DE RITIS RATIO OF COVID-19 PATIENTS ADMITTED DURING FIRST, SECOND AND THIRD WAVE

DE RITIS RATIO OF COVID-19 PATIENTS ADMITTED DURING FIRST, SECOND AND THIRD WAVE

Saurabh Kumar Deo, Nitin Tangri, Neeru Bhaskar and Vijay Chaudhary *

Department of Biochemistry, M. M. Medical College and Hospital, Laddo, Sultanpur Road, Kumarhatti, Solan, Himachal Pradesh, India.

ABSTRACT: Background: To date, the 2019 novel coronavirus pneumonia (COVID-19) is the greatest public medical issue in the world. World Health Organization (WHO) declared this outbreak a “public health emergency of international concern” on January 31, 2020. Therefore, it bodes well to look for a potential biomarker that could quickly and effectively distinguish serious cases early. Of the total confirmed Covid-19 patients, the severe cases often suffer from underlying diseases such as cardiovascular disease and diabetes that can accelerate the movement of 2019 novel coronavirus (SARS-CoV-2) infection. Moreover, acute respiratory distress syndrome could lead to death in some severe Covid-19 patients, and various disorders often accompany this. Biochemical findings showed representative features of acute respiratory distress syndrome and association of multiple organs. Aim: To estimate routine biochemical parameters of patients admitted to the Covid-19 ward. Method: Clinical samples from cases of Covid-19 admitted to Adesh Medical College and Hospital, Mohri, Shahbad (M), Haryana, India, during 1^st, 2^nd, and 3^rd waves were collected and analyzed. Result: In this study, we investigated routine biochemical investigations (RBS, LFT, RFT & Serum Electrolyte) of Covid-19 patients and calculated De Ritis ratio. It was found that biochemical parameters and De Ritis ratio were worse affected than the first and second waves. Conclusion: De Ritis ratio may be a good marker for liver abnormalities and prognosis and a hospital stay of the Covid-19 patients.

Keywords: Covid-19, SARS-CoV-2, De Ritis ratio, AST, ALT, Acute respiratory distress syndrome

INTRODUCTION: At present, the world is overwhelmed by a pandemic disease caused by a novel coronavirus which emerged in Wuhan, Hubei, China at the end of December 2019, named as severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) ¹.

The 2019 novel coronavirus pneumonia (Covid-19) is the greatest public health issue on the planet. The disease is sustained by a coronavirus named Covid-19 by the World Health Organization due to more than 79% homology with SARS-CoV, SARS-CoV-2 was responsible for coronavirus disease 2019 (Covid-19) ².

The number of cases is exponential; however, related data concerning the clinical highlights and hematological changes of infected patients is restricted ^3-6. The serious cases regularly experience the ill effects of hidden sicknesses like cardiovascular illness and diabetes that can quicken the movement of 2019 novel coronavirus (SARS-CoV-2) contamination ^{7, 8}. Furthermore, acute respiratory distress syndrome could prompt demise in some extreme Covid-19 patients, and this is often accompanied by heart failure, liver failure, and kidney failure ⁹. In this manner, an early, basic, and effective diagnosis of severe Covid-19 pneumonia and prognosis would greatly decrease mortality and shorten the hospitalization period. In this study, we investigated routine biochemical parameters (RBS, LFT, and RFT) of Covid-19 patients during the first, second and third waves in India, calculated De Ritisratio and compared the data for further application in diagnosis and prognosis of covid related complications.

Aim: To estimate routine biochemical parameters of patients admitted to Covid-19 ward of Adesh Medical College and Hospital, Mohri, Shahbad (M).

MATERIALS AND METHODS: The study was carried out in the Department of Biochemistry in collaboration with Respiratory Medicine of Adesh Medical College and Hospital, Mohri, Shahbad (M). Confirmed cases[by real-time (RT)-PCR] of Covid-19, admitted to Covid-19 ward of the hospital [special hospital for isolating and treating SARS-CoV-2 infection]during the first, second, and the third wave, were taken.

