Anemia and COVID-19

Year 2023, Volume: 9 Issue: 5 - September 2023, 1074 - 1082, 04.09.2023

Vildan Gürsoy , Suna Avcı , Selime Ermurat , Ali Erol , Melike Yazıcı

https://doi.org/10.18621/eurj.1169438

Abstract

Objectives: Coronavirus disease-19 (COVID-19) is an infective-inflammatory disease that mainly affects the lungs. Hematological symptoms such as thrombocytopenia, decreased eosinophil and lymphocyte counts are quite common and are of prognostic importance. Although it is known that the presence of anemia generally increases the severity of respiratory diseases, there is little data on the prevalence and importance of anemia in COVID-19. In this study, our aim is to evaluate the clinical features of patients with anemia in COVID-19 infection and to investigate the relationship between the presence of anemia and the prognosis of the disease.

Methods: This retrospective, observational study included 353 patients who presented to our pandemic reference hospital between 15.04.2020 and 15.05.2020 and were diagnosed with SARS-CoV-2 infection confirmed by real-time reverse transcription polymerase chain reaction (PCR) test and typical clinical symptoms.

Results: Our study included 167 female and 186 male patients. The mean age was 54.54 ± 18.28 years (range 19-99). One hundred forty-eight (41.93%) patients had anemia. In patients with anemia, age was higher than others (p < 0.001). The percentage of women was significantly higher in the anemia group (p < 0.001). Comorbidities were observed more in the anemia group. The percentages of intensive care stay (p = 0.003) and mortality (p = 0.001) were significantly higher in the anemia group compared to the group without anemia. Logistic regression analysis was performed to determine the important risk factors of death. We found patients with high age (p = 0.001), high red cell distribution width-coefficient of variation (RDW-CV) levels (p = 0.009), high D-dimer levels (p = 0.012) and high ferritin levels (p < 0.001) have higher risk of death. Anemia was found to be non-significant.

Conclusions: Anemia is frequently observed in patients with severe COVID-19 disease and low hemoglobin values at presentation are thought to be associated with a worse prognosis. Being more sensitive to the hemoglobin levels of COVID-19 patients is important for early recognition of the high-risk patient group and for successful patient management. However, in our study, the presence of anemia was found to be effective in mortality in univariate analysis, but not in multivariate analysis. According to the multivariate analysis of this study, advanced age, high D-dimer, high ferritin and RDW-CV determine death.

