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Journal of Stress Physiology & Biochemistry, Vol. 17, No. 3, 2021, pp. 105-112 ISSN 1997-0838 Original Text Copyright © 2021 by Astagimath, Raviraj and Doddamani
ORIGINAL ARTICLE
Biochemical and Inflammatory Markers in Covid-19 Patients of a Tertiary Care Hospital at North Karnataka - A Descriptive Study
M. N. Astagimath, Raviraja A., Suman Doddamani
1 Department of Biochemistry, Karnataka Institute of medical sciences, Vidyanagar, Hubballi -580021, Karnataka, India.
*E-Mail: suman_medico4((yahoo.co.in
Received April 28, 2021
Background: Covid-19 has emerged as a public health crisis. Biochemical and laboratory parameters play a role in understanding the disease process.
Aims and objectives: 1. Understanding the demographic pattern of Covid-19 disease in the study population. 2. To analyze biochemical and inflammatory markers in Covid-19 patients. Study includes the data collected from Covid -19 Hospital laboratory of a tertiary care hospital at KIMS (Karnataka Institute of medical sciences, Hubballi, Karnataka, India). Data was collected from March to October 2020 (Total 7800 patients had Covid-19 during this period). The present study includes the data from the 4478 Covid-19 patients of age group ranging from 1year to 99 years. Newborn to Covid-19 positive mothers and patients whose complete data was not available were excluded from the study. The parameters included in the study are CRP(c reactive protein), Ferritin, LDH (Lactate dehydrogenase), Troponin-I, and D-dimer. Results: The levels of CRP, LDH, Ferritin were significantly increased in males compared to females. There was a significant difference in the levels of CRP, LDH, Ferritin, and D-dimer among different age groups, but no such statistical difference was found for Troponin-I. Conclusion: This study suggests the possibility of increase in severity of the disease with increasing age. This possibility of association between age and severity of disease was earlier studied only on small sample size. This study also suggests that disease severity is more common in males than in females.
Key words: CRP, LDH, Troponin-I, Ferritin, D-dimer
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The Covid-19 pandemic is a major challenge faced by the health care sector worldwide. Covid-19 is caused by severe acute respiratory syndrome Corona Virus 2 (SARS -CoV-2)1. The covid-19 disease has rapidly spread worldwide and the World Health Organization (WHO) has declared this disease as pandemic on 11th March 20 202. WHO has reported 129 215 179 confirmed cases of Covid-19 and 2 820 098 deaths worldwide till 02/04/2021. In India 12 303 131confirmed cases and 163 396 deaths are reported till 02/04/20213. Currently, real-time reverse transcription PCR is the most reliable test to diagnose Covid-19 around the world1. In the management of Covid-19 disease many laboratory markers are used like lymphocyte count, neutrophil count, neutrophil-lymphocyte ratio, LDH, Troponin-I, Ferritin, D-dimer, CRP, ESR (Erytrocyte sedimentation rate), procalcitonin, AST (Aspartate Transaminase), Interleukin-6. In our study, we planned to study CRP, LDH, Troponin-I, Ferritin, D-dimer. C reactive protein is an acute phase reactant and a plasma protein synthesized in the liver. CRP levels are used as a biomarker for many inflammatory conditions4. LDH is present in most of the cells of the body. It has many isoenzyme forms and is mainly present in the liver, heart, lungs, muscles, kidneys, and blood cells. LDH is found to be increased in acute and severe lung damage5. Increased levels of LDH are also found in interstitial lung infections6. Troponin-I is a protein that acts by binding to actin and inhibiting the interaction between actin and myosin7. The increase in the levels of Troponin-I is directly correlating with the degree of myocardial inflammation8. Ferritin is a protein involved in iron storage and is involved in iron homeostasis9. Serum ferritin is also considered an acute phase reactant and is found to be increased in chronic inflammation10. D-dimers are by-products said to be derived from the lysis of cross-linked insoluble molecules of fibrin11. Earlier D-dimer assays were restricted to the diagnosis of Disseminated Intravascular coagulation, but in recent years D-dimer is used as a diagnostic and prognostic indicator of thrombotic status12. Hence we planned to study these parameters in patients with Covid-19 disease.
