Correlation analysis of coagulation dysfunction and liver damage in patients with novel coronavirus pneumonia: a single-center, retrospective, observational study ORIGINAL ARTICLE Correlation analysis of coagulation dysfunction and liver damage in patients with novel coronavirus pneumonia: a single-center, retrospective, observational study Sai Chena , Hanting Liua, Tie Lib, Rong Huanga, Rong Guia and Junhua Zhanga aDepartment of Blood Transfusion, the Third Xiangya Hospital of Central South University, Changsha, China; bDepartment of Clinical Laboratory, the First People’s Hospital of Yueyang, Yueyang, China ABSTRACT Background: The novel coronavirus disease 2019 (COVID-19) is currently breaking out worldwide. COVID-19 patients may have different degrees of coagulopathy, but the mechanism is not yet clear. We aimed to analyse the relationship between coagulation dysfunction and liver damage in patients with COVID-19. Methods: A retrospective analysis of 74 patients with COVID-19 admitted to the First People’s Hospital of Yueyang from 1 January to 30 March 2020 was carried out. According to the coagulation function, 27 cases entered the coagulopathy group and 47 cases entered the control group. A case control study was conducted to analyse the correlation between the occurrence of coagulation dysfunction and liver damage in COVID-19 patients. Results: Alanine aminotransferase (ALT) and aspartate aminotransferase (AST), markers of liver damage, were positively correlated with coagulopathy (p ¼ 0.039, OR 2.960, 95% CI 1.055–8.304; and p ¼ 0.028, OR 3.352, 95% CI 1.137–9.187). Alkaline phosphatase (ALP), c-glutamyl transpeptidase (c-GT), and total bilirubin (TBIL) were not statistically correlated with coagulopathy. According to the diagnosis and treatment plan, the included cases were classified into mild, moderate, severe, and critical. The results showed that the occurrence of coagulation dysfunction had no statistical correlation with the severity of COVID-19. Conclusion: Coagulation dysfunction in patients with COVID-19 is closely related to liver damage. A longer course of the disease may cause a vicious circle of coagulopathy and liver damage. Clinicians need to closely monitor coagulation and liver function tests and to give prophylactic or supportive therapy when needed. ARTICLE HISTORY Received 6 July 2020 Revised 4 September 2020 Accepted 8 September 2020 KEYWORDS Blood coagulation dysfunction; COVID-19; liver damage; pneumonia; SARS- CoV-2 Introduction The novel coronavirus disease (COVID-19) is currently break- ing out worldwide, threatening human health and quality of life seriously. Its main clinical manifestations are fever, dry cough, and fatigue. In some severe cases, acute respiratory distress, multiple organ failure, and even death may occur (1). COVID-19 is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), belonging to the group of b-coronaviruses. It has the characteristics of a long incuba- tion period (1–14 days, average 6.4 days), a long onset period, and strong infectivity. The S protein on the surface of SARS- CoV-2 binds to angiotensin-converting enzyme II (ACE2), which leads SARS-CoV-2 to enter the host cell (2,3). Some researchers (4–6) have reported that patients with COVID-19 have varying degrees of coagulopathy and liver damage as the disease progresses. The liver is closely related to the syn- thesis of coagulation factors, which means that when the liver is damaged, it will directly affect the coagulation func- tion. The relationship between coagulation dysfunction induced by COVID-19 and liver damage is unclear. This study retrospectively analysed the clinical data of 74 confirmed cases of COVID-19 to explore the correlation between COVID-19 patients’ coagulopathy and liver damage. Methods A total of 74 patients with COVID-19 admitted to the First People’s Hospital of Yueyang, Hunan Province from 1 January to 30 March 2020 were enrolled. The hospital is the designated hospital for the treatment of COVID-19 patients. The Ethics Committee of the Third Xiangya Hospital of Central South University approved this study. Inclusion crite- ria were in line with the ‘Novel Coronavirus Infection Pneumonia Diagnosis and Treatment Program (Trial Version 7)’ (7) diagnosis requirements: (1) Have fever and/or respira- tory symptoms; (2) Have lung-imaging features of new CONTACT Rong Gui aguirong@163.com; Junhua Zhang xy3zhangjunhua@csu.edu.cn Department of Blood Transfusion, the Third Xiangya Hospital of Central South University, Changsha, China � 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. UPSALA JOURNAL OF MEDICAL SCIENCES 2020, VOL. 125, NO. 4, 293–296 