Research - International Journal of Medical Research & Health Sciences ( 2021) Volume 10, Issue 9
Can Addressal and Correction of Hematological and Kidney Function Parameters Reduce Mortality in COVID-19?
Annette Angel1, Bennet Angel1, Vinod Joshi1*, Manisha Jindal2, Pooja Rastogi2, Nuzhat Peer1, BM Shareef1, Soumi Sadhu1, Swati Singh1, Sunita Sharma3, Kanu Priya1, Rashmi Chouhan4 and Jyoti Jethani52School of Medical Sciences & Research, Sharda Hospital, Sharda University Campus, Greater Noida, Uttar Pradesh, India
3Department of Biotechnology, School of Engineering, Sharda University, Greater Noida, Uttar Pradesh, India
4Shri Maneklal M Patel Institute of Science & Research, Kadi Sarva Vishwavidhyalaya, Gandhinagar, Gujrat, India
5Virology Laboratory, Department of Microbiology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
Vinod Joshi, Department of Life Sciences, School of Basic Sciences & Research, Sharda University, Greater Noida, Uttar Pradesh, India, Email: vinodjoshidmrc@gmail.com
Received: 16-Aug-2021 Accepted Date: Sep 23, 2021 ; Published: 30-Sep-2021, DOI: O
Abstract
Background: Present study was aimed to analyze the difference of hematological parameters and blood urea levels between recovered and dead cases of COVID-19. Material and Methods: A hospital-based study was undertaken wherein hematological parameters and blood urea level of 65 cases were analyzed. Results: Recovered patients, 16 (42.1%) showed higher levels of neutrophils with corresponding 22 (57.9%) patients showing the normal level of lymphocytes, 25 (65.7%) with normal hemoglobin, and 35 (92%) with normal blood urea. On other hand, among 27 died cases, 26 (96.2%) showed higher counts of neutrophils, 1 patient showed normal lymphocytes (3.8%), and 26 (96.2%) with a low count of lymphocytes. Conclusion: Recovery was associated with high counts of lymphocytes, normal hemoglobin, and blood urea levels whereas Mortality was closely associated with deficiency of lymphocytes, low hemoglobin, and high blood urea level. The study suggests supplementation of fresh blood (with live leucocytes) to address the deficiencies and reduce mortalitys.
Keywords
COVID-19, Hemoglobin, Urea, Mortality, Fresh blood, Coronavirus
Introduction
Severe Acute Respiratory Syndrome-CoronaVirus-2 (SARS-COV-2) is an ongoing challenge for the health and ultimate survival of the human population. India is currently facing the second wave of pandemics starting from 11th February 2021 embracing 177,108,695 total cases and 3,840,223 total deaths to date i.e. 20th June 2021[1,2].
To reduce case fatality, we need to study carefully, how the recovered and dead cases differ from each other with regards to their vital body function parameters. Although hospital admitted cases of COVID-19 are examined for their vital functions parameters yet the inter-parameter study of vital functionalities does not seem to guide the course of hospital management in the majority of COVID-19 cases.
The present paper reports the comparative account of haematological parameters of recovered and dead cases of COVID-19 and highlights important observations that the majority of the dead cases were deficient in lymphocyte counts, had low haemoglobin levels, and corresponding high blood urea. The case fatality was associated with a combination of poor immunity, less oxygen combining capacity, and corresponding kidney disease among dead cases. The results of the present study sensitize to investigate further whether addressal and correction of haematological and kidney function parameters, along with ongoing treatment protocols of COVID-19 patients can reduce mortality.
Materials and Methods
A study of the association between Kidney Function Tests and haematological parameters and survival/mortality of COVID-19 patients was undertaken among patients reporting in Noida and Greater Noida, UP, India. Surviving and Dead cases were chosen at random for the study. Few investigations were done in the residential society as per the information of COVID-19 patients obtained from the society notifications/news board. Few samples were also studied among students, staff, and faculty in Sharda University who had either been a patient of COVID-19 or had any family members infected with COVID-19 in the past. Some information was collected from the patient’s records of Sharda Hospital, Greater Noida, UP, India after obtaining appropriate permission from the hospital administration. The contact details of the COVID-19 patients obtained from the above survey were tabulated and patients were contacted telephonically. The aims and objectives of this study were telephonically conveyed to the patients or their family members (whosoever were available on phone for the conversation). After taking their verbal consent for participation in the study, their kidney function tests parameters were noted down along with other clinical parameters.