The study results will provide an important baseline for planning a proforma for the diagnostic management of Covid-19 patients by health care authorities. This will facilitate the allocation of resources in the proper direction.
So far the studies published on the laboratory markers are mostly Meta-analysis or review articles, the studies included in the meta-analysis and reviews were from different geographical backgrounds and also these studies were done on a small group of the population, or the sample size was very less. As our study includes large sample size and also the population under study mostly comes from a similar geographical area, the results obtained from the study can be extended to the population at large and will help in improving the existing knowledge about the laboratory markers in Covid-19 disease.
MATERIALS AND METHODS
This study included the data of patients from a tertiary care Covid-19 center of KIMS Hubballi. The majority of patients admitted belonged to the Dharwad district of Karnataka state (Dharwad district population -Approximately 19.5 lakh) and some patients were referred from surrounding districts of North Karnataka. This study is a descriptive retrospective study. Data is collected from the Covid-19 hospital laboratory at KIMS Hubballi from May 2020 to October 2020. (Total 7800 patients had Covid-19 during this period). The present study includes the data from the 4478 Covid-19 patients of age group ranging from 1year to 99 years. Exclusion criteria: newborn to Covid-19 positive mothers, patients whose complete data was not available.
The parameters included in the study are CRP, Ferritin, LDH, Troponin-I, and D- dimer. CRP and LDH were estimated by micro-slide method, Ferritin and Troponin-I were estimated by Chemiluminescence immunoassay and D-dimer was estimated by turbidimetric immunoassay. Ethical committee clearance was obtained from the institutional ethical committee on 23-12-2020.
Statistical analysis: This is a retrospective demographic study. p-value < 0.05 is considered to be significant and p < 0.001 is considered as highly
significant. Statistical analysis was done using SPSS software and Medcalc software.
RESULTS
Table I shows demographic details of CRP, Table 2 shows demographic details of LDH, Table 3 shows demographic details of Troponin-I, Table 4 shows demographic details of Ferritin, Table 5 shows demographic details of D-dimer, Table 6 shows
demographic characteristics of different parameters in Females and Males. Table VII shows comparison tables of different parameters (ANOVA table). We found that statistical significance was found among the different age groups for all parameters except Troponin-I (Table 7). All parameters were found to be significantly increased in males compared to females except for Troponin-I and D-dimer (Table 6).
Table 1: Demographic details of CRP
Sl no AGE (yrs) Mean (mg/L) S.D S.E 95 % confidence (Lower Bound) 95 % confidence (Upper Bound) Min Max
1 (1-15) n = 54 289.66 301.05 40.96 207.493 371.840 .0 1001.0
2 (16-25) n = 226 226.41 206.25 13.71 199.376 253.447 .0 1001.0
3 (26-35) n = 453 252.01 191.12 8.97 234.370 269.665 .0 1001.0
4 (36- 45) n = 627 300.53 231.29 9.23 282.393 318.672 .0 1001.0
5 (46 - 55) n = 1011 357.88 252.37 7.93 342.308 373.459 .0 1001.0
6 (55 - 65) n = 1220 365.12 251.37 7.20 350.986 379.255 .0 1001.0
7 ( > 65 ) n = 887 387.67 294.68 9.89 368.254 407.092 .0 3198.0
8 Total n = 4478 339.55 256.03 3.82 332.057 347.059 .0 3198.0
Sl no AGE (yrs) Mean (U/L) S.D S.E 95 % confidence (Lower Bound) 95 % confidence (Upper Bound) Min Max
1 (1-15) n = 54 289.66 301.05 40.96 207.493 371.840 .0 1001.0
2 (16-25) n = 226 226.41 206.25 13.71 199.376 253.447 .0 1001.0
3 (26-35) n = 453 252.01 191.12 8.97 234.370 269.665 .0 1001.0
