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Comparative Study
. 2021 Jan;100(1):37-43.
doi: 10.1007/s00277-020-04256-3. Epub 2020 Sep 12.

Prognostic significance of hemoglobin level and autoimmune hemolytic anemia in SARS-CoV-2 infection

Abdulrahman A Algassim  1   2 , Assem A Elghazaly  3 , Abdulrahman S Alnahdi  4 , Owais M Mohammed-Rahim  4 , Abdulaziz G Alanazi  4   5 , Nawaf A Aldhuwayhi  4   6 , Mashael M Alanazi  7 , Mohammed F Almutairi  7 , Ibrahim M Aldeailej  7 , Najeeb A Kamli  7 , Mahmoud D Aljurf  8
Affiliations
Comparative Study

Prognostic significance of hemoglobin level and autoimmune hemolytic anemia in SARS-CoV-2 infection

Abdulrahman A Algassim et al. Ann Hematol. 2021 Jan.

Abstract

Higher levels of D-dimer, LDH, and ferritin, all have been associated with the poor prognosis of COVID-19. In a disease where there are acute inflammation and compromised oxygenation, we investigated the impact of initial hemoglobin (Hgb) levels at Emergency Department (ED) triage on the severity and the clinical course of COVID-19. We conducted a cross-sectional study on 601 COVID-19 patients in a COVID-19 national referral center between 13 and 27 June 2020. All adult patients presented at our hospital that required admission or hotel isolation were included in this study. Patients admitted to the intensive care unit (ICU) had a lower initial Hgb than those admitted outside the ICU (12.84 g/dL vs. 13.31 g/dL, p = 0.026) and over the course of admission; the prevalence of anemia (Hgb < 12.5 g/dL) was 65% in patients admitted to ICU, whereas it was only 43% in non-ICU patients (odds ratio of 2.464, 95% CI 1.71-3.52). Anemic ICU patients had a higher mortality compared with non-anemic ICU patients (hazard ratio = 1.88, log-rank p = 0.0104). A direct agglutination test (DAT) for all anemic patients showed that 14.7% of ICU patients and 9% of non-ICU patients had autoimmune hemolytic anemia (AIHA). AIHA patients had significantly longer length of hospital stay compared with anemic patients without AIHA (17.1 days vs. 14.08 days, p = 0.034). Lower Hgb level at hospital presentation could be a potential surrogate for COVID-19 severity.

Keywords: AIHA; Anemia; COVID-19; Hemolysis; Prognosis.

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Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
CONSORT patients flow chart. Patients presented to our facility with respiratory symptoms between 13 and 27 June 2020 were tested for SARS-CoV-2 infection by PCR. Patients with stable vitals were sent for home isolation without further testing whereas those with unstable vitals were admitted. Patients without suitable home for isolation were provided with a hotel room and remained under our supervision. A total of 601 patients with confirmed SARS-CoV-2 infection were investigated for the presence of anemia (Hgb < 12.5 g/dL). Anemic patients were screened for autoimmune hemolytic anemia
Fig. 2
Fig. 2
Hematological parameters at ED triage. a Mean hemoglobin level for patients admitted to the hospital and patients isolated in hotels. b Mean hemoglobin level for patients admitted in general wards (GW) and patients admitted in intensive care units (ICU). c Median platelets count in GW patients and in ICU patients. d Median D-dimer level in GW patients and in ICU patients. e Median LDH level in GW patients and in ICU patients. f Median ferritin level in GW patients and in ICU patients. g Prevalence of anemia (Hgb < 12.5 g/dL) among GW patients and ICU patients. h Mean hemoglobin level at admission and hemoglobin nadir in GW and ICU patients. *p < 0.05, **p < 0.01, ***p < 0.001, and ****p < 0.0001. Error bars represent 95% confidence interval
Fig. 3
Fig. 3
Outcomes of anemic patients. a Median age of anemic and non-anemic patients. b Mean length of hospital stay (LoS) for patients admitted in GW, anemic indicates patients with Hgb < 12.5 g/dL. c Survival analysis for ICU admitted anemic (Hgb < 12.5 g/dL) and non-anemic patients. *p < 0.05 Error bars and shaded areas represent 95% confidence interval
Fig. 4
Fig. 4
Types of anemia observed in COVID-19 patients. a Number of anemic patients based on mean corpuscular volume (MCV): microcytic if < 80 fL, macrocytic if > 95 fL, and normocytic if in between. b Prevalence of direct agglutinin test (DAT)-positive patients among GW anemic patients (Hgb < 12.5 g/dL) and ICU anemic patients. c Number of patients with the indicated type of DAT reaction. d Mean hemoglobin level at triage for DAT-positive anemic patients compared with DAT-negative anemic patients. e Bilirubin level comparison between DAT+ and DAT− patients. f 100× blood film for anemic patients (Hgb = 11.1), the arrow indicates a spherocyte. g The median level of LDH in DAT-positive anemic patients and in DAT-negative anemic patients. *p < 0.05, **p < 0.01, and error bars represent 95% confidence interval
Fig. 5
Fig. 5
Outcomes of DAT-positive patients. a The age of DAT-positive anemic patients and of DAT-negative anemic patients, lines represent the median age. b Percentages of death among DAT-positive and DAT-negative patients. c Mean LoS of DAT-positive anemic patients and DAT-negative anemic patients. *p < 0.05 and error bars represent 95% confidence interval
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