Results
Association between Haematological Parameters, Blood Urea level, and Recovery of Patients of COVID-19
The observations on haematological parameters in association with a kidney function parameter, blood urea level was analysed concerning 38 COVID-19 cases who recovered from the disease and 27 cases of died of the disease. In total 65 cases were studied. The age composition of the total 38 patients who were in the category of recovered, ranged from children to old age people. 5.2% were of the age 0-20 (1 female and 1 male), 34.21% were of the age 21-40 years (7 female and 6 male), 26.31% were of the age 41-60 years (5 females and 5 males) and 31.57% were above 61 years of age (2 females and 10 males). The duration of treatment and recovery was observed to be two days’ minimum period to a maximum period of 18 days.
It was observed that 16 (42.1%) patients showed higher levels of neutrophils indicating chances of bacterial or fungal infections mixed with SARS CoV-2 infection. Parallel to this, 16 patients also showed low levels of lymphocytes indicating the possibility of a weak immune response against mixed infections.
Out of 38 Recovered patients, 25 (65.7%) had normal values of haemoglobin and only 13 recovered cases (34.21%) were on the margin of being anaemic. Blood urea level among 35 recovered cases (92%) was in the normal range indicating that the majority of recovered patients had normal haemoglobin and blood urea levels (Table 1).
| S.No | Patient code | Age | Sex | Day of discharge after hospitalization | Neutrophils (%) Reference level: 40%-70% | Lymphocytes (%) Reference level: 20%-45% | Haemoglobin (g/dl) Reference level: 12 gm/dl-15.00 gm/dl | Blood Urea (g/dl) Reference level:20 mg/dl -43.0 mg/dl |
|---|---|---|---|---|---|---|---|---|
| 1. | SCR 5 | 41 | M | 8th | 64 | 25 | 14.5 | 38.5 |
| 2. | SCR 7 | 56 | F | 9th | 58 | 30 | 11.5 | 99.7 |
| 3. | SCR 9 | 35 | M | 10th | 50 | 43 | 13.7 | 19.2 |
| 4. | SCR 13 | 62 | M | 10th | 57 | 33 | 11.5 | 30.9 |
| 5. | SCR 15 | 23 | F | 11th | 60 | 30 | 10.8 | 19.2 |
| 6. | SCR 16 | 31 | F | 10th | 60 | 30 | 12 | 16.2 |
| 7. | SCR 17 | 25 | F | 11th | 64 | 27 | 9.7 | 14.8 |
| 8. | SCR 18 | 35 | F | 9th | 60 | 32 | 13.2 | 22 |
| 9. | SCR 19 | 5 | F | 6th | 30 | 62 | 11.2 | 20.5 |
| 10. | SCR 20 | 65 | M | 8th | 58 | 30 | 13.2 | 20.8 |
| 11. | SCR 22 | 37 | M | 3rd | 70 | 20 | 14.8 | 23.1 |
| 12. | SCR 25 | 46 | M | 8th | 67 | 23 | 13 | 24.7 |
| 13. | SCR 26 | 48 | F | 5th | 83 | 13 | 13.6 | 29.7 |
| 14. | SCR 27 | 65 | M | 14th | 90 | 6 | 10.3 | 125.3 |
| 15. | SCR90 | 35 | F | 7th | 40 | 48 | 12.6 | ND |
| 16. | SCR 28 | 51 | M | 7th | 71 | 21 | 14.5 | 23.4 |
| 17. | SCR 31 | 78 | M | 13th | 89 | 6 | 13.1 | 61.4 |
| 18. | SCR 32 | 58 | F | 11th | 72 | 19 | 12.1 | 30.4 |
| 19. | SCR 35 | 62 | M | 8th | 57 | 32 | 15.5 | 25.6 |
| 20. | SCR 37 | 65 | M | 11th | 79 | 13 | 10 | 26.5 |
| 21. | SCR 38 | 30 | F | 7th | 81 | 16 | 10.5 | ND |
| 22. | SCR 41 | 23 | M | 7th | 46 | 42 | 17.7 | 20.9 |
| 23. | SCR 44 | 23 | F | 13th | 40 | 50 | 12 | 17.5 |
| 24. | SCR 45 | 21 | M | 13th | 43 | 45 | 17.1 | 17.9 |
| 25. | SCR 53 | 59 | F | 18th | 86 | 8 | 10.9 | 35.3 |
| 26. | SCR 54 | 62 | M | 3th | 59 | 30 | 14.3 | 24.4 |
| 27. | SCR 55 | 74 | M | 9th | - | 30 | 10.8 | 40 |
| 28. | SCR 56 | 75 | F | 8th | 86 | 11 | 10.2 | 41.4 |
| 29. | SCR 60 | 52 | M | 7th | 95 | 3 | 16.1 | 82.8 |
| 30. | SCR 61 | - | F | 2nd | 60 | 27 | 15.9 | 21.3 |
| 31. | SCR 62 | 41 | F | 9th | 92 | 6 | 13.7 | 40.1 |
| 32. | SCR 64 | 35 | M | 30th | 74 | 15 | 13.9 | 53.1 |
| 33. | SCR 65 | 62 | M | 4th | 85 | 10 | 16 | 34.2 |
| 34. | SCR 67 | 72 | F | 2nd | 78 | 18 | 11.5 | 24.5 |
| 35. | SCR 70 | 68 | M | 10th | 79 | 11 | 12.6 | ND |
| 36. | SCR 72 | 14 | M | 10th | 88 | 10 | 13.4 | 25.9 |
| 37. | SCR 73 | 40 | M | 8th | 38 | 48 | 14.2 | 22.9 |
| 38. | SCR 74 | 49 | M | 12th | 94 | 3 | 10.1 | 59.4 |
Association between Haematological Parameters, Blood Urea level, and Mortality of Patients of COVID-19
We studied a total of 27 patients who died of COVID-19. It was observed that except 1, all the 26 patients (96.2%) who died showed higher levels of neutrophils revealing the possibility of mixed infections. It was interesting to further observe that one of the patients (93.7%) had normal counts of lymphocytes, the cells responsible for imparting adaptive immunity.
