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\begin{document}

\title{The Relationship Between COVID-19 Suspected Patient's Coagulation and
Platelet Parameters and Polimerase Chain Reaction Results}



\author[1]{Mukadder  Arslanbek Erdem}%
\author[2]{Seçil Müderrisoğlu}%
\author[3]{Mahcube CUBUKCU}%
\author[3]{Recai  Acı}%
\author[1]{Eda Türe}%
\affil[1]{Affiliation not available}%
\affil[2]{Ondokuz Mayis University}%
\affil[3]{Samsun Education and Research Hospital}%


\vspace{-1em}



  
  \date{May 17, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Aim: Our aim was to investigate the relationship between
prothrombintime(PT), activated partial thromboplastin time (aPTT), INR
(International Normalized Ratio) and D-dimer levels, platelet
(PLT)levels at admission to hospital and positivity or negativity of
Polymerase Chain Reaction (PCR) result in patients with suspected
COVID-19 followed at COVID-19 services. Material and Method: 238 people
who applied with suspicion of COVID-19 in March-April-May of 2020 were
included in the study. According to COVID-19 results, PCR negative 119
participants and PCR positive 119 patients were included in the study.
PT, aPTT, Ddimer, INR and PLT levels were examined. Results: While PCR
negative participants had a mean PT value of 11.46\selectlanguage{ngerman}±0.86 sec, PCR
positive patients had a mean PT value of 12.97±3.65 sec
(p\textless{}0.001). There was no significant difference in mean aPTT
values of PCR positive and negative patients. Whereas INR, D-dimer
increased significantly in PCR positive patients. PLT value decreased
from mean value of 266.75±71.36*109/L in PCR negative participants to
241.18±96.64*109/L in PCR positive patients (p=0.002). Conclusion: In
our study, it was found that in patients who were admitted to Samsun
Training and Research Hospital with COVID-19 suspicion and followed up
in COVID-19 services, PT, D-dimer, INR, PLT values were important in
detecting Coagulopathy and Thrombocytopenia in the group who were PCR
positive according to COVID-19 results. Keywords: COVID-19, PT, aPTT,
D-dimer, INR, PLT%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{Introduction}

Coronavirus disease- 19 (COVID-19), which shares similarities with SARS
(Severe Acute Respiratory Syndrome) and Middle East Respiratory Syndrome
(MERS) viruses responsible for endemic diseases in 2003 and 2012, is a
novel beta corona virus \textsuperscript{1-2}. In addition to being a
critical disease for health, coronavirus 2019 (COVID-19) poses a global
threat \textsuperscript{3}.

First, pneumonia cases of unknown etiology occurred in Wuhan, Hubei
province of China; the cases were reported to WHO (World Health
Organization) in December 2019 and in March 2020 WHO declared this new
infection as a pandemic \textsuperscript{4-5}.

COVID-19 is described as a new beta coronavirus. It is closely related
to Severe Acute Respiratory Syndrome (SARS). It is a new infectious
disease in which the virus is the causative pathogen\textsuperscript{5}.
Despite the presence of pulmonary pathophysiology during the disease,
severe COVID-19 infection which is not fully understood is associated
with pronounced alveolar inflammatory cell infiltration and it is
accompanied by systemic cytokine storm\textsuperscript{6}. One of the
most important poor prognosis indicators is the development of
coagulopathy in patients \textsuperscript{7-8-9}. Increased plasma
levels of fibrin degradation D-dimers with COVID-19 infection constitute
an independent biomarker for poor prognosis.9 \selectlanguage{english}In the COVID-19
pathogenesis of coagulation activation, significant pathological changes
involving lung microvasculature including widespread micro thrombus and
significant hemorrhagic necrosis have been highlighted, particularly in
line with post mortem studies\textsuperscript{10-11}.

Severe COVID-19 increases the risk of developing significantly
associated deep vein thrombosis and pulmonary
embolism\textsuperscript{12-13}. For estimating the severity of
COVID-19, monitoring of useful screening parameters for PLT, PT, aPTT
and D-D (D-dimer) and daily changes in coagulation function is important
in patients with COVID-19 \textsuperscript{14}.