https://doi.org/10.1080/03009734.2020.1822960 http://crossmark.crossref.org/dialog/?doi=10.1080/03009734.2020.1822960&domain=pdf&date_stamp=2020-10-19 http://orcid.org/0000-0003-4677-0169 http://orcid.org/0000-0001-7790-0291 http://orcid.org/0000-0001-7028-0632 http://creativecommons.org/licenses/by-nc/4.0/ https://doi.org/10.1080/03009734.2020.1822960 http://www.tandfonline.com coronavirus pneumonia; (3) Real-time fluorescent RT-PCR detection of SARS-CoV-2 nucleic acid is positive. On this basis, according to coagulation function, patients with coagulation dysfunction were included in the coagulation dysfunction group, and those without coagulation dysfunc- tion were included in the control group. Exclusion criteria: (1) history of coagulation disease or taking coagulation- related drugs; (2) liver and/or kidney dysfunction; (3) hepato- biliary diseases; (4) incomplete clinical data. We collected clinical data from electronic medical records of all confirmed patients, including past history, gender, age, length of hospital stay, clinical symptoms and laboratory findings, mainly liver and coagulation function test results. Patients’ first test results were selected for inclusion in the analysis. Diagnostic criteria for coagulopathy A fully automatic blood coagulation analyser (CS5100, Sysmex Corp., Japan) was used to detect the blood coagula- tion function. Prior to testing, all projects were subject to strict quality control testing. When one or more of the indi- cators listed in Table 1 were abnormal, it was defined as coagulation dysfunction. Diagnostic criteria for liver damage A fully automatic biochemical analyser (BS800, Mindray Corp., China) was used to detect liver function. Prior to test- ing, all projects were subject to strict quality control testing. When one or more of the following indicators exceeded the upper limit of normal value, it was defined as liver damage: serum alanine aminotransferase (ALT), serum aspartate ami- notransferase (AST), total bilirubin (TBIL), c-glutamyl trans- peptidase (c-GT), and alkaline phosphatase (ALP). The reference values were: ALT, 7–40 U/L; AST, 13–35 U/L; TBIL, 1.7–25 lmol/L; c-GT, 7–45 U/L; and ALP, 50–135 U/L. Statistical analysis This study was conducted during the outbreak of COVID-19. Therefore, we did not estimate the sample size by formal hypotheses, and we have included the maximum number of patients who met the inclusion criteria. Qualitative data were expressed in number of cases, per- centage, or composition ratio. We used chi-square test to compare the qualitative data between the two groups. The quantitative data were tested for normality and homogeneity of variance. Normally distributed quantitative data were expressed as mean ± standard, and we used Student’s t test for two independent samples to compare the qualitative data of the two groups. Tests were two-sided with signifi- cance set at a < 0.05. SPSS 23.0 for Windows (SPSS Inc.) was applied for all analysis. Results Following the inclusion and exclusion criteria strictly, 74 patients (36 female and 38 male) with COVID-19 were included; 27 cases entered the coagulopathy group, and 47 cases entered the control group. General information between the two groups was compared (Table 2). There was no statistically significant difference. According to the ‘New Coronavirus Infected Pneumonia Diagnosis and Treatment Program (Trial Version 7)’ (7), patients with different severity of pneumonia were classified into mild, moderate, severe, and critical. In the coagulation group, 4 cases were mild (14.8%), 12 were moderate (44.4%), and 11 were severe/critical (40.8%). In the control group, 14 cases (29.8%) were mild, 19 cases (40.4%) were moderate, and 14 cases (29.8%) were severe/critical. There was no sig- nificant correlation between coagulation dysfunction and COVID-19 severity (chi-square ¼ 3.012, p > 0.05). This study analysed the relationship between changes in liver damage markers and COVID-19 coagulation dysfunction. ALT and AST are markers that can reflect liver damage. COVID-19 coagulation dysfunction was associated with ALT and AST (Pearson chi-square test, both p < 0.05) (Table 3). However, ALP, c-GT, and TBIL, reflecting the function of the bile duct system, showed no significant correlation with coa- gulopathy in the COVID-19 patients (Pearson chi-square test, all p > 0.05). The above single factor analysis showed a statistically sig- nificant difference of ALT and AST levels between the coagu- lation dysfunction group and the control group. Therefore, a logistic regression analysis model of the influencing factors of coagulation dysfunction was constructed. Taking whether the