ASSIGNMENT #1: Systematic Literature Review Proposal

Evaluation of Biomarkers for Mortality Risk in COVID-19

Jane J. Doe

Department of Clinical Laboratory Sciences

The University of Texas Medical Branch at Galveston

CLLS 4100: Introduction to Clinical Laboratory Science Research

Mr. Daniel F. M. González, MSMLS, MLS(ASCP)CMSCCMPBTCM

June 13, 2022

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Introduction

Since the onset of the SARS-CoV-2 pandemic in December 2019, there has been an

increased interest in prognostic test results of patients afflicted by COVID-19. Patients can have

unusual coagulation, chemistry, microbiology, and hematology laboratory results. In deadly

cases, the disease can quickly progress to acute respiratory distress syndrome, septic shock,

coagulation disorders, and multiple organ failure.1 Research regarding these abnormal laboratory

results aids clinicians in monitoring patients with COVID-19. Due to its recent emergence,

research is ongoing and widespread in theory.

This leads to the question, what biomarkers can be used as predictors of severity of

COVID-19 infection? The hypothesis is that inflammatory biomarkers D-Dimer, Interleukin-6

(IL-6), C-Reactive Protein (CRP), Ferritin, and LDH correlate with the severity of COVID-19

infection. The objective of this systematic literature review is to evaluate biomarkers such as D-

dimer, interleukin-6 (IL-6), C-reactive protein (CRP), ferritin, and lactate dehydrogenase (LDH)

as effective predictors of COVID-19. This is important when monitoring patient response to

treatment and prognosis of the disease.

Literature Review

In December 2019, a series of atypical respiratory disease occurred in Wuhan, China.

The outbreak of severe acute respiratory syndrome coronavirus 2, more frequently termed

SARS- CoV-2, is considered to have originally started via a zoonotic transmission associated

with the seafood market in Wuhan, China.2 This viral infection was titled coronavirus disease of

2019 (COVID-19). The viral infection spread very rapidly among the society. COVID-19 is

transmitted by respiratory droplets and aerosolization of the virus. Symptoms appear 1−14 days
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after infection, although most patients develop symptoms within 3−7 days.1 As more people

continued to be infected with this virus, on March 11, 2020, the World Health Organization

declared COVID-19 a pandemic.1

COVID-19 Illness

Those who have COVID-19 experience the symptoms of shortness of breath, fever,

cough, chills, muscle pain, sore throat, fatigue, congestion, loss of taste or smell, nausea,

diarrhea, or vomiting.1 The infectious disease can be diagnosed based on patient’s symptoms,

computed tomography (CT) imaging of the chest, nucleic acid-based methods, and

immunoassays. The hallmarks of these CT images include ground glass opacities, crazy-paving

pattern, consolidative opacities, septal thickening, and the reverse-halo sign.1 In nucleic acid-

based methods, reverse transcription-polymerase chain reaction (RT-PCR) is used to detect the

virus. Immunoassay testing may be used to detect serum antibodies on those who were

previously exposed when the virus is no longer detectable by RT-PCR.

COVID-19 Coagulopathy and Testing

A frequent and potentially deadly complication of COVID-19 is its tendency to induce a

hypercoagulable state. Patients with COVID-19 are at risk for thrombosis and embolisms. This is

a complication which needs to be monitored, and by the time infected individuals present for

medical care, the coagulopathy has often already begun.3 Testing to monitor the risk of this

complication is important. An ideal blood test for this task is D-dimer, a coagulation test. It

measures the quantity of a fibrin degradation product. Fibrin is created during the coagulation

process and degraded. Traditionally, low levels of D-dimer can be used to rule out the diagnosis

of thrombosis.4 In the case of COVID-19, patients who present with elevated D-dimer levels are

at a greater risk of serious illness and mortality. D-dimer levels are often elevated five-fold
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beyond acceptable levels.5 In addition to the complication of pulmonary embolism, systemic