Poor prognosis that continues with COVID- 19 and continuation of D-dimer
increase are precursors of multi organ failure and development of DIC
(Disseminated Intravascular Coagulation) \textsuperscript{15}.
Especially, high D-dimer level is associated with increased mortality.
In patients who lost their lives, the increase is evident from the
fourth day of hospitalization. Despite coagulopathy, hemorrhage findings
are not a common biomarker \textsuperscript{15-16-17}.

\textbf{Materials and Methods}

\textbf{Study design and participants}

This study presents a retrospective evaluation of the 238 patients
admitted to Health Sciences University Samsun Training and Research
Hospital who applied with suspicion of COVID-19 between March 11 and May
30, 2020. PCR results are determined in two categories, PCR positive
group, and PCR negative group in line with The World Health
Organization's guide titled ''Laboratory Testing for 2019 Novel
Coronavirus (2019-nCoV) in Suspected Human Cases'' published on March 2,
2020 and TC Ministry of Health COVID-19 Guidelines.

All samples were studied with the SARS CoV-2 Double Gene RT-q PCR Kit
(BioSpeedy, Turkey) in accordance with the manufacturer's instructions.
Briefly, after nucleic acid isolation in nasopharyngeal lavage/aspirate,
broncho alveolar lavage, nasopharyngeal suture, oropharyngeal swab and
sputum samples, detection by single-step reverse transcription (RT) and
Real-Time PCR targeting the ORF1ab and N gene regions were performed.

Extract ion and inhibition control were checked by targeting the human
RNase P gene as an internal control. Nucleic acid extraction was
validated with the vNAT buffer and this process was conducted without
any additional work during sample transfer. Nasopharyngeal swap
ororopharyngeal swab samples taken with swabs (dacronor polyester flock)
were placed in a sterile transport solution containing vNAT solution and
transferred. Reaction components 2X Prime Script mix 10\selectlanguage{greek}µ\selectlanguage{english}L, CVD Di Oligo
mix 5\selectlanguage{greek}µ\selectlanguage{english}L, template nucleic acid 5\selectlanguage{greek}µ\selectlanguage{english}L total reaction amount of 20\selectlanguage{greek}µ\selectlanguage{english}Lvolume
was created. Qiagen Rotor Gene (Germany) Real-Time PCR instrument was
run on sigmoidal curves under 38 cycles and were evaluated as positive.

Prothrombin time (PT), activated partial thromboplastin time (aPTT),
D-dimer, International Normalized Ratio (INR) and platelet (PLT) levels
of 119 patients followed in COVID-19 services were taken from hospital
information management system. In addition, PT, aPTT, D-dimer, INR and
PLT levels of 119 individuals with COVID-19 PCR negative were taken.

D-dimer test was worked on a Beckman Coulter Au 680 device, PT, aPTT and
INR tests were worked at Siemens Ca-7000 device and platelet level was
worked in Beckman Coulter Dx-800 device by using suitable tubes and
kits.

\textbf{Ethical approval}

Ethical committee approval was obtained with the Ethics Committee
decision dated 10 September 2020 and No. of Health Sciences University
Samsun Training and Research Hospital Ethics Committee.

\textbf{Data analysis}

SPSS 22.0 Windows program was used to analyze the data. One Sample
Kolmogorov -- Simirnov and the Shapiro-Wilks tests were used to examine
whether the differences between the groups and differences between the
groups by gender were normally distributed, and it was found that the
data did not show a normal distribution. Therefore, non-parametric
analyses were used. Mann--Whitney U-test was used in the comparison of
parameters between the groups and (p \textless{}0.05) was considered
statistically significant. G*Power 3.1.9.7 program was used to calculate
the sample size. One hundred ten sample size results were obtained for
each group, in this calculation (test=t-test (Wilcoxon-Mann-Whitney test
(two groups)), Analysis: A priori: Compute required sample size, Tail(s)
=Two, Parent~distribution=Normal, Effect size d=0.5, \selectlanguage{greek}α \selectlanguage{english}err prob=0.05,
Power (1-\selectlanguage{greek}β \selectlanguage{english}err prob)=0.95, Allocation ratio N2/N1=1).

