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CMAAO Coronavirus Facts and Myth Buster: COVID and Anemia

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Dr KK Aggarwal    28 August 2020

With input from Dr Monica Vasudev

1068: Anemia associated with severe COVID-19 illness

DG Alerts excerpts: A study published in the Journal of Medical Virology suggests that anaemia could be an independent risk factor linked with severe COVID‐19.

The odds ratio (OR) of anemia related to severe manifestations of COVID‐19 was found to be 3.47 and 3.77 after adjustment for baseline data and laboratory indices, respectively.

This retrospective, observational study included 222 patients with laboratory-confirmed SARS-CoV-2 infection. Patients were admitted to Wuhan Ninth Hospital between December 1, 2019 and March 20, 2020. Overall, 202 of these had non-severe COVID-19 while 20 had severe disease. About 35.6% of the 222 patients had anemia (hemoglobin level <120 g/L in women and <130 g/L in men).

Among patients with severe COVID-19, there was a significant reduction in hemoglobin levels in comparison with non-severe patients (128 g/L vs 111.5 g/L, P=0.002). Significantly more patients in the severe group fulfilled the diagnostic criteria for anemia (32.2% vs 70.0%, P=0.001).

Additionally, the prevalence of severe illness was significantly higher in patients having anemia compared to those not having anemia (8.1% vs 17.7%, P=0.001). Furthermore, in comparison with non-anemic patients, those with anemia were older and had increased likelihood of having chronic kidney disease (0.0% vs 3.8%), cardiovascular disease (CVD) (3.5% vs 15.2%), and chronic obstructive pulmonary disease (COPD) (0.0% vs 10.1%) (all P<0.05).

COVID-19 patients with anemia appeared to have a predisposition to more severe inflammatory responses, coagulation disorders, and organ injuries. A higher proportion of patients with anemia had elevated C-reactive protein (CRP) (8.5% vs 24.7%) and procalcitonin (PCT) (1.3% vs 15.6%) (all P<0.05). These patients also had significantly higher levels of erythrocyte sedimentation rate (ESR), D-dimer, myoglobin, T‐pro brain natriuretic peptide (T‐pro‐BNP) and urea nitrogen (BUN) (all P<0.05).

Among the group with anemia, 46 patients had mild anemia, 29 had moderate anemia and 4 patients had severe anemia.

Investigators noted that there appeared to be no significant difference in the proportion of severe patients or in mortality between the anemia subtypes. Severity of anemia was; however, had a strong and positive association with inflammatory responses and a positive correlation with coagulation disorders. There was no significant relationship with organ injuries.

According to univariate analysis, baseline data, including age ≥60 years, anemia, any comorbidities, hypertension, CVD, COPD, and laboratory indices such as CRP ≥10 mg/L, lactate dehydrogenase (LDH) ≥250 U/L, D-dimer ≥0.5 mg/L and creatinine ≥133 μmol/L, had a significant association with greater disease severity in COVID-19 patients.

In the multivariable analysis, anemia continued to be significant independent risk factor for patients with severe COVID-19, even after adjusting for baseline data and laboratory indices.

There were 3 deaths in the severe COVID-19 group (15%) compared to none in the non-severe group.

The prevalence of anemia in hospitalized COVID-19 patients in this study was nearly 35.5%; much higher than a previous report that reported the frequency of anemia in COVID-19 patients as 15%.

Anemia and low hemoglobin can potentially reduce oxygen delivery. This might suggest that COVID-19 patients are more prone to severe illness owing to deteriorated pulmonary function and poor tissue oxygenation.

Patients with moderate-to-severe anemia had higher odds of developing symptoms of dyspnea and lower levels of PaO2 and SaO2 compared to those with mild anemia.

Myocardial injury and renal dysfunction appeared more prominent in patients with anemia, possibly as a result of a progressive reduction in blood oxygen content and restricted tissue oxygen delivery.

As a result, it seems tough to ascertain whether SARS-CoV-2 has a direct role in anemia, and whether patients have anemia of chronic disease.

 

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

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