A total of 250 adult patients with a positive nasopharyngeal swab polymerase chain reaction (PCR) test for SARS-CoV-2 performed at participating hospitals were recruited during the first pandemic wave in Spain from March 16th to the 15th of April 2020. The patients recruited were of three different categories. The first corresponded to patients examined at an emergency room and discharged within the first 24 h (outpatients group, n = 50). The second group were patients hospitalized to pneumology, infectious diseases or internal medicine wards (wards group, n = 100). Patients who required critical care or died during hospitalization were excluded from this group, in order to have a group of clear moderate severity. The third group corresponded to patients admitted to the ICU (n = 100). Patient`s recruited by participating hospital are detailed in the Additional file 1. Twenty healthy blood donors were included as controls. These controls were recruited during the pandemics, in parallel to the SARS-CoV-2 infected patients, and were negative for SARS-CoV-2 IgG. This study was registered at Clinicaltrials.gov with the identification NCT04457505.
Plasma from blood collected in EDTA tubes samples was obtained from the three groups of patients in the first 24 h following admission to the emergency room, to the ward, or to the ICU, at a median collection day since disease onset of 7, 8 and 10, respectively, and also from 20 blood donors (10 men and 10 women).
A panel of biomarkers was profiled by using the Ella-SimplePlex™ immunoassay (San Jose, California, USA), informing of the following biological functions potentially altered in severe COVID-19, based in the available evidence on COVID-19 physiopathology   and also in our previous experience on emerging infections and sepsis [18,19,20,21]: neutrophil degranulation: Lipocalin-2/NGAL, myeloperoxidase; endothelial dysfunction: ICAM-1, VCAM-1/CD106, angiopoietin-2; T cell survival and function: IL-7, Granzyme B; immunosuppression: IL-1ra, B7-H1/PD-L1, IL-10; chemotaxis: CXCL10/IP10, CCL2; Th1 response: interleukin 1 beta, IFN-γ, IL-12p70, IL-15, TNF-α, IL-2; Th2 response: IL-4, IL-10; Th17 response: IL-6, IL-17A; granulocyte mobilization / activation: G-CSF, GM-CSF; coagulation activation: D-Dimer; acute phase reactants: ferritin (C-reactive protein and LDH were profiled in each participant hospital by their central laboratories).
Detection and quantification of SARS-CoV-2 RNA in plasma
RNA was extracted from 100 µl of plasma using an automated system, eMAG® from bioMérieux® (Marcy l'Etoile, France). Detection and quantification of SARS-CoV-2 RNA was performed in five µl of the eluted solution using the Bio-Rad SARS-CoV-2 ddPCR kit according to manufacturer’s specifications on a QX-200 droplet digital PCR platform from the same provider. This PCR targets the N1 and N2 regions of the viral nucleoprotein gene and also the human ribonuclease (RNase) P gene using the primers and probes sets detailed in the CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel . Samples were considered positive for SARS-CoV-2 when N1 and/or N2 presented values ≥ 0.1 copies/µL in a given reaction. RNase P gene was considered positive when it presented values ≥ 0.2 copies/µL, following manufacturer`s indications. The test was only considered valid when RNase P gene was positive. Final results were given in copies of cDNA / mL of plasma. IgG specific for the nucleocapsid protein of SARS–CoV-2 was detected in 150 µl of plasma using the Abbott Architect SARS-CoV-2 IgG Assay (Illinois, USA). Viral RNA and SARS-CoV-2 IgG were profiled in the same plasma sample.
For the demographic and clinical characteristics of the patients, the differences between groups were assessed using the Chi-square test / Fisher's exact test where appropriated for categorical variables. Differences for continuous variables were assessed by using the Kruskal–Wallis test with post hoc tests adjusting for multiple comparisons. Multivariate logistic regression analysis was employed to evaluate the association between viral RNAemia and viral RNA load in plasma with severity, in the comparisons [outpatients vs ward patients] and [ward patients vs ICU patients]. Variables showing significant differences between groups in each comparison in the Kruskal–Wallis test were further introduced in the multivariate analysis as adjusting variables. The list of variables considered as potential adjusting variables were [Age (years)], [Sex (male)], [Alcoholism], [Smoker], [Drug abuse], [Cardiac disease], [Chronic vascular disease], [COPD], [Asthma], [Obesity], [Hypertension], [Dyslipidemia], [Chronic renal disease], [Chronic hepatic disease], [Neurological disease], [HIV], [Autoimmune disease], [Chronic inflammatory bowel disease], [Type 1 diabetes], [Type 2 diabetes], [Cancer], [Invasive mechanical ventilation], [Non-invasive mechanical ventilation], [SARS-CoV-2 IgG], [Temperature (ºC)], [Systolic pressure (mmHg)], [Oxygen saturation (%)], [Bilateral pulmonary infiltrate], [Glucose (mg/dl)], [Creatinine (mg/dl)], [Na (mEq/L)], [K (mEq/L)], [Platelets (cell × 103 / µl)], [INR], [D Dimer (pg/ml)], [LDH (UI/L)], [GPT (UI/L)], [Ferritin (pg/ml)], [CRP (mg/dl)], [Haematocrit (%)], [Lymphocytes (cells/mm3)], [Neutrophils (cells/mm3)], [Monocytes (cells/mm3)]. Multivariate logistic regression analysis was performed using the “Enter” method, but also the backward stepwise selection method (Likelihood Ratio) was employed in each case to confirm the association between viral RNAemia and viral RNA load in plasma with disease severity (pin < 0.05, pout < 0.10), not forcing entry of these variables in the model. Correlation analysis was performed using the Spearman test applying the Bonferroni correction of the p value. Variables evaluated for correlation with viral RNA load were: [Temperature (ºC)], [Systolic pressure (mmHg)], [Oxygen saturation (%)], [Lymphocytes (cells/mm3)], [Neutrophils (cells/mm3)], [Monocytes (cells/mm3)], [Creatinine (mg/dl)], [LDH (UI/L)], [GPT (UI/L)], [Platelets (cell × 103 / µl)], [INR], [CRP (mg/dl)], and all the biomarkers analysed by Ella-SimplePlex. Statistical analysis was performed with IBM SPSS® version 20 (IBM, Armonk, New York, USA).