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Aims: The Coronavirus Disease 2019 (COVID-19), that results of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, manifests with dysfunction of hemostasis and thrombosis. This study aims to evaluate laboratory parameters of hemostasis in hospitalized individuals with suspected COVID-19. Method(s): Individuals aged 18 years or older with suspected COVID-19 admitted to two hospitals were invited to participate in this study. The study inclusion period was from April 2020 to March 2021. The study was approved by the institutional ethics committees. The diagnosis of COVID-19 was confirmed by positive SARS-CoV-2 real-time reverse-transcription polymerase chain reaction. Antithrombin, factor V, factor VII, factor XI, factor XII, factor XIII and prothrombin assays were performed using the Multiplex immunoassay technique (ThermoFisher Scientific, Vienna, Austria). Propensity score matching for sex and age were estimated by a logistic regression model for COVID-19 and non-COVID-19 individuals in the R software. The proportions found in each group were compared by Fisher's exact test, when the variable was categorical, and by the Mann-Whitney test, when it was continuous. Linear regression was performed adjusting the levels of clotting factors and antithrombin for the severity score (Sequential Organ Failure Assessment - SOFA). Correlation between SOFA, clotting factors and antithrombin in individuals with COVID-19 were performed by using the Spearman test. Only very strong correlations (>=0.9) were considered;p-value<0.05 was considered statistically significant. Result(s): A total of 151 individuals were included in the study, of whom 138 (91.4%) with the diagnosis of COVID-19 and 13 (8.6%) non-COVID-19. After 2:1 matching, 26 individuals with COVID-19 and 13 non-COVID-19 participated in the study. In the univariate analysis, the group of COVID-19 had higher levels of antithrombin, factor V, factor VII, factor XI and prothrombin compared to the non-COVID-19 group. However, after adjusting for SOFA, only the levels of factor XI and prothrombin remained different between the groups (higher in the COVID-19) (p=0.04 and p=0.04, respectively). We found no association between factor XI and prothrombin with mortality. However, we found a very strong correlation between coagulation factors V and VII (r=0.923, p<0.0001). Discussion(s): Our results show that plasma levels of antithrombin, factor V, factor VII, factor XI and prothrombin were higher in the COVID-19 when compared with non-COVID-19 group of critically-ill patients, but the difference was lost after adjusting the analysis for SOFA. Only the levels of factor XI and prothrombin remained significant in the COVID-19 group after adjustment. This finding suggests that the severity of the disease rather than viral etiology was the main determinant of the difference in the plasma levels of these proteins. We also showed a strong correlation between factor V and VII in our study. Indeed, factor VII is the major trigger of coagulation in vivo. Therefore, it is possible that factor V and VII could act together to boost coagulation and promote thrombus formation in patients with COVID-19. Conclusion(s): Our study suggests that increased levels of procoagulant factors in hospitalized critically-ill individuals with suspected COVID-19 are rather related to disease severity than to its cause. Copyright © 2022
ABSTRACT
Introduction: The novel Coronavirus (SARS-CoV-2), responsible for severe acute respiratory syndrome, has emerged as a threat to humans since December 2019, and the search for a better understanding of the pathophysiology of coronavirus disease 2019 (COVID-19) and its definitive treatment is still in progress. Objective(s): To evaluate the plasma pro- and anti-inflammatory cytokines in COVID-19 patients and their associations with the disease severity and outcome. Method(s): Reverse-Transcriptase Polymerase Chain Reaction (RT-PCR)-confirmed COVID-19 unvaccinated patients at the Hospital de Clinicas (HC), UNICAMP, Campinas, SP, were enrolled. Clinical and laboratory data were extracted from the medical records, and the plasma cytokines levels were quantified using LUMINEX and ELISA. Result(s): There were 154 COVID-19 patients (99 survivors and 55 non-survivors) with male:female of 1.4:1, and a median age of 60 years. The non-survivors were older than survivors (65 vs. 55 years, p < 0.0001);and coronary