patient has coagulation dysfunction as the dependent variable (normal ¼ 0, abnormal ¼ 1), and AST and ALT as the independent variable (normal ¼ 0, abnormal ¼ 1), a bin- ary logistic regression analysis was performed. It was found that AST and ALT levels were the main risk factors affecting COVID-19 patients’ coagulopathy (p ¼ 0.039, OR 2.960, 95% CI 1.055–8.304; and p ¼ 0.028, OR 3.352, 95% CI 1.137–9.187). Table 1. Diagnostic criteria for coagulopathy. Indicator Reference values Diagnostic criteria PT 9.8–14.8 s Extension > 3 s TT 14–21 s Extension > 3 s INR 0.86–1.27 >1.3 APTT 23.3–32.5 s Extension > 10 s Fibrinogen content 2–4 g/L <2 g/L D-dimer <500 lg/L >500 lg / L Platelet count 125–350 � 109/L <125 � 109/L APTT: activated partial thromboplastin time; INR: international normalised ratio; PT: prothrombin time; TT: thrombin time. Table 2. General information on the two evenly matched groups. Parameters Coagulopathy group (n ¼ 27) Control group (n ¼ 47) p Age (y) 52.5 ± 12.1 47.8 ± 17.1 >0.05 Gender Male 14 (51.9%) 24 (51.1%) >0.05 Female 13 (48.1%) 23 (48.9%) Basic diseases Hypertension 5 (18.5%) 4 (8.5%) >0.05 Diabetes 1 (3.7%) 1 (2.1%) >0.05 COPD 1 (3.7%) 2 (4.3%) >0.05 Other 7 (25.9%) 10 (21.3%) >0.05 COPD: chronic obstructive pulmonary disease. 294 S. CHEN ET AL. Discussion At present, it has been observed that COVID-19 can lead to different degrees of coagulation dysfunction. Endothelial cells play a key role in the regulation of blood coagulation and fibrinolysis. The immune response in vivo of patients with COVID-19 implies the release of a variety of inflammatory mediators such as interleukin 6 (IL-6). There is damage of vascular endothelial cells, initiating endogenous coagulation pathways. The damaged endothelial cells increase the release of von Willebrand factor (vWF) and tissue factor (TF), and then subendothelial tissues become exposed. In the presence of calcium ions, FVII is activated to start the exogenous coagulation system and accelerates the production of throm- bin, resulting in activation of the coagulation or fibrinolysis system (8,9). In addition, systemic inflammation may activate Nox2, and reactive oxygen species (ROS) derived from Nox2 will adversely affect blood coagulation. Several studies have shown that, in addition to coagula- tion dysfunction, COVID-19 patients will have different degrees of liver damage as well. The pathogenesis of liver damage complicated by COVID-19 is not yet clear; however, current mainstream views on the mechanism of liver injury include: (1) Angiotensin-converting enzyme 2 (ACE2) medi- ates SARS-CoV-2 invasion of target cells. Bile duct epithelial cells highly express ACE2, and its expression level is similar to alveolar type II cells, which is the main target cell type of SARS-CoV-2 in the lung. But according to current clinical data, the levels of bile duct injury markers such as ALP and c-GT in COVID-19 patients have not increased, so this mech- anism needs further studies (10–12). (2) After infection with SARS-CoV-2, the immune cells are activated, and excessive accumulation of immune cells occurs. The excessively acti- vated inflammatory cells infiltrating the tissue release many proinflammatory cytokines, oxygen free radicals, etc., which can cause damage. The cytokine storm triggered may be one of the mechanisms of liver injury (13,14). (3) Hypoxaemia and respiratory distress syndrome may occur in severe and critical pneumonia. When the tissue is hypoxic, an oxidative stress response may be triggered, resulting in liver function damage. At the same time, it promotes reactive oxygen spe- cies increasing continuously, which further initiates the release of various proinflammatory factors to induce liver damage. (4) Patients with COVID-19, especially those with severe and critical disease, usually receive different kinds of pharmacological therapy. A drug in itself or the interaction between different drugs may cause liver damage (15–18). Recent research has shown that the hypercoagulable state of COVID-19 patients alters intrahepatic vascular structures and causes a variable degree of luminal thrombosis. This may add to other mechanisms of liver damage in COVID-19 patients (19). The synthesis of coagulation factors is closely related to the liver. Liver, as a production site for multiple clotting fac- tors, might play a huge role in COVID-19 coagulopathy. Liver damage leads to reduced coagulation factors, plasma plas- minogen activator inhibitors, and tissue-type plasminogen activator secretion, causing bleeding tendency. Fibrinogen (Fbg), one of the important proteins of the blood coagula- tion system, is synthesised by liver