|Year : 2017 | Volume
| Issue : 2 | Page : 92-95
A comparative study of D-dimer levels in adult patients with sickle cell anemia at Ahmadu Bello University Teaching Hospital Zaria, Nigeria
Ibrahim U Kusfa1, Aisha I Mamman1, Aliyu A Babadoko1, Garba Yahaya1, Ismaila N Ibrahim1, Sani Awwalu1, Ali D Waziri1, Jibril M El-Bashir2
1 Department of Haematology and Blood Transfusion, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Chemical Pathology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Web Publication||5-Oct-2017|
Ibrahim U Kusfa
Department of Haematology and Blood Transfusion, Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
Introduction: Sickle cell anemia (SCA) is a chronic disease presenting with acute and painful exacerbations with multi-organ affectation. An alteration in the components of hemostasis such as the fibrinolytic system is observed among patients with SCA. Routine care of patients with SCA rarely involves the investigation of this component, and little attention is paid to the role of this system in the evaluation of patients with vaso-occlusive crisis. Objectives: To determine the D-dimer levels and some hematological parameters of adult patients with sickle cell anemia in steady state attending the hematology clinic of Ahmadu Bello University Teaching Hospital (ABUTH) Zaria, Nigeria. Materials and Methods: We conducted a case-control study involving 50 patients with SCA (HbSS) in steady state and 25 healthy volunteers with normal hemoglobin (HbAA) as controls. Steady state refers to absence of acute painful crisis or any changes due to therapy for at least four consecutive weeks after a previous painful crisis. Hemoglobin concentration (Hb), white blood cell count (WBC), and platelet count were determined by hematology analyzer. D-dimer levels were determined by ELISA method using Microplate Reader (Rayto RT-2100C), calibrated to a wavelength of 450 nm. Results were summarized as frequencies, proportions, and median with interquartile range (IQR) where appropriate and the level of significance was set at ≤0.05. Results: The mean age of the patients was 23.80 ± 7.46 years while that of the controls was 24.28 ± 4.8 years (P = 0.76), respectively. The mean hematological parameters of both groups were Hb (8.57 ± 1.33 vs 13. ± 1.29 g/dL, P value <0.0001), WBC (10.63 ± 3.19 vs 5. 76 ± 1.21 × 109/L, P value <0.0001), platelet count (494.38 ± 213.88 vs 220.83 ± 75.26 × 109/L, P value <0.0001), respectively. The median and IQR of D-dimer levels of the patients and the controls was 1730.25 ng/mL (12359.2–36.2 ng/mL) and 324.00 ng/mL (1034.0–127.8 ng/mL), respectively. Conclusion: Marked increase in D-dimer levels in patients with sickle cell anemia in this study suggested that multiple sites were involved in thrombi formation and this requires extensive fibrinolytic activity to dissolve these thrombi.
Keywords: Crisis, D-dimer, fibrinolytic system, sickle cell anemia, steady state, volunteers
|How to cite this article:|
Kusfa IU, Mamman AI, Babadoko AA, Yahaya G, Ibrahim IN, Awwalu S, Waziri AD, El-Bashir JM. A comparative study of D-dimer levels in adult patients with sickle cell anemia at Ahmadu Bello University Teaching Hospital Zaria, Nigeria. Niger J Basic Clin Sci 2017;14:92-5
|How to cite this URL:|
Kusfa IU, Mamman AI, Babadoko AA, Yahaya G, Ibrahim IN, Awwalu S, Waziri AD, El-Bashir JM. A comparative study of D-dimer levels in adult patients with sickle cell anemia at Ahmadu Bello University Teaching Hospital Zaria, Nigeria. Niger J Basic Clin Sci [serial online] 2017 [cited 2019 Sep 22];14:92-5. Available from: http://www.njbcs.net/text.asp?2017/14/2/92/216044
| Introduction|| |
Hemostatic components including fibrinolytic systems are altered in favour of a procoagulant phenotype and as such sickle cell disease (SCD) is frequently referred to as hypercoagulable state. External exposure of phosphatidylserine (PS) alters the adhesive properties of sickle RBC  and appears to contribute to the hemostatic changes observed in sickle cell anemia (SCA)., Several studies provide evidence of a relationship between PS exposure and the hemostatic changes. However, the number of PS-positive sickle RBC is significantly correlated with plasma prothrombin fragments (F1.2) D-dimer levels. There is also a strong correlation between antibodies against PS and plasma D-dimers, suggesting a significant role for anti-PS antibodies in coagulation activation in SCD.