artery disease and autoimmunity, disease severity, and oxygen therapy, intensive care, and intubation were associated with mortality. Non-survivors had higher leukocyte and neutrophil counts, and RDW and lower lymphocyte count at diagnosis. Non-survivors had higher levels of pro-inflammatory (TNF-alpha, IL-6, IFN-gamma, CCL3, IL-17/IL-17A, IL-8, G-CSF, CCL2/MCP-1) and anti-inflammatory (IL-1ra and IL-27) cytokines, but lower TGF-beta levels than the survivors. TNF-alpha levels were positively correlated with all studied cytokines except TGF-beta, while TGF-beta levels were negatively correlated with TNF-alpha, IL-6, CCL3, G-CSF, and IL-27. IL-27 levels were significantly correlated with all the cytokines except IL-37 and IL-17E. More than half (55.2%) of our patients had severe COVID-19, 18.8% had moderate, 16.2% had critical, 5.2% had mild, and 4.5% were asymptomatic. Majority of the patients (68.2%) required ICU care and had higher TNF-alpha, IL-6, IL-8, IL-17, CCL3, CCL2, IL-1ra, and IL-27 than others. 59.7% of the patients required endotracheal intubation and had higher TNF-alpha, IL-6, IL-8, CCL3, CCL2, and IL-1ra than those who did not have intubation. TNF-alpha, IL-6, and IL-8 had the highest Area Under the Receiver Operating Characteristics (AUROC) curve, sensitivity, and specificity for predicting mortality in these COVID-19 patients. Discussion and conclusion: The altered levels of pro- and anti-inflammatory cytokines support the role of SARS-CoV-2 in inducing cytokine storm, and higher concentrations seen in the deceased patients meant a more severe storm. Also, the increased leukocytes and neutrophils in our patients could have led to the release of reactive oxygen species, and end-organ damage, thus leading to poor outcomes. This study showed that the levels of these cytokines could be used as markers of mortality in COVID-19. It is possible to suggest that TNF, IL-6, and IL-8 levels at diagnosis could be efficient predictors of fatal outcomes in COVID-19 patients. If properly measured at diagnosis, these markers could be useful for triaging and predicting the outcome of COVID-19, thus guiding the treatment of the COVID-19. Funding(s): CNPq (#190374/2017-9), CAPES, FAPESP and FAEPEX (#338619). Copyright © 2022
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Objetivo: Avaliar incidência de eventos trombóticos em indivíduos hospitalizados por Coronavirus Disease 2019 (COVID-19). Material e métodos: Foram avaliados indivíduos de ambos os gêneros com idade ≥ 18 anos internados por complicações da COVID-19 em dois hospitais de Belo Horizonte, Minas Gerais, entre abril de 2020 e março de 2021. Todos os participantes apresentaram um resultado positivo de real-time reverse-transcription polymerase chain reaction (RT-PCR) para severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A inclusão no estudo foi feita mediante assinatura de termo de consentimento lido e esclarecido que foi oferecido aos participantes potencialmente elegíveis ou seu responsável legal. Foi realizado duplex scan venoso em membros inferiores em todos os indivíduos à admissão do estudo, no terceiro e no sétimo dias de internação hospitalar, além na suspeita de trombose venosa profunda quando a mesma não ocorreu nesses dias estabelecidos. Na suspeita clínica de tromboembolismo pulmonar ou acidente vascular encefálico, foram realizadas angiotomografia arterial de tórax e tomografia computadorizada de crânio, respectivamente. Os dados coletados foram tabulados para análise por intermédio do programa Research electronic data Capture – RedCap. As variáveis numéricas foram descritas como mediana e intervalo interquartil, conforme distribuição não normal, avaliada em teste de Shapiro-Wilk. As variáveis categóricas foram expressas em frequência e percentual. Para a realização das análises, o software SPSS 22.0 foi utilizado. O estudo foi aprovado pelo comitê de ética institucional. Resultados: Foram inclusos 151 indivíduos com suspeita de COVID-19. Houve exclusão de 13 indivíduos pelo fato de apresentarem RT-PCR negativo para SARS-CoV-2 e de dois, por falta de dados necessários para a análise. 66,7% dos indivíduos avaliados eram do sexo masculino, com mediana de idade de 63 anos (intervalo interquartil 51 – 72). 80,8% necessitaram de internação em centro de tratamento intensivo e 86,8% possuíam comorbidades. 