microvascular thrombosis has been found in cases of COVID-19 death upon autopsy.3 In some

cases, the patient may be tested daily for D-dimer levels. The use of anticoagulants in the

treatment of COVID-19 is further aided by regular testing of coagulation parameters such as D-

dimer, PT, and PTT.3

Multi-Organ Involvement

In addition to the lungs, COVID-19 is involved in different organs such as the heart,

liver, and kidney, as well as the hematological and nervous systems. It can induce multi-organ

failure. Several studies have shown that COVID-19 is a certain pathogen for the heart and

induces myocarditis in the infected patients.6 Some patients can also experience acute liver

failure (ALF). ALF may result from the virus invasion, which directly infects liver cells.6

Patients with ALF can have raised serum biochemistries of the liver, such as irregular aspartate

aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin (TB) levels. There

are also those patients who can develop acute renal infection (ARI). The activation of

complement and cytokine storm, infiltration of inflammatory cells, and rarely thrombosis may

mainly contribute to the renal damage observed in COVID-19 patients.6

Cytokine Storm and Inflammatory Biomarkers

Deterioration into critical condition can occur relatively rapidly in COVID-19. A large

reason for this is an inflammatory process called the cytokine storm. Various biomarkers can be

used to track this process, as several inflammatory cytokines and chemokines are involved.

Tumor necrosis factor-α (TNF-α), interleukin-10 (IL-10), and IL-6 elevations have been cited

across multiple studies.7 One of the most frequently assessed is IL-6. Increased levels are

associated with severe cases of COVID-19 due to the cytokine storm and further complications.
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For instance, IL-6 can cause thrombocytosis and hyperfibrinogenemia, which increase the risk of

coagulopathy.5 IL-6 inhibitors are one form of treatment used for COVID-19.8 Another non-

specific inflammatory biomarker that is elevated in COVID-19 is CRP. Additionally, ferritin has

been found to be elevated because of the systemic inflammation.9

Assessing Laboratory Data for Care Management

One of the issues of most impact that must be managed with the advent of a new,

widespread disease is the management of patient care and placement. A great concern has been

the prevention of hospital overcrowding, as well as the provision of adequate care for COVID-19

patients.10 It is important to be able to recognize patients who need, or may need in the future,

critical care. Laboratory results provide insight into the condition of a patient. Unlike imaging or

invasive procedures, obtaining a laboratory blood test usually requires little time and has

virtually no risk for complications. Therefore, using laboratory testing that effectively assesses a

patient’s risk of mortality can be extremely useful both for the individual patient and for the

facility providing care.

Methods

Through the research study, researchers intend to evaluate the use of biomarkers to

determine the risk of mortality in patients diagnosed with COVID-19. This will be accomplished

by the following objectives:

a) Establishing routine biomarkers that are frequently abnormal in patients hospitalized

with COVID-19.

b) Determining which biomarkers present as abnormal upon admission are associated

with mortality, and

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c) Determining which biomarker most precisely correlates with mortality throughout

previous studies.

Methodology

The methodology will consist in a systematic review of cohort studies conducted

regarding the comparison of laboratory parameters in SARS-CoV-2 infection. Online databases

Google Scholar and PubMed will be used to review literature and identify relevant studies

published between December 2019 and June 6, 2021. The search will include variants of

keywords such as Coronavirus, COVID-19, SARS-CoV-2, OR Coronavirus-19; mortality, death,

survival, prognosis, OR organ failure/damage; laboratory parameter, biomarker, lab result,

laboratory test, OR laboratory medicine; and U.S. OR United States. Microsoft Excel will be

used to organize the article records. Duplicate articles in search results, as well as studies that

may contain data from the same patient population, (i.e., the same location of hospital admission

and the same time), will be eliminated.