4 (36- 45) n = 627 300.53 231.29 9.23 282.393 318.672 .0 1001.0
5 (46 - 55) n = 1011 357.88 252.37 7.93 342.308 373.459 .0 1001.0
6 (55 - 65) n = 1220 365.12 251.37 7.20 350.986 379.255 .0 1001.0
7 ( > 65 ) n = 887 387.67 294.68 9.89 368.254 407.092 .0 3198.0
8 Total n = 4478 339.55 256.03 3.82 332.057 347.059 .0 3198.0
Normal range: 140UL to 280U/L
Normal range of CRP: 1.0 to 3.0mg/L Table 2. Demographic details of LDH
Table 3. Demographic details of Troponin-I
Sl no AGE (yrs) Mean (ng/ml) S.D S.E 95 % confidence (Lower Bound) 95 % confidence (Upper Bound) Min Max
1 (1-15) n = 54 0.334 2.380 0.323 -0.315374 0.983892 0.000 17.50
2 (16-25) n = 226 0.484 0.272 0.018 0.012641 0.084208 0.000 3.710
3 (26-35) n = 453 0.299 0.175 0.082 0.013774 0.046146 0.000 2.780
4 (36- 45) n = 627 0.179 3.013 0.120 -0.056718 0.416252 0.000 74.80
5 (46 - 55) n = 1011 0.257 2.641 0.831 0.093906 0.420108 0.000 47.00
6 (55 - 65) n = 1220 0.654 14.07 0.403 -0.136558 1.446452 0.000 485.0
7 ( > 65 ) n = 887 1.950 31.70 1.064 -0.138890 4.044038 0.000 772.0
8 Total n = 4478 0.657 16.01 0.239 0.188336 1.127138 0.000 772.0
Normal range < 0.04ng/ml
Table 4. Demographic details of Ferritin
Sl no AGE (yrs) Mean (micro g / L) S.D S.E 95 % confidence (Lower Bound) 95 % confidence (Upper Bound) Min Max
1 (1-15) n = 54 167.2 256.6 34.92 97.253 237.340 .0 1001
2 (16-25) n = 226 149.3 246.1 16.37 117.051 181.569 .0 1406
3 (26-35) n = 453 200.0 385.5 18.11 164.406 235.598 .0 6387
4 (36- 45) n = 627 258.9 299.3 11.95 235.495 282.445 .0 1001
5 (46 - 55) n = 1011 308.9 313.7 09.86 289.578 328.309 .0 1001
6 (55 - 65) n = 1220 340.3 355.3 10.17 320.364 360.281 .0 5305
7 ( > 65 ) n = 887 375.4 341.1 11.45 352.929 397.897 .0 1001
8 Total n = 4478 339.3 339.3 05.07 292.934 312.819 .0 6387
Normal range: Males: 24-336micro g/ L, Females: 11- 307 micro g/L.
Table 5. Demographic details of D-dimer
Sl no AGE (yrs) Mean (ng/ml) S.D S.E 95 % confidence (Lower Bound) 95 % confidence (Upper Bound) Min Max
1 (1-15) n = 54 214.6 823.2 112.02 -10.006 439.376 .0 5574
2 (16-25) n = 226 583.7 1679.5 111.71 363.602 803.903 .0 13300
3 (26-35) n = 453 486.7 1410.7 66.282 356.511 617.030 .0 17900
4 (36- 45) n = 627 927.0 2756.2 110.07 710.906 1143.222 .0 26100
5 (46 - 55) n = 1011 1259.8 4744.4 149.21 967.087 1552.699 .0 90500
6 (55 - 65) n = 1220 1278.2 5149.2 147.42 988.974 1567.431 .0 118000
7 ( > 65 ) n = 887 1614.9 6620.9 222.310 1178.678 2051.311 .0 97200
8 Total n = 4478 1163.6 4744.8 70.90 1024.668 1302.690 .0 118000
Normal range: D-dimer <250ng/ml
Table 6. Demographic characteristics of different parameters in Females (F) and Males (M)
Gender CRP LDH Troponin-I Ferritin D-dimer
Mean F 32.127 313.032 1.0285 192.002 979.871
M 38.138 352.222 .480650 355.808 1251.429
p < 0.001 p < 0.001 p = 0.284 p < 0.001 p =0.073
N F 1447 1447 1447 1447 1447
M 3031 3031 3028 3031 3031
S D F 36.7004 251.5406 19.2657 251.1190 4230.2103
M 39.8437 257.2268 14.2027 362.4976 4970.1109
S E of Mean F 0.9648 6.6126 0.5066425 6.6015 111.2059
M 0.7237 4.6722 0.2581037 6.5843 90.2762
Table 7. Comparison tables of different parameters (ANOVA table)
Sum of squares Df Mean square F significance
CRP Between Groups Within Groups Total 323407.532 6469800.494 6793208.025 6 4471 4477 53901.255 1447.059 37.249 0.000
LDH Between Groups Within Groups Total 10644244.92 282834113.4 293478358.3 6 4471 4477 1774040.820 63259.699 28.044 0.000
TROP I Between Groups Within Groups Total 2056.248 1145176.366 114732.615 6 4467 4477 342.708 256.362 1.337 0.237
FERRTIN Between Groups Within Groups Total 18740072.98 496881482.9 515621555.9 6 4471 4477 3123345.397 111134.306 28.104 0.000
D-DIMER Between Groups Within Groups Total 573338835.7 1.002E+11 1.008E+11 6 4471 4477 95556472.62 22415938.71 4.263 0.000
DISCUSSION