Keywords

COVID-19, anemia, iron metabolism, mortality

References

• 1. Wang L, Duan Y, Zhang W, Liang J, Xu J, Zhang Y, et al. Epidemiologic and clinical characteristics of 26 cases of COVID-19 arising from patient-to-patient transmission in Liaocheng, China. Clin Epidemiol 2020;12:387-91.
• 2. Yang J, Zheng Y, Gou X, Pu K, Chen Z, Guo Q, et al. Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis. Int J Infect Dis 2020;94:91-5.
• 3. Wu Y, Feng Z, Li P, Yu Q. Relationship between ABO blood group distribution and clinical characteristics in patients with COVID-19. Clin Chim Acta 2020;509:220-3.
• 4. Bi Q, Wu Y, Mei S, Ye C, Zou X, Zhang Z, et al. Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study. Lancet Infect Dis 2020;20:911-9.
• 5. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020;395:1054-62.
• 6. Herold T, Jurinovic V, Arnreich C, Lipworth BJ, Hellmuth JC, von Bergwelt-Baildon M, et al. Elevated levels of IL-6 and CRP predict the need for mechanical ventilation in COVID-19. J Allergy Clin Immunol 2020;146:128-36.
• 7. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA 2019;323:2052-9.
• 8. Onder G, Rezza G, Brusaferro S. Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy. JAMA 2020;323:1775-6.
• 9. Wu C, Chen X, Cai Y, Zhou X, Xu S, Huang H, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med 2020;180:934-43.
• 10. Henry BM, De Oliveira MHS, Benoit S, Plebani M, Lippi G. Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (COVID-19): a meta-analysis. Clin Chem Lab Med 2020;58:1021-8.
• 11. Taneri PE, Gómez-Ochoa SA, Llanaj E, Raguindin PF, Rojas LZ, Roa-Díaz ZM, et al. Anemia and iron metabolism in COVID-19: a systematic review and meta-analysis. Eur J Epidemiol 2020;35:763-73.
• 12. Saaby L, Poulsen TS, Hosbond S, Larsen TB, Diederichsen ACP, Hallas J, et al. Classification of myocardial infarction: frequency and features of type 2 myocardial infarction. Am J Med 2013;126:789-97.
• 13. DeFilippis AP, Chapman AR, Mills NL, De Lemos JA, Arbab-Zadeh A, Newby LK, et al. Assessment and treatment of patients with type 2 myocardial infarction and acute nonischemic myocardial injury. Circ J 2019;140:1661-78.
• 14. Cappellini MD, Comin-Colet J, de Francisco A, Dignass A, Doehner W, Lam CS, et al. Iron deficiency across chronic inflammatory conditions: International expert opinion on definition, diagnosis, and management. Am J Hematol 2017;92:1068-78.
• 15. Wouters HJ, van der Klauw MM, de Witte T, Stauder R, Swinkels DW, Wolffenbuttel BH, et al. Association of anemia with health-related quality of life and survival: a large population-based cohort study. Haematologica 2019;104:468-76.
• 16. Camaschella C. Iron deficiency. Blood 2019;133:30-9.
• 17. Weiss G, Schett G. Anaemia in inflammatory rheumatic diseases. Nat Rev Rheumatol 2013;9:205-15.
• 18. Doshi S, Rueda A, Corrales-Medina V, Musher D. Anemia and community-acquired pneumococcal pneumonia. Infection 2011;39:379-83.
• 19. Reade MC, Weissfeld L, Angus DC, Kellum JA, Milbrandt EB. The prevalence of anemia and its association with 90-day mortality in hospitalized community-acquired pneumonia. BMC Pulm Med 2010;10:15.
• 20. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708-20.
• 21. Geneva S, Organization WH. Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity. Vitamin and Mineral Nutrition Information System. Document Reference WHO. NMH/NHD/MNM/11.1. http://www. who. int/entity/vmnis/indicators/haemoglobin; 2011.
• 22. Weiss G, Ganz T, Goodnough LT. Anemia of inflammation. Blood 2019;133:40-50.
• 23. Liu Z, Sun R, Li J, Cheng W, Li L. Relations of anemia with the all-cause mortality and cardiovascular mortality in general population: a meta-analysis. Am J Med Sci 2019;358:191-9.
• 24. Lomholt FK, Laulund AS, Bjarnason NH, Jørgensen HL, Godtfredsen NS. Meta-analysis of routine blood tests as predictors of mortality in COPD. Eur Clin Respir J 2014;1:24110.
• 25. Rasmussen L, Christensen S, Lenler-Petersen P, Johnsen SP. Anemia and 90-day mortality in COPD patients requiring invasive mechanical ventilation. Clin Epidemiol 2011;3:1-5.
• 26. Henry BM, Benoit JL, Benoit S, Pulvino C, Berger BA, Olivera MHSd, et al. Red blood cell distribution width (RDW) Predicts COVID-19 severity: a prospective, observational study from the cincinnati SARS-CoV-2 emergency department cohort. Diagnostics (Basel) 2020;10:618.
• 27. Tao Z, Xu J, Chen W, Yang Z, Xu X, Liu L, et al. Anemia is associated with severe illness in COVID-19: a retrospective cohort study. J Med Virol 2021;93:1478-88.
• 28. Theurl I, Aigner E, Theurl M, Nairz M, Seifert M, Schroll A, et al. Regulation of iron homeostasis in anemia of chronic disease and iron deficiency anemia: diagnostic and therapeutic implications. Blood 2009;113:5277-86.
• 29. Wolf MS, Serper M, Opsasnick L, O'Conor RM, Curtis L, Benavente JY, et al. Awareness, attitudes, and actions related to COVID-19 among adults with chronic conditions at the onset of the US outbreak: a cross-sectional survey. Ann Intern Med 2020;173:100-9.
• 30. McGonagle D, Sharif K, O'Regan A, Bridgewood C. The role of cytokines including interleukin-6 in COVID-19 induced pneumonia and macrophage activation syndrome-like disease. Autoimmun Rev 2020;19:102537.
• 31. Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet 2020;395:1033-4.
• 32. Phua J, Weng L, Ling L, Egi M, Lim C-M, Divatia JV, et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet Respir Med 2020;8:506-17.
• 33. Bach V, Schruckmayer G, Sam I, Kemmler G, Stauder R. Prevalence and possible causes of anemia in the elderly: a cross-sectional analysis of a large European university hospital cohort. Clin Interv Aging 2014;9:1187-96.
• 34. Artz AS, Xue Q-L, Wickrema A, Hesdorffer C, Ferrucci L, Langdon JM, et al. Unexplained anaemia in the elderly is characterised by features of low grade inflammation. Br J Haematol 2014;167:286-9.
• 35. Wang C, Deng R, Gou L, Fu Z, Zhang X, Shao F, et al. Preliminary study to identify severe from moderate cases of COVID-19 using combined hematology parameters. Ann Transl Med 2020;8:593.
• 36. Foy BH, Carlson JC, Reinertsen E, Valls RPI, Lopez RP, Palanques-Tost E, et al. Association of red blood cell distribution width with mortality risk in hospitalized adults with SARS-CoV-2 infection. JAMA Netw Open 2020;3:e2022058.
• 37. Kim CH, Park JT, Kim EJ, Han JH, Han JS, Choi JY, et al. An increase in red blood cell distribution width from baseline predicts mortality in patients with severe sepsis or septic shock. Crit Care 2013;17:R282.