A Prospective Study of Specialized Coagulation Parameters in Admitted COVID-19 Patients and Their Correlation With Acute Respiratory Distress Syndrome and Outcome

Protein C and S activities in COVID-19: A systematic review and meta-analysis

COVID-19 has been associated with alterations in coagulation. Recent reports have shown that protein C and S activities are altered in COVID-19. This may affect the complications and outcome of the disease. However, their exact role in COVID-19 remains uncertain. The aim of the current study was therefore to analyze all papers in the literature on protein C and S activities in COVID-19. We searched three medical electronic databases. Of the 2442 papers, 28 studies were selected for the present meta-analysis. For the meta-analysis, means ± standard deviations with 95% confidence intervals (CI) for protein C and S activities were extracted. Pooled p values were calculated using STATA software. Protein C and S activities were significantly lower in COVID-19 patients than in healthy controls (pooled p values: 0.04 and 0.02, respectively). Similarly, protein C activities were considerably lower in nonsurviving patients (pooled p value = 0.00). There was no association between proteins C or S and thrombosis risk or ICU admission in COVID-19 patients (p value > 0.05). COVID-19 patients may exhibit lower activities of the C and S proteins, which might affect disease outcome; however, additional attention should be given when considering therapeutic strategies for these patients.

Coagulopathy and adverse outcomes in hospitalized patients with COVID-19: results from the NOR-Solidarity trial

Background

Several studies have examined parameters of increased thrombogenicity in COVID-19, but studies examining their association with long-term outcome and potential effects of antiviral agents in hospitalized patients with COVID-19 are scarce.

Objectives

To evaluate plasma levels of hemostatic proteins during hospitalization in relation to disease severity, treatment modalities, and persistent pulmonary pathology after 3 months.

Methods

In 165 patients with COVID-19 recruited into the NOR-Solidarity trial (NCT04321616) and randomized to treatment with hydroxychloroquine, remdesivir, or standard of care, we analyzed plasma levels of hemostatic proteins during the first 10 days of hospitalization (n = 160) and at 3 months of follow-up (n = 100) by enzyme immunoassay.

Results

Our main findings were as follows: (i) tissue plasminogen activator (tPA) and tissue factor pathway inhibitor (TFPI) were increased in patients with severe disease (ie, the combined endpoint of respiratory failure [Po2-to-FiO2 ratio, <26.6 kPa] or need for treatment at an intensive care unit) during hospitalization. Compared to patients without severe disease, tPA levels were a median of 42% (P < .001), 29% (P = .002), and 36% (P = .015) higher at baseline, 3 to 5 days, and 7 to 10 days, respectively. For TFPI, median levels were 37% (P = .003), 25% (P < .001), and 10% (P = .13) higher in patients with severe disease at these time points, respectively. No changes in thrombin-antithrombin complex; alpha 2-antiplasmin; a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13; or antithrombin were observed in relation to severe disease. (ii) Patients treated with remdesivir had lower levels of TFPI than those in patients treated with standard of care alone. (iii) TFPI levels during hospitalization, but not at 3 months of follow-up, were higher in those with persistent pathology on chest computed tomography imaging 3 months after hospital admission than in those without such pathology. No consistent changes in thrombin-antithrombin complex, alpha 2-antiplasmin, ADAMTS-13, tPA, or antithrombin were observed in relation to pulmonary pathology at 3 months of follow-up.

Conclusion

TFPI and tPA are associated with severe disease in hospitalized patients with COVID-19. For TFPI, high levels measured during the first 10 days of hospitalization were also associated with persistent pulmonary pathology even 3 months after hospital admittance.

Status of major hemostatic components in the setting of COVID-19: the effect on endothelium, platelets, coagulation factors, fibrinolytic system, and complement

The coagulation, fibrinolytic, anticoagulation, and complement systems are in delicate balance with the vessel wall endothelium ensuring appropriate hemostasis. Coagulopathy in coronavirus disease 2019 (COVID-19) is not a simple disorder of one hemostatic component but a complicated process affecting most of the hemostasis system. COVID-19 disturbs the balance between the procoagulant systems and the regulatory mechanisms. Here, we investigate the effect of COVID-19 on key hemostatic components, including platelets, endothelial cells, coagulation factors, fibrinolytic system, anticoagulant protein system, and complement system, to improve our understanding of the pathophysiological processes underlying COVID-19 coagulopathy based on evidence.

Higher Risk of Acute Respiratory Distress Syndrome and Risk Factors among Patients with COVID-19: A Systematic Review, Meta-Analysis and Meta-Regression

OBJECTIVE

To estimate the global risk and risk factors associated with acute respiratory distress syndrome (ARDS) among patients with COVID-19: Design: A systematic review, meta-analysis and meta-regression.

SETTING AND PARTICIPANTS

Hospitals or nursing homes and patients with acute respiratory distress syndrome after COVID-19.