parenchymal cells. It is the final substrate for the successive activation of coagula- tion factors during coagulation. Because of its functions of hemostasis and mediating platelet aggregation, liver damage will cause a decrease in Fbg synthesis, which will affect blood coagulation. It is worth mentioning that some studies have pointed out that the incidence of liver damage is related to the severity of COVID-19, and that patients with severe disease are more likely to have liver damage. In this study, however, it was found that there was no correlation between coagul- opathy and the severity of COVID-19, which is inconsistent with a liver–COVID-19 relationship. Rather, it may suggest that the occurrence of coagulation dysfunction is not related to liver abnormalities. Moreover, we found that ALT and AST were positively correlated with COVID-19 coagulopathy, sug- gesting that after COVID-19 infection liver damage might be detrimental. It might also be envisaged that the coagulation dysfunction in COVID-19 patients may cause liver damage due to throm- bosis. A longer course of COVID-19 may cause a vicious circle of coagulation dysfunction and liver damage, which does not promote patient survival. Although there is yet no highly effi- cient specific therapy for SARS-CoV-2, it is important to prevent thrombosis and to identify coagulation and liver dysfunction by laboratory monitoring to enable supportive therapy. In this study we found a correlation between coagulop- athy and elevated liver transferases in COVID-19 patients. The coagulopathy was, in contrast to other studies, not related to the severity of the disease. The mechanism behind the association between coagulopathy and liver damage is still unclear and needs further investigation. Acknowledgements We thank all patients and their families involved in the study. Disclosure statement The authors declare that they have no conflicts of interest. Table 3. The correlation between biochemical test index with coagulopathy in COVID-19. Group Abnormala ALT Abnormala AST Abnormala TBIL Abnormala ALP Abnormala c-GT Coagulopathy group 12 11 7 3 6 Control group 10 8 5 2 14 Chi-square 4.406 5.056 1.932 0.423 0.498 p 0.036 0.025 0.165 0.516 0.481 aAbnormal means that the indicator exceeds the upper limit of normal value. UPSALA JOURNAL OF MEDICAL SCIENCES 295 Notes on contributors Sai Chen, MM, Department of Blood Transfusion, the Third Xiangya Hospital of Central South University, Changsha, China. Hanting Liu, MM, Department of Blood Transfusion, the Third Xiangya Hospital of Central South University, Changsha, China. Tie Li, MB, Department of Clinical Laboratory, the First People’s Hospital of Yueyang, Yueyang, China. Rong Huang, MD, Department of Blood Transfusion, the Third Xiangya Hospital of Central South University, Changsha, China. Rong Gui, MD, is a professor of Clinical Transfusion Immunology, Department of Blood Transfusion, the Third Xiangya Hospital of Central South University, Changsha, China Junhua Zhang, MD, Department of Blood Transfusion, the Third Xiangya Hospital of Central South University, Changsha, China. ORCID Sai Chen http://orcid.org/0000-0003-4677-0169 Rong Gui http://orcid.org/0000-0001-7790-0291 Junhua Zhang http://orcid.org/0000-0001-7028-0632 References 1. 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CHEN ET AL. https://doi.org/10.1016/j.ijantimicag.2020.105924 https://doi.org/10.1016/j.ijantimicag.2020.105924 https://doi.org/10.1128/JVI.00127-20 https://doi.org/10.1016/bs.aivir.2019.08.002 https://doi.org/10.1016/S0140-6736(20)30183-5 https://doi.org/10.1016/S2213-2600(20)30079-5 https://doi.org/10.1016/S2213-2600(20)30079-5 https://doi.org/10.1111/jth.14768 https://doi.org/10.1111/jth.14768 http://www.nhc.gov.cn/yzygj/s7652m/202003/a31191442e29474b98bfed5579d5af95.shtml http://www.nhc.gov.cn/yzygj/s7652m/202003/a31191442e29474b98bfed5579d5af95.shtml https://doi.org/10.1016/j.blre.2014.09.003 https://doi.org/10.1055/s-0035-1556586 https://doi.org/10.1101/2020.02.03.931766 https://doi.org/10.1016/j.cell.2020.03.045 https://doi.org/10.1016/j.cell.2020.02.058 https://doi.org/10.1016/j.ebiom.2020.102763 https://doi.org/10.1001/jama.2020.1585 https://doi.org/10.1016/S2213-2600(20)30076-X https://doi.org/10.5582/bst.2020.01020 https://doi.org/10.5582/bst.2020.01020 https://doi.org/10.1016/j.toxlet.2020.01.026 https://doi.org/10.1007/s00204-020-02734-1 https://doi.org/10.1007/s00204-020-02734-1 https://doi.org/10.1111/liv.14601 Abstract Introduction Methods Diagnostic criteria for coagulopathy Diagnostic criteria for liver damage Statistical analysis Results Discussion Acknowledgements Disclosure statement Orcid References