Pathways of Coagulopathy and Inflammatory Response in SARS-CoV-2 Infection among Type 2 Diabetic Patients

Thrombotic risk assessed by PAI-1 in patients with COVID-19: The influence of hyperglycemia and diabetes mellitus

OBJECTIVE

To assess thrombotic risk with PAI-1 levels in patients with COVID-19, to evaluate PAI-1 differences between hyperglycemic and/or Type 2 Diabetes Mellitus (T2DM) versus non-hyperglycemic patients, and to analyze the association of plasminogen activator inhibitor-1 (PAI-1) with hyperglycemia and T2DM.

METHODS

A cross-sectional study carried out in 181 patients hospitalized for COVID-19. Two groups were formed: the patients with hyperglycemia at admission and/or previously diagnosed T2DM group and the non-hyperglycemic group. Fibrinolysis was assessed by measuring PAI-1 levels by ELISA.

RESULTS

The mean age was 59.4±16.1 years; 55.8% were male 54.1% of patients presented obesity, 38.1% had pre-existing T2DM and 50.8% had admission hyperglycemia and/or pre-existing T2DM. The patients with admission hyperglycemia and/or preexisting T2DM had higher PAI-1 compared with non-hyperglycemic patients [197.5 (128.8-315.9) vs 158.1 (113.4-201.4) ng/mL; p=0.031]. The glucose levels showed a positive correlation with PAI-1 levels (r=0.284, p=0.041). A multivariate logistic regression analysis showed association of PAI-1 level and hyperglycemia and pre-existing T2DM with severity of COVID-19.

CONCLUSION

Patients hospitalized for COVID-19 infection with preexisting T2DM or hyperglycemia detected during their hospitalization presented a greater increase in PAI-1 levels, which suggests that hyperglycemia contributes directly to the hypercoagulable state and probably a worse outcome from the patients.

Systemic inflammation and quality of life in patients with coronavirus disease: interrelation features

OBJECTIVE

Aim: To characterize the features of the interrelation of systemic inflammation with the quality of life of patients with coronary virus disease.

PATIENTS AND METHODS

Materials and Methods: 30 patients were examined 1 month after inpatient treatment for COVID-19. Quality of life (QoL) of patients was determined according to the questionnaire Medical Outcomes Study - 36-item Short Form (SF-36). The glucose level, circulating immune complexes (CICs), concentration of immunoglobulin (Ig) A, interleukin (IL)-8 and IL-33 levels were determined in the blood serum of patients.

RESULTS

Results: QoL of patients after coronavirus disease is significantly deteriorated: patients note a significant limitation in physical functioning, pain perception, vitality, role-physical and social functioning and mental health. The increase in glycemia and glycated hemoglobin levels in post-COVID-19 patients was significantly associated with the deterioration of patients` general health (GH) (r = -0,228; (p=0,040) and (r = -0,280; (p=0,014), respectively). The IL-33 concentration in such patients correlated directly with role-physical functioning (RP) (r = 0,385; p=0,029). The CICs level decline was associated with deterioration of RP (r = 0,227; p=0,042) and GH (r = 0,227; p=0,041).

CONCLUSION

Conclusions: The study of clinical-functional, biochemical, immunological and psychological indicators, quality of life, and their mutual influences should be included in the development of the program for the diagnosis, treatment, and rehabilitation of patients after the transfer of COVID-19 at the outpatient stage of treatment by doctors of general practice-family medicine.

Hyperglycaemia and Its Prognostic Value in Patients with COVID-19 Admitted to the Hospital in Lithuania

BACKGROUND AND OBJECTIVES

Increased blood glucose levels atadmission are frequently observed in COVID-19 patients, even in those without pre-existing diabetes. Hyperglycaemia is associated with an increased incidence of severe COVID-19 infection. The aim of this study was to evaluate the association between hyperglycaemia at admission with the need for invasive mechanical ventilation (IMV) and in-hospital mortality in patients without diabetes who were hospitalized for COVID-19 infection.

MATERIALS AND METHODS

This retrospective observational study was conducted at Vilnius University Hospital Santaros Clinics, Lithuania with adult patients who tested positive for severe acute respiratory syndrome coronavirus 2 SARS-CoV-2 and were hospitalized between March 2020 and May 2021. Depersonalized data were retrieved from electronic medical records. Based on blood glucose levels on the day of admission, patients without diabetes were divided into 4 groups: patients with hypoglycaemia (blood glucose below 4.0 mmol/L), patients with normoglycaemia (blood glucose between ≥4.0 mmol/L and <6.1 mmol/L), patients with mild hyperglycaemia (blood glucose between ≥6.1 mmol/L and <7.8 mmol/L), and patients with intermittent hyperglycaemia (blood glucose levels ≥7.8 mmol/L and <11.1 mmol/L). A multivariable binary logistic regression model was created to determine the association between hyperglycaemia and the need for IMV. Survival analysis was performed to assess the effect of hyperglycaemia on outcome within 30 days of hospitalization.