The entire world is hit by the Covid-19 pandemic. Several laboratory parameters were found to alter in Covid-19 disease. We studied the following lab
parameters CRP, LDH, Ferritin, D-dimer, and Troponin-I. These parameters play an important role in the management of Covid-19. In this study, we have compared the mean values of the different laboratory parameters in males and females (Table 7). We found
that the given parameters were found to be increased
An increase in CRP levels may reflect the severity of lung disease13.In our study, we found that the CRP levels were more than the normal reference range in patients with all age groups (Table I). We also found that CRP levels increased as the age increased except for patients with age group (1-15 years), which might be due to the small sample size of patients in this age group and it may not reflect the actual mean. The lowest level of CRP was found in the 16-25 age group (mean CRP = 17.92) and the highest level was found in the age group above 65 years (mean CRP = 44.13). The increase in CRP levels with an increase in age might indicate that the severity of the Covid-19 disease may be seen more commonly in the older age group, as it has been shown in many studies that an increase in CRP levels predict the severity of the disease15. In a study conducted by Trupti et al14 authors showed a comparison of patients with normal CRP and abnormal CRP levels in different age groups and the results were similar to our study. We also found that CRP levels in males were significantly increased when compared to females (p<0.001). A study conducted by Trupti Bajpai14 et al on 556 patients found that there was no significant difference in CRP values in males and females.
LDH is said to be a good marker of vessel permeability in immune-mediated lung injury16. In our study, we found that the LDH levels were more than the normal reference range in patients of all age groups (Table II). We also found that LDH levels increased as the age increased except for patients with age groups (1-15 years). The lowest level of LDH was found in the 16-25 age group (mean LDH = 226.41) and the highest level was found in the age group above 65 years (mean LDH = 387.67). A Meta-analysis conducted by Lukasz Szarpak et al concluded that LDH level can be used as a COVID-19 severity marker and is a predictor of survival17. We also found that LDH levels in males were significantly increased when compared to females (p<0.001). This observation was also seen in a study conducted by Jin Hu18 et al which showed LDH levels were increased in males compared to females (p<0.01).
An increase in Troponin-I levels is commonly seen in Covid-19 patients and is associated with fatal outcomes19. In our study, we found that the Troponin-I levels were more than the normal reference range in patients of all age groups (Table III). We also found that the lowest level of Troponin-I was seen among the age group 36-45 years (mean Troponin = I0.179) and the highest value was found in the age group >65 years (mean Troponin = 1.950). Hence we may conclude that patients above 65 years are more prone to developing cardiac complications in Covid-19. It was also observed that even though there was a difference among the age groups, it was not statistically significant (Table VII). A meta-analysis conducted by Bing - Cheng20 found that elevated Troponin on admission was associated with a higher risk of subsequent death (risk ratio 2.68, 95%CI 2.08 - 3.46) after adjusting confounders in multivariable analysis. In this study, we found that Troponin-I levels were elevated in males compared to females but it did not show any statistical significance (p = 0.284), this finding was similar to the study conducted by Simen Ozylmaz21, where there was no statistical significance found (p = 0.913).