Out of 27 Dead cases we studied, as many as 17 (62.9%) showed low levels of haemoglobin, 9 (33.3%) that is around 12-13 gm/dl and only one of the dead patients showed a haemoglobin level of 15.3 gm/dl of blood. Of these patients whose majority showed low haemoglobin, 22 (81.4%) showed a higher level of blood urea.
It was interesting to observe that among 38 patients who recovered of COVID-19 and 27 patients who died, the recovery was associated with high counts of immunity imparting cells lymphocytes, normal haemoglobin, and blood urea levels whereas Mortality was closely associated with deficiency of Immune important lymphocytes, low haemoglobin levels and corresponding high blood urea level (Table 2).
| S.No | Patient code | Age | Sex | Day of discharge after hospitalization | Neutrophils (%) Reference level: 40%-70% | Lymphocytes (%) Reference level: 20%-45% | Haemoglobin (g/dl) Reference level: 12 gm/dl-15.00 gm/dl | Blood Urea (g/dl) Reference level: 20 mg/dl-43.0 mg/dl |
|---|---|---|---|---|---|---|---|---|
| 1. | SCD 1 | 60 | M | 5th | 78 | 13 | 9.4 | 234.9 |
| 2. | SCD 2 | 63 | F | 6th | 92 | 4 | 9.4 | 52.6 |
| 3. | SCD 3 | 80 | M | 5th | 88 | 5 | 9.9 | 86.6 |
| 4. | SCD 4 | 70 | M | 4th | 91 | 3 | 7.6 | 221.8 |
| 5. | SCD 5 | 51 | F | 3rd | 90 | 7 | 11.2 | 39 |
| 6. | SCD 7 | 52 | F | 8th | 93 | 4 | 9.2 | 114.8 |
| 7. | SCD 8 | 24 | F | 4th | 93 | 6 | 7.9 | 63.5 |
| 8. | SCD 9 | 80 | F | 4th | 90 | 5 | 12.2 | 52.4 |
| 9. | SCD 10 | 46 | M | 6th | 89 | 4 | 10.5 | 123.4 |
| 10. | SCD 11 | 63 | M | 5th | 83 | 8 | 15.3 | 116.3 |
| 11. | SCD 19 | - | M | 9th | 96 | 3 | 12.4 | 36.1 |
| 12. | SCD 21 | 56 | M | 2nd | 67 | 31 | 9.5 | ND |
| 13. | SCD 22 | 67 | M | 9th | 89 | 7 | 8.7 | 29.7 |
| 14. | SCD 23 | 57 | F | 7th | 86 | 10 | 10.2 | 36.3 |
| 15. | SCD 24 | 68 | F | 2nd | 80 | 15 | 12 | 47.8 |
| 16. | SCD 28 | 67 | M | 5th | 90 | 7 | 9.6 | 87 |
| 17. | SCD 32 | 58 | M | 3rd | 90 | 6 | 8.7 | 85.1 |
| 18. | SCD 35 | 71 | M | 2nd | 90 | 7 | 11.8 | ND |
| 19. | SCD 38 | 57 | M | 1st | 80 | 16 | 12.2 | 43.2 |
| 20. | SCD 42 | 60 | F | 2nd | 90 | 6 | 13.2 | 67 |
| 21. | SCD 52 | 66 | F | 7th | 93 | 4 | 10.3 | 45.2 |
| 22. | SCD 53 | 66 | M | 2nd | 90 | 6 | 13 | 75.7 |
| 23. | SCD 55 | 40 | M | 5th | 90 | 5 | 12.6 | 42.3 |
| 24. | SCD 61 | 80 | M | 4th | 87 | 8 | 11.5 | 47.7 |
| 25. | SCD 62 | - | M | 8th | 88 | 6 | 12.6 | 44.8 |
| 26. | SCD 68 | - | M | 3rd | 83 | 10 | 12.6 | 54.3 |
| 27. | SCD 69 | 82 | M | 3rd | 93 | 3 | 11.7 | 133.9 |
Discussion
The objective of the present study was to analyse how concerning haematological parameters and blood urea level, the two categories of patients, one who recovered and the other who died, differ from each other? In present investigations which were based on the analysis of 65 patients (38 recovered; 27 died), we observed that both recovered, as well as dead patients, showed haematological evidence of mixed infections, yet among patients who died, lymphocytes were below the normal level of counts. Under the circumstances when a mix of bacterial fungal and viral infections is infesting, strong quantitative support of lymphocytes is required to impart innate as well as adaptive immunity. It is well known that among patients of COVID-19 or any other infections, blood is the only medium where either directly through injections or indirectly through oral route medicines against pathogens are given. In addition, due to depleting oxygen saturation levels of lungs, an additional measure of pulmonary oxygen supplementation is taken to bring normalcy and avoid mortality. However, we need an optimum level of haemoglobin to combine with the pulmonary supplementation of oxygen. In the present study, we observed that the majority of the patients who died did not have