remains poorly understood, but some hypotheses are currently being discussed. Obese patients tend to be younger at the time of ICU admission, a population generally at lower risk of mortality [20]. This was evident in our findings with a lower mean age among those with higher BMI. Alternatively, medical staff, anticipating possible risks and complications, may admit obese patients earlier to the ICU in relatively stable condition to initiate aggressive interventions [4]. In support of this hypothesis, obese subjects in our study were admitted with lower SAPS3 and CCI while underweight patients presented higher mean SAPS3 and MFI scores (Table 2), albeit with poor predictive performance. Despite our study was not specifically designed for this purpose, others have suggested that obese individuals have a greater nutritional reserve, thereby offering protection against hypercatabolic states experienced during critical illness as compared to their underweight counterparts [4, 13]. Still, others hypothesize that the adipokine profile in obese patients may modulate and dampen the immunological response to severe acute illness which may be absent in the underweight population [4]. While we did not confirm obesity as a protective factor when adjusting for comorbidities, the mortality risk for underweight critically ill patients found in our study supports prior findings from the developed world [13, 14, 15, 16]. Our study has certain limitations. First, as a single-center study, there may be unmeasured local confounders that could impact the analyses performed. Also, in this study, only variables obtained at admission of patients were considered. The use of BMI as a parameter for obesity diagnosis, while useful at the population level, does not distinguish between lean mass and fat mass, thus being less precise in elderly and muscular individuals [21]. Moreover, BMI may not accurately assess visceral fat, a risk factor for disease independent of total body fat [22]. Future studies using BMI together with accurate methods of assessing body fat are suggested to address this limitation.

Conclusion

Overall, the SAPS3 is inaccurate for predicting mortality in critically ill underweight patients, even with this group presenting a greater chance of death. Recalibration of this tool may aid in the clinical management of these patients.

Declarations

Author contribution statement

Isabella B B Ferreira and Rodrigo C Menezes: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper. Kevan M Akrami: Conceived and designed the experiments; Analyzed and interpreted the data; Wrote the paper. Nivaldo Filgueiras Filho: Conceived and designed the experiments; Contributed reagents, materials, analysis tools or data; Wrote the paper. Bruno B Andrade: Conceived and designed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper. Matheus L Otero: Performed the experiments; Wrote the paper. Thomas A Carmo: Performed the experiments; Analyzed and interpreted the data; Wrote the paper. Gabriel A Agareno, Gabriel P Telles and Bruno V B Fahel: Performed the experiments. María B Arriaga and Kiyoshi F Fukutani: Analyzed and interpreted the data. Licurgo Pamplona Neto and Sydney Agareno: Contributed reagents, materials, analysis tools or data.

Funding statement

This work was supported by National Institute of Allergy and Infectious Diseases, National Institutes of Health (Intramural Research Program), USA, Universidade do Estado da Bahia (research fellowship), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (finance code 001) and Fundação de Amparo à Pesquisa do Estado da Bahia (research fellowship), Brazil. Bruno Andrade is a senior scientist from the Brazilian National Council for Scientific and Technological Development (CNPq), Brazil. The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

Data availability statement

Data will be made available on request.

Declaration of interests statement

The authors declare no conflict of interest.

Additional information

No additional information is available for this paper.
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