\textbf{Results}

In our study PT, aPTT, D-dimer, INR, PLT levels of a total of 238
individuals who were admitted to our hospital with a suspicion of
COVID-19 were examined and evaluated according to their COVID-19
results. Half of these 238 individuals were individuals with a negative
COVID-19 test result and the other half were patients with a positive
COVID19 test result. The descriptive information of the study is given
in table 1.

The test reference range of the samples analysed in Biochemistry
Laboratory was taken as 10-14 seconds (sec) for prothrombin time (PT).
While 11.46\selectlanguage{ngerman}±0.86 sec. PT mean value was found in PCR negative
individuals, 12.97±3.65 sec was found in PCR positive patients. When PT
values were examined, a significant difference was found between both
groups and the difference was found as statistically significant
(p\textless{}0.001), (Table 2).

The test reference range of the samples analysed in Biochemistry
Laboratory was taken as 18-36 seconds (sec) for activated partial
thromboplastin (aPTT). While 24.38±3.40 sec. aPTT mean value was found
in PCR negative individuals, 24.18±4.83 sec was found in PCR positive
patients. No significant difference was found between the two groups
(Table 2).The test reference range of the samples analysed in
Biochemistry Laboratory was taken as 0-0.5 \selectlanguage{greek}µ\selectlanguage{english}g/ml for D-dimer. While
0.23\selectlanguage{ngerman}±0.12 \selectlanguage{greek}µ\selectlanguage{english}g/ml D-dimer mean value was found in PCR negative
individuals, 2.10\selectlanguage{ngerman}±5.60 \selectlanguage{greek}µ\selectlanguage{english}g/ml was found in PCR positive patients. When
D-dimer values were examined, a significant difference was found between
both groups and the difference was found as statistically significant
(p\textless{}0.001), (Table 2).The test reference range of the samples
analysed in Biochemistry Laboratory was taken as 0.8-1.2 for
International Normalized Ratio (INR). While 0.99\selectlanguage{ngerman}±0.12 INR mean value was
found in PCR negative individuals, 1.14±0.35 was found in PCR positive
patients. When INR values were examined, a significant difference was
found between both groups and the difference was found as statistically
significant (p\textless{}0.001), (Table 2).The test reference range of
the samples analysed in Biochemistry Laboratory was taken as
142-424*10\textsuperscript{9}/L for platelet (PLT). While
266.75±71.36*10\textsuperscript{9}/L PLT mean value was found in PCR
negative individuals, 241.18±96.64*10\textsuperscript{9}/L was found in
PCR positive patients. When PLT values were examined, a significant
difference was found between both groups and the difference was found as
statistically significant (p=0.002), (Table 2). In addition, the
evaluation by gender for all parameters is given in table 2.

\textbf{Discussion}

Coagulopathy becomes evident with increase in D-dimer and fibrinogen
levels and minimal change in prothrombin time (PT), active partial
thromboplastin time (aPTT) and platelet count \textsuperscript{15}.
Hematological laboratory results can be used to determine the severity
and prognosis of COVID-19 infection. Thrombocytopenia has been shown to
be associated with an increased risk of severe disease and mortality
associated with COVID-19 \textsuperscript{18}. Platelet count has been
accepted as a potential marker for COVID-19 since it is a simple,
inexpensive and easily available hematological marker and since it is
independent of disease severity and morbidity risk in the intensive care
Unit \textsuperscript{19}.

In a study conducted on thrombocytopenia with patients with COVID-19,
~mild thrombocytopenia was observed in approximately 5\% of patients who
had mild disease, thrombocytopenia was observed in 70-95\% of patients
who had severe disease~\textsuperscript{5-19}. In a meta-analysis, when
platelet count was compared, a significant difference was found between
the COVID-19-negative group and the group that had severe COVID-19 in
terms of platelet count and the individuals who had severe disease were
found to have lower platelet count \textsuperscript{18}. In another
study conducted on 1476 patients, a direct correlation was found in
patients with COVID-19 between the decrease in platelet count and
mortality \textsuperscript{20}. In another study conducted on patients
with COVID-19, it was reported that low platelet count was associated
with increased severe disease and death risk and it could serve as an
indicator of worsening of the disease during the hospital stay in
COVID-19 \textsuperscript{18}. It has been reported that platelet count
decreases significantly in patients with COVID-19\textsuperscript{21-22}
and it is lower in patients who do not survive compared with those who
survive \textsuperscript{23}.