Patients with SCA have elevated plasma levels of D-dimers,,, plasmin-antiplasmin (PAP) complexes and fibrinopeptide A in steady state. The frequency of pain episodes in patients with SCA correlates with the extent of fibrinolytic activity, which can be assessed by D-dimer levels, in steady state. This suggests that D-dimer levels may be used to predict the frequency of vaso-occlusive crisis in patients with SCA.
Previous studies have shown that a hypercoagulable state is present in patients with SCA , and that changes in coagulation activity in patients with SCA reflect the degree of disease severity of the hemoglobin disorder.
| Materials and Methods|| |
This was a case-control study involving 50 patients with SCA (HbSS) in steady state attending the hematology clinic of Ahmadu Bello University Teaching Hospital, Zaria and 25 healthy volunteers with normal hemoglobin (HbAA) as controls, and it was conducted in 2015 over a five-week period. Interviewer-administered questionnaire was used to extract the information from the participants after obtaining informed written consent. Ethical approval was obtained from the Health Research Ethic Committee (HREC) of the ABUTH, Zaria. Venous blood of 7.5 milliliters (7.5 ml) was withdrawn, 3 ml of which was dispensed into the ethylenediamine tetra acetic acid-containing bottle (EDTA) for the determination of hemoglobin concentration (Hb), white blood cell count (WBC) and platelet count using automated hematolgy analyzer (SYSMEX XT-2000i, SYSMEX CORPORATION, CPO BOX 1002 KOBE 650-8691, JAPAN). The remaining 4.5 ml was dispensed into a bottle containing 0.5 ml of 3.2% trisodium citrate (blood anticoagulant ratio of 9:1) for the determination of D-dimer levels. A ZYMUTEST DDIMER, Complete ELISA kit for the assay of human D-DIMER (HYPHEN BioMed, FRANCE) was used. The D-dimer levels were determined by Microplate Reader (Rayto RT-2100C microplate reader, Rayto Life and Analytical Science Co., Ltd. Shanghai International Holding Corp. GmbH; Europe) calibrated to a wavelength of 450 nm with strict adherence to the manufacturer's instructions. Proportions, frequencies for normally distributed data while median with interquartile range (IQR) for skewed data were performed using SPSS version 20.0 and the level of significance was set at ≤0.05.
| Results|| |
The mean ages and hematological parameters of both the patients and controls were: 23.80 ± 7.46 and 24.28 ± 3.48 years (P = 0.76), Hb (8.57 ± 1.33 vs 13. ± 1.29 g/dL, P value < 0.0001), WBC (10.63 ± 3.19 vs 5. 76 ± 1.21 × 109/L, P value < 0.0001), platelet count (494.38 ± 213.88 vs 220.83 ± 75.26 × 109/L, P value < 0.0001), respectively, and majority of the study participants (53.0%) were females. The distributions of D-dimer levels within the patients group is skewed and showed evidence of extreme departure from normality according to the Shapiro-Wilk test. Due to non-normality, we used Mann-Whitney to compare medians rather than means [Figure 1]. The median with IQR of D-dimer levels of the patients and that of the controls was 1730.25 mg/mL (12359.2–36.2 ng/mL) and 324.00 ng/mL (1034.0–127.8 ng/mL) with P value < 0.0001, respectively [Table 1] and [Table 2].
| Discussion|| |
Forty-eight (96%) of the patients with SCA had significantly elevated levels of D-dimer, above the cut off limit compared to the controls [Table 2]. Fakunle et al., Hagger et al.,, and Francis RB  reported similar findings in separate studies with significantly high D-dimer levels in patients with SCA in steady state compared to controls. It is possible that the marked increase in D-dimer levels observed in this study was due to multiple sites, with varying severity, being involved in thrombi formation in individuals with SCA. It is also possible that some of the patients with SCA during this study had some form of crises as reflected in their D-dimer levels [Table 1]. However, a study by Akinola et al. in patients with SCA in steady state showed biochemical as well as rheological changes that are consistent with minor episodes of microvascular stasis, and these episodes were insufficient to cause overt vaso-occlusive crisis.