Inclusion Criteria:

1. Covid-19 Positive cases.
2. Age matched

Exclusion Criteria:

1. Negative cases

Total 60, age-matched, Covid-19 positive cases (20 cases from each pandemic wave) were taken for the study. The cases were selected randomly independent of sex. After approval from the Institutional Ethical Committee (IEC) of Adesh Medical College and Hospital, Mohri, Shahbad (M), Haryana, the study was undertaken.

Data Abstraction: The routine investigations of RBS (Radom Blood Sugar), LFT, RFT, and Serum Electrolytes were identified, enlisted, and analyzed in blood samples using Chem-7^TM Semi-Automated Clinical Chemistry Analyzer (Transasia Bio-medicals Limited, Mumbai, India). The data obtained was further processed to find biochemical relationships among the parameters.

RESULTS AND DISCUSSION: Total 60 Covid-19 positive cases were taken. 20 patients during each wave were selected independent of sex. The patients selected were of the same age group during 3 waves. The mean age was found to be 33.18±17.19 years (range 09 - 68 years). Various studies have demonstrated that males are more likely affected by the SARS-CoV-2 infection across all age groups ^{10, 11, 12}.

On studying liver functions test (LFT) among Covid-19 patients, it was found that mean serum bilirubin (Total) was within the normal range with a slight increase during the second wave Table 1. Mean total serum protein (TSP) was within the normal range. The mean serum albumin level during the second wave was reported to be below the normal range. Serum AST and ALT levels were reported to be highest during the second wave. The most rearranged LFT values are observed during the second wave compared to the two other waves. But during the first and second waves, the LFT parameters like bilirubin (T), AST, and ALT are also on the upper borderline and serum albumin on the lower borderline. Table 1 indicates that the viral infection might have affected the liver.

TABLE 1: DE RITIS RATIO AND OTHER PARAMETERS UNDER LFT

Zhao et al (2020), conducted a comparative study on the clinical features of Covid-19 pneumonia to other pneumonia” and reported that liver function damage is more frequent in Covid-19 ¹³. Cai et al. (2020) also found that 76.3% out of 417 Covid-19 patients had abnormal liver test results having AST, ALT and total bilirubin levels raised to more than 3× the upper limit.

The abnormal liver tests turned out to be more pronounced during hospitalization within about fourteen days. They also suggested that patients with abnormal liver tests were at higher risk of progressing to severe illness ¹⁴. In their study, Fan et al. (2020) also showed that more than 33% of patients admitted to the hospital with SARS-CoV-2 disease have abnormal liver function, which is related to longer hospital stay ¹⁵. Because SARS-CoV-2 can specifically target the liver, specifically cholangiocytes, through ACE2 and along these lines, the hepatobiliary injury seems conceivable ¹⁶.

Increased concentrations of serum AST and ALT are reported in Covid-19 patients. However, their capacity to predict mortality, particularly the AST/ALT ratio, commonly referred to as the De Ritis ratio, is unknown. De Rities ratio was highest during the second wave compared to two other waves Table 1. This may be evident with the deadly effect of the virus during the second wave. The low De Ritis ratio during the first and third waves may indicate the low effect during the waves. The raised De Ritis ratio has been linked to a longer hospital stay and even mortality of the patients. Various studies have been carried out to seek the relation of De Ritis ratio with factors of the Covid-19 patients across the gender and age groups. Drácz et al. (2022) found raised De Ritis ratio among 322 Covid-19 patients. They also found that patients with De Ritis ratio ≥ 1.218 were significantly associated with mortality, severity, and higher AST. Patients with De Ritis ratio ≥1.218 are significantly susceptible to liver damage and cytokine released storm¹⁷. Yazar et al. (2020) found De Ritis ratio of Covid-19 patients was higher than in healthy individuals and this ratio was significantly higher in females than in male patients. They also suggested that De Ritis ratio could be considered as a parameter possible to be a prognostic biomarker for females with Covid-19 ¹⁸.

Paliogiannis et al. (2020), in their preliminary report, stated that a higher De Ritis value of 1.50±0.66 among Covid-19 Pneumonia against 1.11±0.46 among Non-Covid Pneumonia. They also found that De Ritis ratio was higher among non-survivor due to Covid-19 than those survived (2.00 ± 0.79 against 1.27 ± 0.44respectively) ¹⁹.