Our study was found to be in parallel with the literature, a significant
difference was found between groups and platelet count was found to be
lower in the COVID-19 (+) group (U=5435.000, p=0.002, Effect
size=0.20)(Table 2).

D-dimer is a fragment produced by the cleavage of fibrin by plasmin
during clot breakdown \textsuperscript{24}. One of the most common
laboratory findings in patients with COVID-19 who require
hospitalization is the obvious elevation in D-dimer. A high D-dimer
value has been reported as a poor prognostic marker associated with
consistent critical course and higher mortality in patients with
COVID-19 \textsuperscript{25-26}. In a study conducted on 1099 patients
with COVID-19 in China, high D-dimer levels were found in almost half of
the patients \textsuperscript{27}.

In an observational study conducted on 183 patients in China, a
statistically significant difference was found in the mean D-dimer
concentration at admission between patients with COVID-19 who survived
and those who did not \textsuperscript{8}. In another study conducted,
patients with COVID-19 treated in ICU (Intensive Care Unit) were found
to have higher D-dimer levels than patients with COVID-19 who were not
treated in ICU \textsuperscript{5}. Finally, in another study involving
5279 patients with COVID-19, the COVID-19 (+) group was compared with
the COVID-19 (-) group.~The D-dimer level of the COVID-19 (+) group was
found to be four times higher \textsuperscript{28}.

Our study was found to be consistent with the literature.~The difference
between groups was found to be significant.~D-dimer levels were found to
be higher in the COVID-19 (+) group, while they were found to be lower
in the Cov\selectlanguage{polish}ı\selectlanguage{english}d-19 (-) group (U=1457.500, p\textless{}0.001, Effect
Size=0.69)(Table 2).

Among coagulation parameters, PT is another laboratory parameter with
varying consequences in COVID-19. PT and aPTT are exogenous and
endogenous coagulation system factors that can be used for the early
diagnosis of DIC (Disseminated Intravascular Coagulation). In another
observational study conducted on 183 patients in China, a mild
prolongation was found in the mean PT concentration at admission between
patients with COVID-19 who survived and those who did not and a
statistically significant difference was found between the
groups\textsuperscript{8}. In another study conducted in China, the
patients receiving treatment in ICU were found to have higher PT
prolongation compared with patients who were not receiving treatment in
ICU and a significant difference was found between the groups
\textsuperscript{5}. In another study conducted on 187 patients
diagnosed with COVID-19 and treated in the hospital, patients with high
troponin-T level were~found to have prolonged PT and aPTT levels
\textsuperscript{29}. More pronounced prolongation of PT and APTT
parameters indicates that patients are in a transition from high
coagulation state to fibrinolytic state due to excessive coagulation
factor consumption.

Our study was found to be consistent with the literature, a significant
difference was found between the groups in terms of PT levels and
prolongation was found to be higher in the PCR (+) Group (U=3765.500,
p\textless{}0.001, Effect Size=0.40) (Table 2).

In conclusion, the relationship between PT, aPTT, D\selectlanguage{polish}İ\selectlanguage{english}MER, INR, PLT levels
was evaluated according to COVID-19 results and gender. Our study showed
statistical significance between groups in PT, D-dimer, INR, PLT values
between PCR positive and negative groups in terms of especially COVID-19
results (p\textless{}0.01). It is important to find out coagulopathy and
thrombocytopenia in Covid-19 patients. These parameters are also
important biomarkers for the prognosis of the disease in COVID-19.

The results of this study have shown that hypercoagulation exists in
patients with COVID-19 at an early stage and hypercoagulation is closely
associated with disease progression and clinical outcome. For this
reason, coagulation indicators such as D-dimer and PT should be
monitored as early as possible to determine thrombotic complications. It
is imperative to take preventive treatment to decrease thromboembolism
and DIC risk secondary to coagulation disorder and thus to reduce the
morbidity and mortality of patients infected with COVID-19.

Conflict of interest statement

There is no conflict of interest between the authors.

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