METHODS

The literature review was systematically conducted on Embase, MEDLINE, CINAHL, and Web of Science, in addition to manual searches and reference list checking from 1 January 2019 to 2 March 2022. The search terms included coronavirus, acute respiratory syndrome, acute respiratory distress syndrome and observational studies. Three reviewers independently appraised the quality of the studies and extracted the relevant data using the Joanna Briggs Institute abstraction form and critical appraisal tools. A study protocol was registered in PROSPERO (CRD42022311957). Eligible studies were meta-analyzed and underwent meta-regression.

RESULTS

A total of 12 studies were included, with 148,080 participants. The risk ratio (RR) of ARDS was 23%. Risk factors were age ≥ 41-64 years old (RR = 15.3%, 95% CI =0.14-2.92, p = 0.03); fever (RR = 10.3%, 95% CI = 0.03-2.03, p = 0.04); multilobe involvement of the chest (RR = 33.5%, 95% CI = 0.35-6.36, p = 0.02); lymphopenia (RR = 25.9%, 95% CI = 1.11-4.08, p = 0.01); mechanical ventilation with oxygen therapy (RR = 31.7%, 95% CI = 1.10-5.25, p = 0.002); European region (RR = 16.3%, 95% CI = 0.09-3.17, p = 0.03); sample size ≤ 500 (RR = 18.0%, 95% CI = 0.70-2.89, p = 0.001).

CONCLUSIONS AND IMPLICATIONS

One in four patients experienced ARDS after having COVID-19. The age group 41-64 years old and the European region were high-risk groups. These findings can be used by policymakers to allocate resources for respiratory care facilities and can also provide scientific evidence in the design of protocols to manage COVID-19 worldwide.

Role of Fibrinolysis in the Management of Patients with COVID-19 and Thromboembolic Complications: A Review

An impaired fibrinolytic process has been demonstrated in patients infected with SARS-CoV-2, including those in severe or critical condition. Disruption of fibrinolysis leads to fibrin deposition, which exacerbates inflammation and fibrosis and damages the pulmonary surfactant. Numerous authors point out the different course of coagulopathy in patients with COVID-19. It is reported that they may have a state of secondary hyperfibrinolysis, which may explain, at least in part, the increased incidence of venous thromboembolism, even among those patients already receiving appropriate anticoagulant treatment. This raises the question of whether current guidelines for the prevention and treatment of embolic–thrombotic complications, among patients with severe COVID-19, are sufficient. Some studies show evidence of clinical improvement in patients who have received fibrinolytic therapy, beyond the current indications for its implementation. However, when considering the inclusion of systemic fibrinolytic therapy, the benefits of such treatment should always be weighed over the risk of adverse effects. Thromboelastography and rotational thromboelastometry can be helpful in making such decisions. The purpose of this study was to review the current knowledge regarding fibrinolysis and its role in the treatment of patients with severe COVID-19, including those with thromboembolic complications.

Dysregulation of Protein S in COVID-19

Coronavirus Disease 2019 (COVID-19) has been widely associated with increased thrombotic risk, with many different proposed mechanisms. One such mechanism is acquired deficiency of protein S (PS), a plasma protein that regulates coagulation and inflammatory processes, including complement activation and efferocytosis. Acquired PS deficiency is common in patients with severe viral infections and has been reported in multiple studies of COVID-19. This deficiency may be caused by consumption, degradation, or clearance of the protein, by decreased synthesis, or by binding of PS to other plasma proteins, which block its anticoagulant activity. Here, we review the functions of PS, the evidence of acquired PS deficiency in COVID-19 patients, the potential mechanisms of PS deficiency, and the evidence that those mechanisms may be occurring in COVID-19.

Trend of fluctuations of antithrombin in plasma of patients with COVID-19: a meta-analysis and systematic review

BACKGROUND

Antithrombin is considered as one of the accused markers for the development of thrombosis in patients with COVID-19. Because plasma levels of antithrombin vary in patients with COVID-19, a meta-analysis was performed to determine the trend of antithrombin levels in patients with COVID-19.

RESEARCH DESIGN AND METHODS

A literature search was performed in PubMed, Scopus, and the Web of Science to find papers on antithrombin levels in patients with COVID-19. After removing of duplicate papers, inclusion and exclusion criteria were applied. The full texts of the articles were read to select relevant articles and then to identify the data needed. All meta-analyses were performed using Stata software v16.0.

RESULTS

Testing for differences between subgroups showed a significant difference between ICU and non-ICU patients. Analysis showed a significant decrease in antithrombin level in patients with severe COVID-19. Analysis showed that the mean value of antithrombin level was 89.65% in all patients. The antithrombin level was significantly lower in the non-survivor group (87.52%) than in the survivor group (92.38%).

CONCLUSION

: The determination of antithrombin may be useful to determine the susceptibility of COVID-19 patients to hypercoagulability and to indicate the severity of COVID-19 infection.