RESULTS

Among 1945 patients without diabetes at admission, 1078 (55.4%) had normal glucose levels, 651 (33.5%) had mild hyperglycaemia, 196 (10.1%) had intermittent hyperglycaemia, and 20 (1.0%) had hypoglycaemia. The oddsratio (OR) for IMV in patients with intermittent hyperglycaemia was 4.82 (95% CI 2.70-8.61, p < 0.001), and the OR was 2.00 (95% CI 1.21-3.31, p = 0.007) in those with mild hyperglycaemia compared to patients presenting normal glucose levels. The hazardratio (HR) for 30-day in-hospital mortality in patients with mild hyperglycaemia was 1.62 (95% CI 1.10-2.39, p = 0.015), while the HR was 3.04 (95% CI 2.01-4.60, p < 0.001) in patients with intermittent hyperglycaemia compared to those with normoglycaemia at admission.

CONCLUSIONS

In COVID-19 patients without pre-existing diabetes, the presence of hyperglycaemia at admission is indicative of COVID-19-induced alterations in glucose metabolism and stress hyperglycaemia. Hyperglycaemia at admission in COVID-19 patients without diabetes is associated with an increased risk of invasive mechanical ventilation and in-hospital mortality. This finding highlights the importance for clinicians to carefully consider and select optimal support and treatment strategies for these patients. Further studies on the long-term consequences of hyperglycaemia in this specific population are warranted.

IL-6 and Neutrophil/Lymphocyte Ratio as Markers of ICU Admittance in SARS-CoV-2 Patients with Diabetes

Inflammation along with coagulation disturbances has an essential role in the evolution towards a severe disease in patients with the coronavirus disease 2019 (COVID-19). This study aimed to evaluate inflammatory and coagulation biomarkers when predicting the need to visit an intensive care unit (ICU) in diabetes mellitus (DM) patients. In a retrospective study, laboratory parameters were examined for 366 participants: ICU = 90, of which 44 patients had DM and no ICU admittance = 276. The ability of inflammatory and coagulation markers to distinguish the severity of COVID-19 was determined using univariate and multivariate regression analysis. In all patients, lactate dehydrogenase was the only predictor for ICU admittance in the multivariate analysis. In the DM group, the results showed that the interleukin (IL)-6 and neutrophil/lymphocyte ratio (NLR) values at admission could predict the need for ICU admittance. Even though there were significant differences between the ICU and no ICU admittance groups regarding the coagulation markers, they could not predict the severity of the disease in DM patients. The present study showed for the first time that the IL-6 and NLR admission values could predict ICU admittance in DM patients. This finding could help clinicians manage the infection more easily if the COVID-19 pandemic strikes again.

Neurological Manifestations in Hospitalized Geriatric Patients With COVID-19 at King Abdulaziz Medical City in Jeddah, Western Region, Saudi Arabia From 2020 to 2021: A Cross-Sectional Study