Elevated levels of Ferritin are found to be associated with disease severity in patients with Covid-1922. In our study, we found that the ferritin levels were increased more than the reference range in patients with age groups above 46 years (Table IV). Among these age groups, the highest increase was seen in patients above 65 years (mean ferritin = 375.4 microgram/L). A study conducted by Zhi Lin23 et al concluded that a high level of serum ferritin is an independent risk factor for the severity of Covid-19 and assessing serum ferritin levels during hospitalization may be important to recognize high-risk individuals with Covid-19. Hence we may infer that the patients with age group above 65 years may be at risk for developing severe Covid-19. In this study, we found that serum ferritin levels were more elevated in males compared to females and the difference was found to be statistically significant (p<0.001). A study conducted by O. Gandini24 et al showed a significant difference in serum ferritin levels in males and females.
Estimating the circulating levels of D-dimer is a sensitive indicator to detect thrombotic states in Covid-
when compared to the normal reference values both in males and females (Table I to V).
1925.In our study, we found that D-dimer levels were increased more than the normal reference range in patients with all age groups except for patients less than 15 years of age. The highest level of D-dimer was observed in the age group above 65 years (Table V) (mean D dimer = 1614.9ng/ml). A systemic review and meta-analysis conducted by Panagiotis et al26 found that D-dimer concentrations in patients with severe Covid-19 are significantly higher compared to those with nonsevere forms. Thus we may conclude that the patients with age group above 65 years are more prone to developing a severe form of Covid-19. We also found that D-dimer levels were higher in males compared to females, but there was no statistically significant difference found (p=0.073). A study conducted by Kumar Sharp15 showed that females are at a higher risk of developing thrombotic disorders than men.
CONCLUSION
This study suggests the possibility of increase in severity of the disease with increasing age. This possibility of association between age and severity of disease was earlier studied only on small sample size. This study also suggests that disease severity is more common in males than in females.
LIMITATIONS
The data was collected from the laboratory only. Thus the study lacks clinical correlation of the severity. A study of these parameters along with clinical correlation may give more insight or information into predicting severity, complications, and mortality among Covid-19 patients.
CONFLICTS OF INTEREST
All authors have declared that they do not have any conflict of interest for publishing this research.
REFERENCES
1. Hong KH, Lee SW, Kim TS, Huh HJ, Lee J, Kim SY et al. Guidelines for Laboratory Diagnosis of Coronavirus Disease 2019 (COVID-19) in Korea. Annals of laboratory medicine. 2020;40(5):351-60.
4. Gong J, Dong H, Xia SQ, Huang Y, Wang Z, Zhao
Y et al. Correlation analysis between disease severity and patients inflammation-related parameters in with Covid-19 Pneumonia. medRxiv. 2020;20025643.
5. J. Sepulveda. Challenges in Routine Clinical Chemistry Analysis: Proteins and Enzymes. In: A. Dasgupta, J. L. Sepulveda, eds.Accurate Results in the Clinical Laboratory. Elsevier;2013:131-148.
6. McFadden RG, Oliphant LD. Serum lactate dehydrogenase in interstitial lung disease. Chest.1991;100(4):1182.
7. Antman EM. Decision making with cardiac troponin tests. The New England journal of medicine.2002;346(26):2079-82.
8. Smith SC, Ladenson JH, Mason JW, Jaffe AS. Elevations of cardiac Troponin-I associated with myocarditis: experimental and clinical correlates. Circulation. 1997;95(1):163-168.
9. Knovich MA, Storey JA, Coffman LG, Torti SV, Torti FM. Ferritin for the clinician. Blood reviews.2009;23(3):95-104.
10. Wei Wang, Mary Ann Knovich, Lan G. Coffman,Frank M. Torti,and Suzy V. Torti. Serum Ferritin: Past, Present and Future. Biochim Biophys Acta. 2010;1800(8):760-769.
11. Armaghan Y. Soomro, Alejandra Guerchicoff, Dru J. Nichols, Javed Suleman, George D. Dangas. The current role and future prospects of the D-dimer biomarker. European Heart Journal -Cardiovascular Pharmacotherapy. 2016;2(3):175-184.