However, in another study by Ekwere et al., the D-dimer levels between the patients with SCA and the controls showed no statistically significant difference even though the levels are still higher in the patient group. This may be due to the small sample size which was about half the number of this study. Contrary reports by Philips et al., and Nsiri et al. showed that fibrinolytic activity in patients with SCA in steady state is decreased. Other report showed no impairment of fibrinolytic activity in patients with SCA in steady state.
Although high D-dimer levels do not necessarily imply thrombosis because some factors may contribute to its increase in plasma like inflammation, infections, or surgery. However, normal levels exclude thrombosis with a high probability and the negative predictive value is often >90%.
Reduced hemoglobin concentration (Hb) observed in this study among patients with SCA is similar to the studies reported separately by Ladu et al., Omoti, and Chikhlikar et al. Reduced Hb in patients with SCA has been associated with continuous hemolysis of red blood cells thereby reducing their survival to 10–20 days and splenic sequestration. Therefore, reduced Hb concentration in patients with SCA serves as a reflection of both degree of anemia and degree of hemolysis [Table 3].
|Table 3: Comparison of median values of D-dimer and hematological parameters of patients and controls|
Click here to view
The total WBC count observed in this study was significantly higher among patients with SCA than the controls [Table 3]. Same observation was made by Ladu et al., Sagir, and Okpala  separately. In their studies, leukocytosis was found to be a common feature in patients with SCA in steady state in the absence of infection. In another study by Akinola et al., who suggested that the generation of an inert inflammatory response leads to release of cytokine mediators whose function is to increase production of neutrophils by the bone marrow. A contrary report by Elgari et al. showed no significant difference in the total leukocyte count between the patients with SCA in steady state and that of the controls, even though the study was carried out in children. This finding may depend on maternal factors as maternal health, nutritional status, and antenatal complication such as anemia.
The mean platelets count in this study was higher among patients with SCA than the controls [Table 3]. This is supported by the previous reports of Aliyu et al., and other studies by Liesner et al., Walters et al.,Hagger et al., Green et al., and Platt et al., respectively. Higher platelets count in patients with SCA may explain the cellular activation previously observed in SCA individuals., It may also be due to functional asplenia and chronic hemolysis. Functional asplenia, increased erythropoietic activity as well as thrombopoietin activity resulting in chronic anemia may all contribute to high platelet count in patients with SCA even in steady state.
| Conclusion|| |
Marked increase in D-dimer levels in patients with SCA in this study suggested that multiple sites were involved in thrombi formation. Therefore, extensive fibrinolytic activity as observed in these patients is required to dissolve these thrombi. Significant reduction in Hb concentration, increase in total WBC, and platelet counts were observed in this study.
This study should have included C-reactive protein (CRP) to be able to categorize those with minor episodes of microvascular stasis insufficient to cause overt vaso-occlusive crisis and fibrin degradation products (FDPs), which may help in assessing the markers of intravascular clotting activation and continued clot lysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Helley D, Girot R, Guillin M, Bezaud A. Sickle cell disease: Relation between procoagulant activity of red blood cell from different phenotypes and in vivo
blood coagulation activation. Br J Haematol 1997;99:268-72.
Setty BN, Kulkani S, Stuart MJ. Role of erythrocyte phosphatidylserine in sickle red cell endothelial adhesion. Blood 2002;99:1564-71.
Setty BN, Rao AK, Stuart MJ. Thrombophilia in sickle cell disease: The red cell connection. Blood 2001;98:3228-33.
Setty BN, Kulkani S, Rao AK, Stuart MJ. Foetal haemoglobin in sickle cell disease: Relationship to erythrocyte phosphatidylserine exposure and coagulation activation. Blood 2000;96:1119-24.
Westerman MP, Green D, Gilman-Sachs A, Beaman K, Freels S, Boggio L, et al
. Antiphospholipid antibodies, proteins C and S and coagulation changes in sickle cell disease. J Lab Clin Med 1999;134:352-62.
Wright JG, Malia R, Cooper P, Thomas P, Preston FE, Serjeant GR. Protein C and S in homozygous sickle cell disease: Does hepatic dysfunction contribute to low levels? Br J Haematol 1997;98:627-31.