Eligibility Criteria

Research studies conducted on hospitalized patients only will be selected, as laboratory

data and mortality rates are more accurately obtained during hospitalization. Data involving

pediatric patients will be excluded, restricting the population to patients who were >18 years old

at the time of the study. Studies that don’t include confirmation of SARS-CoV-2 infection by

molecular laboratory methos will be excluded. As systematic reviews have been conducted

heavily regarding the original data that emerged from Wuhan, China, this systematic review will

include studies conducted in the United States, including New York, District of Columbia, and

Texas, were included (Fig. 1).

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Figure 1: Flow chart of study inclusion/exclusion criteria

Data Collection

Two contributors will search the data bases independently using the inclusion/exclusion

criteria. Study records will be reviewed, and duplicates will be eliminated. Further review will be

used to eliminate studies unrelated to COVID19 severity in humans, systematic review studies,

research with non-human subjects, and studies with incomplete data. The remaining publications

will be screened using the inclusion/exclusion criteria to exclude studies outside the U.S., studies

conducted in non-hospital facilities, studies including pediatric patients, studies that fail to

confirm COVID19 infection by molecular methods, and studies missing mortality data. The

accepted studies will be used for semiquantitative systematic review (fig. 2).
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Figure 2: Literature Review Search

Data Analysis

Observational cohort studies conducted on hospitalized patients will be deconstructed to

assess mortality risk. Median and Interquartile range values from the study will be graphed for

IL-6, D-dimer, LDH, CRP, and ferritin for survivor and non-survivor categories to demonstrate

differences between patients who survived and expired. Odds ratios (OR) and hazard ratios (HR)

ratios established by these studies will be compared in tables. Using the data and discussions in

the studies, common tests that demonstrate elevations consistent with mortality will be

compared. Tests that do not demonstrate statistical significance, exhibited by increased p-values,

and possible causes of inconsistency will be discussed.

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References

1. Pokhrel P, Hu C, Mao H. Detecting the Coronavirus (COVID-19). American Chemical

Society Sensors. July 2020: 2283-2293. doi:10.20944/preprints202004.0201.v2

2. Yuki K, Fujiogi M, Koutsogiannaki S. COVID-19 pathophysiology: A review. Clinical

Immunology. 2020; 215: 1-5. doi:10.1016/j.clim.2020.108427

3. Li Y, Zhao K, Wei H, et al. Dynamic relationship between D-dimer and COVID-19 severity.

Br J Haematol. 2020;190(1):e24-e27. doi: 10.1111/bjh.16811

4. Yao Y, Cao J, Wang Q, et al. D-dimer as a biomarker for disease severity and mortality in

COVID-19 patients: a case control study. J Intensive Care. 2020;8(49):1-11. doi:

10.1186/s40560-020-00466-z.

5. Iba T, Levy JH, Connors JM, et al. The unique characteristics of COVID-19 coagulopathy.

Crit Care. 2020;24(360):1-8. doi: 10.1186/s13054-020-03077-0

6. Mokhtari T, Hassani F, Ghaffari N, Ebrahimi B, Yarahmadi A, Hassanzadeh G. COVID- 19

and multiorgan failure: A narrative review on potential mechanisms. Journal of Molecular

Histology. 2020; 51(6): 613-628. doi:10.1007/s10735-020-09915-3

7. Han H, Ma Q, Li C, et al. Profiling serum cytokines in COVID-19 patients reveals IL-6 and

IL-10 are disease severity predictors. Emerg Microbes Infect. 2020;9(1):1123-1130. doi:

10.1080/22221751.2020.1770129.

8. Tang Y, Liu J, Zhang D, et al. Cytokine storm in COVID-19: The current evidence and

treatment strategies. Front Immunol. 2020;11(1708):1-13. doi: 10.3389/fimmu.2020.01708

9. Caricchio R, Gallucci M, Dass C, et al. Preliminary predictive criteria for COVID-19

cytokine storm. Ann Rheum Dis. 2020;80(1):88-95. doi: 10.1136/annrheumdis-2020- 218323