a normal level of haemoglobin and the deficiency appeared to induce kidney disease as we observed a higher level of blood urea in the majority of the fatal cases [3]. This can be supported by the fact that anaemia of chronic kidney failure can lead to an increase in plasma concentrations of the catabolites produced during protein metabolism including urea [4,5]. In such patients, the body tissue blood, being aggressively treated by anti-viral and anti-bacterial drugs but not having enough immunity imparting cells and haemoglobin may produce poor clinical results in terms of their survival. Another important understanding to be added to this COVID-19 triggered uremic manifestation is a relapse of aHUS (Atypical Hemolytic Uremic Syndrome) which may lead to activation of the complement system and thereby endothelial damage [6].
Many viruses Like Epstein Barr Virus, Cytomegalovirus, Human Immunodeficiency Virus, Parvovirus, Hepatitis A, C, etc. have been known to be associated with anaemia [7]. Just as there is an association observed between prevalence of anaemia in Community Associated Pneumonia (CAP), similarly in COVID-19 also, the occurrence of anaemia has been reported but its exact pathogenesis is not known/described [8,9]. And anaemia is known to arise early in the start of kidney disease leading to worsening of the kidney parameters due to reduction/deficiency of erythropoietin production (which is required for the production of RBCs) [3,10-13]. Malnutrition and deficiencies of iron, folate and vitamin B12 have also been found to cause a reduction in Hb concentrations [14]. Besides the contribution of viral and other above said factors in anaemic like condition, administration of Ivermectin may also contribute to further worsen the extent of anaemia as the side effects of the drug with few other side effects viz; decreased Total leucocyte count, eosinophilia, and abdominal distention, etc. [15,16]. A recent study has of COVID-19 patients has shown that Ivermectin damages the intestinal tissues at a dose of 0.22-170 mg/body weight and recovery was slow and observed only after 14-21 days, necessitating prolonged hospitalization of patients [17].
Recommendations
Thus it appears more than necessary that we consider few additions to the ongoing treatment protocol of COVID-19 patients to reduce mortality. Currently, supplemental oxygen therapy like Low and High Flow Nasal Cannula (LFNC and HFNC), Non-invasive ventilation, etc. are being used for reverting the hypoxia occurring at the lung tissue level. Through this paper, we wish to propose the inclusion of fresh blood infusion (blood taken from healthy donors) which will contain both, live leucocytes to generate an innate and specific immune response and will also serve to supplement haemoglobin. On the other hand, if managing the anaemia occurring at the kidney level is required, then Erythropoietin Stimulating Agent (ESA) may be recommended [18]. Another important recommendation to be added is the identification and management of Haemolytic Uremic Syndrome (through its marker C5b-9) and the use of Complement blockade drugs if required [19,20].
Conclusion
The present paper highlights understanding and minutely observing the various COVID-19 patients such that targeted course of action be advised to individual patients.
Declarations
Conflicts of Interest
The authors declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.
Funding
There are no funding sources for this work.
Acknowledgment
We thank Dr. Ashutosh Niranjan, Medical Superintendant, Sharda Hospital for kindly providing us with data for analysis of this work and also to the staff and students who have worked in providing us the data.e.
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