38,4% dos indivíduos evoluíram para óbito durante internação hospitalar. Foram identificados nove eventos trombóticos nos indivíduos participantes: cinco tiveram trombose venosa profunda em membros inferiores, dois apresentaram trombose pulmonar e dois com acidente vascular cerebral isquêmico. A incidência de eventos trombóticos global encontrada nessa coorte foi de 6,6%, sendo 5,1% de casos venosos e 1,5% de ocorrências arteriais. Discussão: A COVID-19 é relacionada à maior ocorrência de eventos trombóticos, com incidência variando pela gravidade da doença e pela diferença de populações analisadas. Estudos demonstram que há grande ocorrência de eventos trombóticos, principalmente venosos, de maneira assintomática. A incidência encontrada neste estudo é semelhante à literatura atual. Conclusão: Tromboprofilaxia injetável é uma importante medida para prevenção de complicações relacionações à COVID-19 em pacientes hospitalizados, principalmente, quando associada a protocolos bem estabelecidos de rastreamento de tromboembolismo venoso.
ABSTRACT
Background/objective: The severity and outcome of COVID-19 are determined by the level of overstimulation of the immune response, age, and comorbidities in the patients infected by severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). Lymphopenia is the most consistent finding that characterizes the hemogram in COVID-19 patients. We evaluated the hemogram and compared the lymphocyte count (LC),neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR) at diagnosis in COVID-19 patients hospitalized at the Clinical Hospital of the State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil. Methods: In this retrospective study, we reviewed the medical notes of 320 adult hospitalized patients with PCR-confirmed COVID-19 at the Clinical Hospital of UNICAMP, Campinas, from March 2020 to March 2021. The hemogram (performed using automated counter-XN 9000™, Sysmex, Japan) at COVID-19 diagnosis was analyzed, and NLR and PLR were calculated. The primary outcomes were discharge (n = 257 patients who recovered from the disease and were discharged from the hospital), and death (n = 63 those who died during treatment). Statistical analyses were performed using SPSS (version 22). Unpaired data of deceased and discharged COVID-19 patients were compared using Mann-Whitney tests. All results were significant if p < 0.05 or except otherwise stated. Results: Compared to the 257 discharged patients, the 63 deceased patients were older 56.0 vs 64.7 ys respectively, p = 0.000), the males are more in each group and the duration of hospitalization was not different (18.6 vs 19.7 days respectively, p = 0.12). The leukocyte (8.89 ± 4.50 vs 10.37 ± 7.03, p = 0.289) and platelet counts (227.00 ± 91.15 vs 197.79 ± 97.47, p = 0.119) were not significantly different in the two groups, the hematocrit was higher in the discharged than in the deceased patients (38.84 ± 6.86 vs 35.89 ± 8.57, p = 0.021). The LC was lower in the deceased (0.81 ± 0.59 × 103 vs 1.09 ± 0.80x103/μL, p = 0.002), and negatively correlated with the age of the patients(r = -0.145, p=0.009 at a significant level of 0.01). The deceased group had a higher NLR (17.52 ± 19.20 vs 10.06 ± 12.31, p < 0.001) and PLR (366.32 ± 275.03 vs 319.23 ± 331.54, p = 0.047) higher than the discharged group, and both parameters were strongly correlated (r = 0.734, p < 0.001 significant level of 0.01). One hundred and thirty-eight (53.7%) of the discharged patients and 45 (71.4%) of the deceased had LC of < 1.0 × 103/μL. The LC is associated with the disease outcome (χ2 = 6.498, df = 1, p = 0.011), and the odds for a deceased to have a lymphopenia is 1.9 times that for the discharged patients [OR = 1.87 (95% CI = 1.135-3.085). Discussion: Though lymphopenia is consistent in COVID-19, the cause is unclear. Acute recruitment of lymphocytes to the site of infection (mainly the lung) may explain this, thus the lymphopenia may worsen and the LRs will be elevated with the increasing severity of COVID-19. The negative correlation of LC with age and higher odds of lymphopenia in the deceased patients suggest that LC and the LRs at diagnosis could be easily accessible and useful predictors of severity and mortality in these patients. Conclusion: Our study supports that lymphopenia is negatively associated with mortality in COVID-19 patients and that the deceased patients have elevated NLR and PLR at diagnosis. These parameters are easily derived from the hemogram and could be utilized as affordable and accessible predictors of outcomes in patients with COVID-19.
