Center for Translational Molecular Medicine, Netherlands.

Key Points Thrombocytopenia on intensive care unit admission is independently associated with increased mortality in patients with sepsis. Thrombocytopenia is associated with a more disturbed host response in critically ill patients with sepsis independent of disease severity.

Rationale We hypothesized that acute respiratory distress syndrome (ARDS) patients 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 (IL-6, interferon gamma, angiopoetin 1/2 and PAI-1) could be used to accurately predict the phenotype in the training cohort (area under the receiver operating characteristics curve: 0.98 [95%-confidence interval: 0.97–0.99]). 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 ICU mortality (training cohort: OR 1.13 [95%-CI: 1.04–1.23]; validation cohort: OR 1.18 [95%-CI: 1.06–1.31]). Conclusions ARDS patients 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 randomized controlled trials, and these results may improve patient selection for future clinical trials targeting host response in patients with ARDS.

Interobserver agreement for classifying sources of infection using Centers for Disease Control and Prevention criteria was excellent overall. However, full concordance on all aspects of the diagnosis between independent observers was rare for some types of infection, in particular for ventilator-associated pneumonia.