12. L.A. Linkins Takach Lapner. Review of D-dimer testing: Good, Bad, and Ugly. International Journal of Laboratory Haematology.2017;39(1):98-103.
13. Wang L. C-reactive protein levels in the early stage of COVID-19. Med Mal Infect. 2020;50(4):332-334.
14. Trupti Bajpai, Prachi Shaw, and Ravi Dosi. Evaluation of C-Reactive protein levels among Covid-19 patients. European Journal Of Pharmaceutical And Medical Research. 2020;07(07):618-21.
15. Ahnach M, Zbiri S, Nejjari S, Ousti F, Elkettani C. C-reactive protein as an early predictor of COVID-
2. https://www.statnews.com/2020/03/11/who.
3. https://www.worldometers.info/coronavirus.
19 severity. Journal of medical biochemistry.2020;39(4):500-7.
dehydrogenase level as a COVID-19 severity marker. American Journal of Emergency Medicine. Nov 2020.
17. Lukasz Szarpak, Kurt Ruetzler, Kamil Safiejko, Michal Hampel, Michal Pruc, Luiza Kanczuga -Koda, Krzysztof Jerzy Filipiak, and Milosz Jaroslaw Jaguszewski. Lactate dehydrogenase level as a COVID-19 severity marker. American Journal of Emergency Medicine.2020(10):1016.
Combination of serum lactate dehydrogenase and sex is predictive of severe disease in patients with COVID-19. Medicine.2020;99(42):22774.
19. Tersalvi G, Vicenzi M, Calabretta D, Biasco L, Pedrazzini G, Winterton D. Elevated Troponin in Patients With Coronavirus Disease 2019:Possible Mechanisms. Journal of cardiac failure.2020;26(6):470-5.
Wei Zhou, Xiao Yang, Tong-Yi Huang et al.Prevalence and prognostic value of elevated troponins in patients hospitalized for coronavirus disease 2019: a systematic review and meta-analysis.Journal of Intensive Care.2020;8:88.
Samir Allahverdiyev and Hakan Ugar. Assessment
of the Relationship between Mortality and Troponin-I Levels in Hospitalized Patients with the Novel Coronavirus (COVID-19). Medicina.2020;56:693.
22. Shani Dahan, Gad Segal, Itai Katz, Tamar Hellou, Michal Tietel, Gabriel Bryk et al. Ferritin as a Marker of Severity in COVID-19 Patients: A Fatal Correlation. Isreal Medical Association Journal.2020;Aug 22(8):494-500.
23. Lin Z, Long F, Yang Y, Chen X, Xu L, Yang M. Serum ferritin as an independent risk factor for severity in COVID-19 patients. The Journal of infection.2020;81(4):647-79.
24. Gandini O, Criniti A, Gagliardi MC, Ballesio L, Giglio S, Balena A et al.Sex-disaggregated data confirm serum ferritin as an independent predictor of disease severity both in male and female COVID-19 patients. The Journal of infection. 2021;82(3):414-51.
25. Panagiotis Paliogiannis, Arduino Aleksander Mangoni, Paola Dettori , Gheyath K. Nasrallah, Gianfranco Pintus et al. D-Dimer Concentrations and COVID-19 Severity: A Systematic Review and Meta-Analysis. Infectious diseases - surveillance, prevention and treatment.Aug 2020.
26. Panagiotis Paliogiannis, Arduino Aleksander Mangoni, Paola Dettori, Gheyath K. Nasrallah, Gianfranco Pintus and Angelo Zinellu. D-Dimer Concentrations and COVID-19 Severity: A Systematic Review and Meta-Analysis. Public Health.04 August 2020.
16. L. Szarpak, K. Ruetzler, K. Safiejko. Lactate
18. Hu J, Zhou J, Dong F, Tan J, Wang S, Li Z et al.
20. Bing-Cheng Zhao, Wei-Feng Liu, Shao-Hui Lei, Bo-
21. Sinem Ozyilmaz, Esra Ergun Al, Emrah Ermi,