ABSTRACT
Background: Brazil became the South American epicenter for coronavirus disease (COVID-19) soon after the first case was diagnosed in February 2020 with the highest infection rate occurring in the state of Sao Paulo. COVID-19 is characterized by marked thrombo-inflammation mechanisms, and neutrophil-lymphocyte ratio (NLR) among many clinical and laboratory data, is becoming an inflammatory marker of severity and mortality of COVID-19. We evaluated the serial weekly lymphocyte ratios, which are easily derivable from the routine blood counts, in the survivors and non-survivors of COVID-19 at the Clinical Hospital of University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil, from time of diagnosis to the 3 rd week of care. This hospital is one of the referral centers for COVID-19 patients in this state. Methods: In this retrospective study, we reviewed the medical notes of 320 adults hospitalized patients with PCR-confirmed COVID-19 at the Clinical Hospital of UNICAMP, from March 2020 to March 2021. The serial weekly hematological parameters (analyzed using automated counter - XN 9000™, Sysmex, Japan) from the time of diagnosis were analyzed and lymphocytes ratios (neutrophil-lymphocyte, NLR, platelet-lymphocyte PLR, and monocyte-lymphocyte MLR) were calculated. The survivors (n=257) were those who recovered from the disease and were discharged from the hospital, while the non-survivors (n=63) were those who died in the course of treatment. Statistical analyses were performed using SPSS (version 22). Unpaired data of Survivors and Non-survivors with COVID-19 were compared using Mann-Whitney tests. Repeated measures were compared within and between groups using univariate and multivariate tests in general linear models. All results were considered significant if p<0.05. Results: Of the 320 patients, 257 (80.3%) were survivors and had lower mean age than the non-survivors (57.73 vs 64.65 years, p<0.001). At diagnosis, the non-survivors had a lower lymphocyte count (p=0.002), basophil count (p=0.049), and hematocrit (p=0.021) than the survivors, Table 1. We used general linear models for repeated measures and corrected for the patients who did not stay long enough to have a complete series of blood counts, Figure 1 A-G. Multivariate tests between the survivor and non-survivor groups showed significant variations with serial weekly lymphocyte count (p<0.001), neutrophil count (P=0.005), NLR (p=0.009), MLR (p=0.010), and PLR (p=0.035) but not with the weekly monocyte count (p=0.352) and platelet count (p=0.505). The NLR was higher and PLR was lower in the non-survivors at diagnosis (p<0.001 and p=0.047 respectively), both were higher in the 2 nd week post-diagnosis (p<0.001 and 0.043 respectively), and in the 3 rd week (p<0.001 and p=0.043 respectively) (Figure 1D and E). The MLR was not significantly different at diagnosis but became elevated in the following two weeks post-diagnosis (p=0.09, p=0.022, and p<0.001 respectively) (Figure 1F). Conclusions: The non-survivors were older and their NLR and MLR tend to increase from the time of diagnosis while their PLR tend to decrease after the 2 nd week post-COVID-19 diagnosis and treatment. On the other hand, all three ratios significantly decrease in the survivors. While neutrophilia and lymphopenia improved in the survivor, they worsen in non-survivors. These cells may have contributed towards the recovery by ameliorating the inflammatory response in survivors, and death by worsening the response in non-survivors of COVID-19. This study shows that serial lymphocyte count, neutrophil count, NLR, PLR, and MLR could serve as good and easily accessible markers of outcomes in patients with COVID-19 and could be used for monitoring of response to treatment. [Formula presented] Disclosures: Costa: Novartis: Consultancy.