D-dimer Levels to Predict in-Hospital Mortality in ICU Patients with COVID-19

INTRODUCTION

Coronavirus disease 2019 (COVID-19), caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Outbreak of pneumonia in Wuhan City, Hubei Province, China, in December 2019, spread rapidly throughout world, areas or territories. SARS-CoV-2 is a novel positive-sense RNA virus with 79% homology with (SARSCoV) and 50% homology with Middle East respiratory syndrome coronavirus;^[1] however, it is far more infectious than either.

The D-dimer is a by-product of the blood clotting and breakdown process that can be measured through analysis of a blood sample. D-dimer is released when a blood clot begins to break down.^[2] Recently, several studies reported that elevated D-dimer levels are positively associated with the severity of COVID-19. A meta-analysis also demonstrated that increased D-dimer values are related to higher risk of severe SARSCoV-2 infection.^[3] To better predict the prognosis of COVID-19, the aim of this study was to investigate the role of changes in D-dimer values.

MATERIAL AND METHODS

RESULTS

A total of 101 COVID-19 patients (77 males and 24 females) were included in the study. All patients admitted to ICU were classified into two groups as discharged group n = 70 and expired group, n = 31. The overall mean age was 58.83 ± 15.32 years. The mean age was – years in the discharged group and – years in the expired group. Approximately two-thirds of the patients had underlying diseases (63%), including hypertension (48%), diabetes (34%), cardiovascular disease (4%), hypothyroidism (9%), cerebrovascular disease (1%), chronic obstructive pulmonary disease (COPD) (2%) and bronchial asthma (2%). There was no history of other diseases in these patients. The mean length of hospital stay was 13.3 ± 6.0 days and mean length of ICU stay was 9.67 ± 6.8.

Laboratory data within 5 days of admission demonstrated that the mean serum D-dimer levels on admission were 1512.36 ± 2341.8, on day 3 was 1542.2 ± 2363.6 and on day 5 was 1967.45 ± 2851.2. Patients who expired had on admission D-dimer levels of 2729 ± 3243 ng/mL while those discharged had D-dimer value of 973 ± 1553 ng/mL (P < 0.007). D-dimer of expired patients on Day 3 was 3206.5 ± 3338.8 and of discharged patients was 828.8 ± 1268.8 (P = 0.001). D-dimer of expired patients on Day 5 was 5184.5 ± 3386.1 versus discharged patients was 588.7 ± 645.5 (P < 0.0001). Number of Days in ICU for patients who expired was 14.22 ± 6.7 while for those who survived 7.6 ± 5.9. Most of the D-dimer values measured in the death cases showed increasing trend after the patients were admitted [Figure 1].

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Figure 1:

Trend D-dimer value in Covid-19 patients admitted in ICU (Discharged vs Expired).

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DISCUSSION

Here, we report on 101 patients with laboratory-confirmed SARS-CoV-2 infection requiring ICU admission in Sevenstar hospital, Nagpur. Of the 101 patients in this cohort, 31 (30.7%) died. In our study, we demonstrated that in patients diagnosed with COVID-19, D-dimer elevation on admission and increasing trend was associated with both increased disease severity and in-hospital mortality. D-dimers are one of the fragments produced when plasmin cleaves fibrin to break down clots. The assays are routinely used as part of a diagnostic algorithm to exclude the diagnosis of thrombosis. However, any pathologic or non-pathologic process that increases fibrin production or breakdown also increases plasma D-dimer levels.^[4] The results showed that mean serum D-dimer levels were approximately 3 times higher in expired group in comparison to discharged group along with it the trend of D-dimer was increasing in expired group and decreasing in discharged group. We also observed that need for ventilatory support was higher in expired group 29 (93.5%) with significant difference (P < 0.0001). In our study, D-dimer levels on admission and its increasing trend were not found to be a strong predictor of mortality.

Comorbidities such as diabetes mellitus, hypertension, coronary artery disease, malignancy, COPD and bronchial asthma were seen. The mortality showed a strong association with underlying disease 20 (64%) of 31 patients had comorbidities.

CONCLUSION

This study demonstrates that D-dimer may be an indicator of disease severity and may contribute to determining the severity of patients with COVID-19. In addition, serial D-dimer measurements may be useful in predicting the prognosis. Additional investigation is needed to further illustrate the mechanisms by which increased D-dimer is synthesised and released in patients infected with SARS-CoV-2.