key: cord-0998186-f28rb5ek
authors: Küçükceran, Kadir; Ayranci, Mustafa Kürşat; Girişgin, Abdullah Sadık; Koçak, Sedat
title: Predictive value of D‐dimer/albumin ratio and fibrinogen/albumin ratio for in‐hospital mortality in patients with COVID‐19
date: 2021-05-13
journal: Int J Clin Pract
DOI: 10.1111/ijcp.14263
sha: 148449fdd6a1b72dd50199a0966ee1476308151c
doc_id: 998186
cord_uid: f28rb5ek

INTRODUCTION: Due to the high mortality of coronavirus disease 2019 (COVID‐19), there are difficulties in the managing emergency department. We investigated whether the D‐dimer/albumin ratio (DAR) and fibrinogen/albumin ratio (FAR) predict mortality in the COVID‐19 patients. METHODS: A total of 717 COVID‐19 patients who were brought to the emergency department from March to October 2020 were included in the study. Levels of D‐dimer, fibrinogen and albumin, as well as DAR, FAR, age, gender and in‐hospital mortality status of the patients, were recorded. The patients were grouped by in‐hospital mortality. Statistical comparison was conducted between the groups. RESULTS: Of the patients included in the study, 371 (51.7%) were male, and their median age was 64 years (50‐74). There was in‐hospital mortality in 126 (17.6%) patients. The area under the curve (AUC) and odds ratio values obtained by DAR to predict in‐hospital mortality were higher than the values obtained by the all other parameters (AUC of DAR, albumin, D‐dimer, FAR and fibrinogen: 0.773, 0.766, 0.757, 0.703 and 0.637, respectively; odds ratio of DAR > 56.36, albumin < 4.015, D‐dimer > 292.5, FAR > 112.33 and fibrinogen > 423:7.898, 6.216, 6.058, 4.437 and 2.794, respectively). In addition; patients with concurrent DAR > 56.36 and FAR > 112.33 had an odds ratio of 21.879 with respect to patients with concurrent DAR < 56.36 and FAR < 112.33. CONCLUSION: DAR may be used as a new marker to predict mortality in COVID‐19 patients. In addition, the concurrent high DARs and FARs were found to be more valuable in predicting in‐hospital mortality than either separately.

more sensitive and specific predictor than fibrinogen in showing the progression of hypercoagulation. 6 Some studies of COVID-19 patients have used D-dimer, albumin, fibrinogen and FAR for this purpose, [7] [8] [9] but to the best of our knowledge, no studies have used the D-dimer to albumin ratio (DAR). Therefore, in this study, we aimed to investigate and compare the predictive value of DAR and FAR for mortality in patients with COVID-19.

Ethics committee approval for this single-centre, retrospective and observational study was obtained from the Necmettin Erbakan

Device Studies Ethical Committee, decision number of 2021/3022.

This study was carried out in a tertiary university hospital.

Patients suspected of having COVID-19 who were admitted to the emergency department and hospitalised and whose PCR test was positive were included in the study from March to October 2020.

Regardless of the number of tests submitted, any PCR result that appeared positive at least once was considered positive, whereas other results were considered negative. Patients who were discharged against medical advice and referred to other hospitals were excluded from the study. Patients, who were discharged against medical advice, transferred to other hospitals and had no results of at least one of the D-dimer, fibrinogen and albumin parameters were excluded.

The following pieces of patient data were recorded from the patients' e-files using the Hospital Information Management Systems programme: D-dimer level, fibrinogen level, albumin level, complaint (fever, cough and shortness of breath), vital signs, comorbidities, information about their ward/intensive care unit (ICU) admission, hospital outcome (discharge and exitus in-hospital) and in-hospital mortality status. The DAR was obtained by dividing the D-dimer level by the albumin level. The FAR was obtained by dividing the fibrinogen level by the albumin level. The primary outcomes of the study were prediction of in-hospital mortality using DAR and FAR and determination of whether DAR or FAR was a more accurate predictor than using D-dimer, fibrinogen and albumin levels.

Statistical analysis of the data was performed using the SPSS 20.0 (SPSS Inc, Chicago, IL) package programme. Histograms and the Kolmogorov-Smirnov test were used to test the normality of the data.

