Identification and validation of distinct biological phenotypes in patients with acute respiratory distress syndrome by cluster analysis

Abstract

Rationale: We hypothesised that patients with acute respiratory distress syndrome (ARDS) can be clustered based on concentrations of plasma biomarkers and that the thereby identified biological phenotypes are associated with mortality.

Methods: Consecutive patients with ARDS were included in this prospective observational cohort study. Cluster analysis of 20 biomarkers of inflammation, coagulation and endothelial activation provided the phenotypes in a training cohort, not taking any outcome data into account. Logistic regression with backward selection was used to select the most predictive biomarkers, and these predicted phenotypes were validated in a separate cohort. Multivariable logistic regression was used to quantify the independent association with mortality.

Results: Two phenotypes were identified in 454 patients, which we named 'uninflamed' (N=218) and 'reactive' (N=236). A selection of four biomarkers (interleukin-6, interferon gamma, angiopoietin 1/2 and plasminogen activator inhibitor-1) could be used to accurately predict the phenotype in the training cohort (area under the receiver operating characteristics curve: 0.98, 95% CI 0.97 to 0.99). Mortality rates were 15.6% and 36.4% (p<0.001) in the training cohort and 13.6% and 37.5% (p<0.001) in the validation cohort (N=207). The 'reactive phenotype' was independent from confounders associated with intensive care unit mortality (training cohort: OR 1.13, 95% CI 1.04 to 1.23; validation cohort: OR 1.18, 95% CI 1.06 to 1.31).

Conclusions: Patients with ARDS can be clustered into two biological phenotypes, with different mortality rates. Four biomarkers can be used to predict the phenotype with high accuracy. The phenotypes were very similar to those found in cohorts derived from randomised controlled trials, and these results may improve patient selection for future clinical trials targeting host response in patients with ARDS.

Keywords: ARDS; Cytokine Biology.

Figure 1

Heatmap of phenotypes Columns: biomarkers. Rows: Patients. First column: green blocks: “uninflamed phenotype”; red: “reactive phenotype”. Second column: patients that died are indicated with black, surviving patients with grey. Heat map: a higher concentration, in comparison to the other included patients is indicated with red, while a lower concentration is indicated by blue.

Figure 2

Orthogonality of phenotypes and Berlin classification. ICU mortality per phenotype and Berlin classification. Boxes indicate phenotypes and the training or validation cohort, separate bars Berlin categories. Differences in mortality between the ‘reactive’ phenotype and ‘uninflamed’ phenotype were independent of the Berlin classification of ARDS (OR 3.1 [95%-CI: 2.0–4.8]) in the training cohort and in the validation cohort (OR 3.8 [95%-CI: 2.0–7.2])

Figure 3

Discrimination of biological phenotype based on a limited set of biomarkers in the training cohort. Receiver operating characteristics curve for the biological phenotype based on (1) Biomarkers depicted in black: plasma concentrations of IL-6, IFN–γ, ANG1/2 and PAI-1 (see also table S3) and (2) Routinely available clinical variables depicted in grey, the same accuracy could be obtained with albumin and bicarbonate only.