Coagulation profile in COVID-19

Objective: To evaluate the coagulation profile in COVID-19 patients and to correlate disease severity with the coagulation parameters. Methodology: This retrospective study was conducted at Pathology and medicine departments, FMH College of Medicine and Dentistry. It included 101 confirmed cases of COVID-19 disease of both genders between 17 and 75-year age. Coagulation profile was compared between survivor and non-survivor groups. Results: Out of 101 patients, 93 (92.1%) patients were in the survivor group and eight (7.8%) in the non-survivor group. Mean APTT (p = 0.02) in non-survivor group showed relatively higher values than survivor group. Mean D-Dimers (p = 0.007) in non-survivors showed a significantly raised values. However other parameters of coagulation like Platelets, MPV, PT and INR showed no significant association statistically. Conclusion: High D-dimers and prolonged APTT were associated with mortality in COVID-19 Patients.

also play a role in this process [4]. A dysfunctional cascade of inflammatory thrombosis is started in pulmonary vasculature as an effect of this hyperinflammatory response. This leads to a phase of local coagulopathy. A widespread hypercoagulable state develops in more sever patients which lead to thrombosis in macro and micro vasculature [5]. Development of coagulopathy is one of the most significant markers of poor prognosis in seriously sick COVID-19 patients [3] and leads to thrombotic events both in the venous and arterial circulations.
This has been linked to excessive inflammation, platelet activation, endothelial dysfunction, and stasis. Although coagulation abnormalities in severe COVID-19 mimic other systemic coagulopathies associated with severe infections, such as DIC (Disseminated intravascular coagulation) or thrombotic microangiopathy, but certain distinct features such as very high D-dimer levels and only moderately decreased platelet counts have been reported only in COVID-19 [6]. Coagulation abnormalities are associated with a higher mortality rate and derangement in various coagulation parameters have been documented in COVID 19 patients according to different reports [7]. Decreased platelet counts were found to be related with augmented risks of more severe forms of disease and more hospital mortality in SARS-CoV-2 patients [8]. Additionally, slight elongations in Prothrombin Time (PT) and Activated Partial Thromboplastin Time (APTT), and slight thrombocytopenia have been observed in some patients whereas immensely raised levels of D-Dimer are seen in several patients, that seem to have a prognostic value. The levels of D-Dimers and Fibrinogen Degradation Products (FDPs) are found to be higher in patients with severe COVID-19 infection that the patients who have milder state of disease1. This study is aimed to evaluate the coagulation profile in COVID-19 patients and to correlate disease severity with the coagulation parameters.

Materials and Methods
Pathology and Medicine Department, FMH college of Medicine and Dentistry conducted a retrospective cross-sectional study.

Discussion
COVID-19 was found more prevalent in males than females in our study, in addition a greater number of males were in the non-survivor group than females. A study by Ajay Pradhan et al. conducted in September 2020 inferred that COVID-19 is not only more common in males but also shows sex biased mortality which is more in men than women [9]. Jian Min Jin in his case series study had inferred 2.4 folds increased mortality in males than females [10]. Mean Platelet count was found to be lower in the non-survivor group than the survivor-group although both groups showed mean platelet count within normal range. However, no association was found between platelet count and mortality.
A study conducted by Geoffery D Wool et al. also determined that platelet count is not an indicator of mortality in COVID-19 patients APTT with deterioration of COVID-19 disease and prolonged APTT was seen in severe and critical cases. The same is observed in our study and APTT is seen prolonged in both survivor and non-survivor groups of COVID-19 patients but a more significant association is seen in the non-survivor group [18].
In a study conducted in Bangladesh by Bhuiyan MN concluded that 40.9% vs 16.6% showed prolonged APTT values in ICU and non-ICU patients' respectively [13]. Raised D-dimers is one of the most consistent abnormal hemostatic laboratory markers in COVID-19 patients. The association of raised D-Dimers and its link with more ICU admissions and mortality has been documented by many studies, like a study done by Maryam Aboughdir concluded that raised D-dimers were observed in ICU patients as well as inhouse deaths [14].This association was also enforced by our study where D-dimers were found raised in a lot of patients in both survivor and non-survivor group, but significantly higher levels were seen in the non-survivor group. Litao Zhang et al. has reported increased incidence of mortality in patients with D-Dimer >0.2 ug/ ml [15][16][17][18].

Conclusion
Coagulation profile in COVID-19 holds not only a prognostic value but also helps in deciding the therapeutic approach for the clinicians. The extent of coagulation dysfunctions also seems to be related with the severity of organ impairment. Coagulation abnormalities have a great impact on disease progression, severity, and prognosis. Prolonged APTT and raised D-Dimers are strongly associated with disease severity as well as poor prognosis leading to mortality of COVID-19 patients.

Declarations
Funding: The authors did not receive support from any organization for the submitted work

Consent to Publish:
The authors affirm that participants provided informed consent for publication of the work.