Zinellu et al. (2020) from Italy also reported that the De Ritis ratio was significantly lower in survivors than non-survivors (1.25 against 1.67 respectively) ²⁰. A meta-analysis done by Pranata et al. (2021) associated raised De Ritis ratio with poor prognosis among the patients with Covid-19 disease ²¹. No data from India have been reported to support or counter our findings.

TABLE 2: OTHER BIOCHEMICAL PARAMETERS

Glycemic control is significant in Covid-19 patients. Diabetes is related to the increased frequency and seriousness of Covid-19. There is experimental evidence of the impact of diabetes on viral passage into cells and fiery reaction to the infection ²². On studying blood glucose levels among Covid-19 patients during 3 waves, the mean blood glucose concentration was observed at 96.8 mg/dl, 298 mg/dl and 147 mg/dl Table 2 during the first, second and third waves, respectively.

Emerging information proposes that people with diabetes are at increased risk for complexities, including passing. Guo et al. (2020) conducted a study on “Diabetes is a risk factor for the progression and prognosis of Covid‐19” His data support the idea that diabetes ought to be considered a risk factor for a fast movement and terrible prognosis of Covid‐19 ²³. A study by Zhang et al. (2020), in 140 patients with Covid-19 in Wuhan, China, suggested that diabetes was not a risk factor for serious infection course ²⁴. Diabetes and different comorbidities are noteworthy indicators of morbidity and mortality in patients with Covid-19and the probable cause may be:

Chronic inflammation, increased coagulation activity, immune response impairment, and potential direct pancreatic damage by SARS-CoV-2 might be among the underlying mechanisms of the association between diabetes and Covid-19 ²⁵. It was also found that the mean serum urea, creatinine and uric acid levels were not alarming Table 2 during the three waves, suggesting that SARS-CoV-2 infection might not affect the kidney, which is consistent with part of the latest findings. ButLi et al. (2019) reported that SARS-CoV-2 disease could harm the kidney in severe patients ²⁶. Wang et al. (2020), showed acute kidney injury was uncommon in Covid-19 with a gentle increment of blood urea nitrogen or creatinine ²⁷. Ronco et al. (2020) also suggested the low prevalence of acute kidney infection among patients with Covid-19 ²⁸. A similar result in Table 2 has been observed during the second wave in our study. The mean serum electrolytes level was also found to be within the normal range, and a slight increase was seen during the second wave Table 2.

A study conducted on 334 Covid-19 patients by Shi et al. (2020), found only 5.1% of the patients have electrolyte disturbances ²⁹. Shi et al. (2020) also conducted a study on 161 patients with severe and critical Covid-19 and reported that 29.81% of the patients had electrolyte disorders ³⁰. The renal function may be determined by the severity of the disease, age of the patients, presence of comorbidities, and use of drugs. Therefore, more studies should be carried out. Two limitations are inherent in our study. To start with, the study zone is moderately restricted. Also, the moderately modest number of members in the study may not completely mirror the general circumstance. Along these lines, further studies are important to execute many data surveys in multiple regions by multicenter participation.

CONCLUSION: Covid-19 is the greatest public health issue on the planet. The number of cases is exponential; however, related data concerning the clinical highlights and hematological changes of infected patients is restricted. Therefore, a small effort was made to gather biochemical data to help the treatment. The study found that De Ritis ratio might play an essential role in managing Covid-19 cases because the raised De Ritis ratio and death rate during the second wave is evidence of the virus's effect.

ACKNOWLEDGEMENTS: The authors wish to thank all the enrolled patients in this study.

Funding: None

Ethical Statement: This study was approved by the Ethics Commissions of the Adesh Medical College & Hospital, Mohri, Shahbad (M), Kurukshetra (AMCH/BIO/202/07/03).

CONFLICTS OF INTEREST: The authors declare that they have no competing interests, and all authors have confirmed the accuracy of this statement.

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    How to cite this article:

    Deo SK, Tangri N, Bhaskar D and Chaudhary V: De ritis ratio of Covid-19 patients admitted during first, second and third wave. Int J Pharm Sci & Res 2022; 13(6): 2534-38. doi: 10.13040/IJPSR.0975-8232.13(6).2534-38.

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