Following the normality analysis result, all quantitative data were expressed as median (25-75% quarters) because they did not show a normal distribution, whereas categorical variables were expressed as frequency (percentage). The differences between the groups were investigated using the Mann-Whitney U test. Intragroup comparisons of the categorical variables were made using the chi square test and the Fisher's exact test. Receiver operating characteristic (ROC) analysis was performed to determine predictive power of the D-dimer, fibrinogen and albumin levels and DAR and FAR for in-hospital mortality. The optimum cut-off levels of the biochemical parameters were determined using Youden's index (sensitivity + 1 − specificity). The sensitivity, specificity and positive and negative predictive values of the parameters were calculated for the optimum cut-off levels. The odds ratios of the groups categorised by the optimum cut-off values of D-dimer, fibrinogen, albumin, DAR and FAR in predicting inhospital COVID-19 mortality were calculated using univariate logistic regression analysis. The area under the curve (AUC) and odds ratio values were used to compare the mortality predictive power of parameters. Statistical significance was set at P < .05.

A total of 749 patients who were brought to the emergency department with suspected COVID-19 within the period from March to September 2020 and who had a positive PCR test result were identified. Of these 749 patients, 11 were excluded from the study because they sought hospital discharge against medical advice, eight because they were referred to another hospital and 13 because they had no result of at least one of the D-dimer, fibrinogen and albumin parameters. The remaining 717 patients were included in the study.

Of the 717 patients who were included in the study, 371 (51.7%) were male, their median age was 64 years (50-74), and their median length of hospital stay was 9 days (5-14 patients, and is a predictor of severity. Fibrinogen to albumin ratio (FAR) was found to be more sensitive and specific predictor than fibrinogen in showing the progression of hypercoagulation. Some studies of COVID 19 patients have used d-dimer, albumin, fibrinogen and FAR for this purpose, but to the best of our knowledge, no studies have used the d-dimer to albumin ratio (DAR).

• The DAR was found to be valuable predictor of inhospital mortality in COVID-19 patients. In addition, the DAR was found to be more valuable than any other parameter in predicting in-hospital mortality. In addition, concurrent high DAR and FAR were found to be more predictive of in-hospital COVID-19 mortality than either taken separately. occurred in 126 patients (17.6%) and did not occur in 591 (76.7%). Table 3 .

The odds ratios for predicting in-hospital COVID-19 mortality were as follows: patients with D-dimer > 292. 5 

In this study, we investigated D-dimer, fibrinogen, albumin, DAR and FAR parameters as predictors for in-hospital mortality of COVID-19

patients. According to the results of this study, whereas DAR was found to be most valuable predictive parameters, FAR was found to be more valuable as a predictor than only fibrinogen. In addition, concurrent high DAR and FAR values as compared with concurrent low DAR and FAR values were found to be more predictively valuable than high values of DAR and FAR separately with respect to low DAR and FAR taken separately.

According to the results of the ROC analysis performed to pre- Hypercoagulation due to COVID-19 may occur for various reasons.

Hypoxia caused by COVID-19 triggering thrombosis may be one of these reasons. 15 In addition, patients with severe COVID-19 are more comorbid, more immobile and exposed to more invasive procedures, increasing the likelihood of thrombotic events. 10 The results of the ROC analysis performed to predict in-hospital mortality showed that fibrinogen levels reached a 0.637 AUC value. 6.058, 2.794). The reason of this is that while fibrinogen levels increase in the early stage of inflammation, they tend to peak and then decrease in the late stages when the disease is severe. 16 In the ROC analysis performed to predict in-hospital mortality, 

In this study, whereas FAR was found to be more valuable than using only fibrinogen levels to predict in-hospital COVID-19 mortality, DAR was found to be more valuable than any other parameter. In addition, concurrent high DAR and FAR were found to be more predictive of in-hospital COVID-19 mortality than either taken separately. 

The authors declare no conflict of interest.

Data will be made available on request to bona fide researchers only.

Data are available on request from the authors.

Kadir Küçükceran https://orcid.org/0000-0001-9758-0803

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