Introduction COVID-19 involvement in the nervous system has been reported in many cases. Viral neuroinvasion has multiple routes of entry. Neurological manifestations of COVID-19 can be divided into ones of the central nervous system (CNS), such as headache, dizziness, altered mental status, ataxia, and seizure, and of the peripheral nervous system (PNS), including ageusia, anosmia, acute illness demyelinating polyneuropathy, and neuralgia. Aim and objectives This study aims to observe and report the neurological manifestations in geriatric patients who were diagnosed with COVID-19 at KAMC-J and report the duration of admission to the in-patient and ICU wards. Methods This was a cross-sectional study conducted on admitted geriatric patients with PCR-confirmed COVID-19 from April 1, 2020 to June 30, 2021 at KAMC-J. Using Raosoft®, the sample size was estimated with a CI of 95% and a 36.4% prevalence of neurological symptoms in COVID-19 patients to be 289. Convenience sampling was used, and the data were collected from BESTCare EMRs. IBM SPSS Statistics for Windows, Version 20 (Released 2011) was used for descriptive and inferential statistical analysis. Results In this study, a total of 290 patients' data were collected, 161 (55.5%) of which were males. In addition, the median age was 71 (Q1-Q3: 65-78) years; furthermore, the median body mass index (BMI) was 30(Q1-Q3: 25-34) kg/m2. In descending order, the most prevalent comorbidities were hypertension (HTN) (70.3%), diabetes mellitus (DM) (68.6%), cardiac disease (42.1%), chronic kidney disease (26.6%), neurological disease (23.6%), cancer malignancy (13.1%), and finally chronic respiratory disease (11.4%). Regarding typical COVID-19 manifestations, 181 patients claimed to have experienced cough (62.4%), dyspnea by 164 (56.7%), fever by 154 (53.5%), fatigue by 93 (32.3%), a reading of anoxia by 68 (23.4%), abdominal pain by 58 (20.0%), diarrhea by 56 (19.4%), and finally throat pain by 19 (6.6%). Manifestations and pathologies of the CNS included headache (25.4%), dizziness (21.5%), impaired consciousness (17.2%), delirium (6.6%), ischemic stroke (4.1%), focal cranial nerve dysfunction (2.8%), seizure (2.8%), intracerebral hemorrhage (ICH) (0.3%), and ataxia (0.3%). Moreover, pathologies of the PNS manifested as taste impairment in 46 patients (15.9%), smell impairment in 33 (11.4%), nerve pain in 7 (24%), visual impairment in 5 (1.7%), Bell's palsy in 2 (0.7%), and Guillain-Barre syndrome in 1 (0.3%). Moreover, the majority of patients who developed an ischemic stroke or ICH, or required admission to the ICU had either DM or HTN. In addition, 17 (25.4%) of the 67 patients admitted to the ICU developed impaired consciousness. All-cause mortality in our study was 31 (10.71%) cases. Conclusion Neurological manifestations of COVID-19 are common and can result in serious complications if not detected and managed early, especially in the elderly. These complications are mostly seen in severely ill patients and may be the only symptoms in COVID-19 patients. In addition, patients' clinical conditions could deteriorate rapidly and result in significant morbidity and mortality. Therefore, a high index of suspicion is required among healthcare providers when dealing with such cases. Moreover, we recommend systematically collecting data on the short- and long-term neurological complications of COVID-19 globally and documenting the functional long-term outcomes after these complications.

Significance of 1,25-Dihydroxyvitamin D3 on Overall Mortality in Peritoneal Dialysis Patients with COVID-19

In previous publications, we pointed out the importance of mannosylation of fibrinogen for the development of cardiovascular complications and fucosylation as a predictor of peritoneal membrane dysfunction in patients on peritoneal dialysis (PD). After a follow-up period of 30 months from the onset of the COVID-19 pandemic, we evaluated the significance of 1,25-dihydroxyvitamin D₃ (calcitriol) therapy, primary disease, biochemical and hematologic analyzes, and previously performed glycan analysis by lectin-based microarray as predictors of mortality in this patient group. After univariate Cox regression analysis, diabetes mellitus (DM) and calcitriol therapy were found to be potential predictors of mortality. Additional multivariate Cox regression analysis confirmed that only DM was a predictor of mortality. Nevertheless, the use of calcitriol in therapy significantly reduced mortality in this patient group, as shown by the Kaplan-Meier survival curve. The presence of DM as a concomitant disease proved to be a strong predictor of fatal outcome in PD patients infected with SARS-CoV-2. This is the first study to indicate the importance and beneficial effect of calcitriol therapy on survival in PD patients with COVID-19 infection. In addition, this study points to the possibility that adverse thrombogenic events observed in PD patients during the pandemic may be caused by aberrant fibrinogen glycosylation.

Mechanisms of COVID-19 Associated Pulmonary Thrombosis: A Narrative Review

COVID-19, the infectious disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is frequently associated with pulmonary thrombotic events, especially in hospitalized patients. Severe SARS-CoV-2 infection is characterized by a proinflammatory state and an associated disbalance in hemostasis. Immune pathology analysis supports the inflammatory nature of pulmonary arterial thrombi composed of white blood cells, especially neutrophils, CD3+ and CD20+ lymphocytes, fibrin, red blood cells, and platelets. Immune cells, cytokines, chemokines, and the complement system are key drivers of immunothrombosis, as they induce the damage of endothelial cells and initiate proinflammatory and procoagulant positive feedback loops. Neutrophil extracellular traps induced by COVID-19-associated "cytokine storm", platelets, red blood cells, and coagulation pathways close the inflammation-endotheliopathy-thrombosis axis, contributing to SARS-CoV-2-associated pulmonary thrombotic events. The hypothesis of immunothrombosis is also supported by the minor role of venous thromboembolism with chest CT imaging data showing peripheral blood clots associated with inflammatory lesions and the high incidence of thrombotic events despite routine thromboprophylaxis. Understanding the complex mechanisms behind COVID-19-induced pulmonary thrombosis will lead to future combination therapies for hospitalized patients with severe disease that would target the crossroads of inflammatory and coagulation pathways.