Tam DA. Protein C and S activity in sickle cell disease and stroke. J Child Neurol 1997;12:19-21.
Fakunle EE, Eteng KI, Shokunbi WA. D-dimer levels in Patients with Sickle Cell Disease during bone pain crises and in the steady state. Pathol Lab Med Int 2012;4:1-5.
Hagger D, Wolf S, Owen J, Samson D. Changes in coagulation and fibrinolysis in patients with Sickle Cell Disease compared with healthy black controls. Blood Coagul Fibrinolysis 1995;6:93-9.
Haut MJ, Cowan DH, Harris JW. Platelets function and survival in sickle cell disease. J Lab Clin Med 1973;82:44-9.
Francis RB. Elevated fibrin D-dimer fragment in sickle cell anaemia: Evidence for activation of coagulation during the steady state as well as in painful crisis. Haemostasis 1989;19:105-11.
Ataga KI, Orringer EP. Hypercoagulability in sickle cell disease: A curious paradox. Am J Med 2003;115:721-8.
Akinola NO, Stevens SME, Franklin IM, Nash GB, Stuart J. Subclinical ischaemic episodes during the steady state of sickle cell anaemia. J Clin Pathol 1992;45:902-6.
Ekwere T, Ogunro SP, Akanmu AS. Assessment of some fibrinolytic proteins in sickle cell anemia patients in steady state and in vaso-occlusive crises. J Appl Hematol 2013;4:131-6. [Full text]
Philips G, Hartman J, Keller VA, Santiago MA, Pizzo S. Regulation of tissue plasminogen activator in sickle cell anemia. Am J Hematol 1990;35:167-70.
Philips G, Mitchell LB, Pizzo SV. Defective release of tissue plasminogen activator in patients with sickle cell anemia. Am J Hematol 1988;29:52-3.
Nsiri B, Gritli N, Bayoudh F, Messaoud T, Fattoum S, Machghoul S. Abnormalities of coagulation and fibrinolysis in homozygous sickle cell disease. Hematol Cell Ther 1996;38:279-84.
Francis RB Jr. Tissue type plasminogen activator antigen and activity in sickle cell disease. J Clin Pathol 1988;41:490-3.
Scarano L, Bernardi E, Prandoni P, Sardella C, Rossi L, Carraro P, et al
. Accuracy of two newly described D-dimer tests in patients with suspected deep vein thrombosis. Thromb Res 1997;86:93-9.
Ladu AI, Abjah UAM, Kagu MB, Bukar AA. A study of Antithrombin III in sickle cell anaemia patients in steady state and during vaso-Occlusive crisis in North-Eastern Nigeria. Am J Sci Ind Res 2013;4:161-6.
Omoti CE. Haematological values in sickle cell anaemia in steady state and during vaso-occlusive crisis in Benin City, Nigeria. Ann Afr Med 2005;4:62-7.
Chikhlikar K, Wilkinson A. A study of red cell parameters in patients of Sickle Cell Trait. IOSR J Dent Med Sci 2014;13:46-50.
Sagir G A. The role of infection in the pathogenesis of vaso-occlusive crisis in patients with sickle cell disease. Mediterr J Hematol Infect Dis 2011;3:e2011028.
Okpala I. The intriguing contribution of white blood cell to sickle cell disease- A red cell disorder. Blood Rev 2004;18:65-73.
Elgari MM, Waggiallah HA. Assessment of hematological parameters of neonatal cord blood in anemic and non-anemic mothers. J Clin Exp Res 2013;1:22-5.
Aliyu ZY, Kato GJ, Taylor JIV, Babadoko AA, Mamman AI, Gordeux VR, Gladwin MT. Sickle cell disease and pulmonary hypertension in Africa: A global perspective and review of epidemiology, pathophysiology, and management. Am J Haematol 2008;83:63-70.
Liesner R, Mackie I, Cookson J, McDonald S, Chitolie A, Donohoe S, et al
. Prothrombotic changes in children with sickle cell disease: Relationship to cerebrovascular disease and transfusion. Br J Haematol 1998;103:1037-44.
Walters MC, Patience M, Leisenring W, Eckman JR, Scott JP, Mentzer WC, et al
. Bone marrow transplantation for sickle cell disease. N Engl J Med 1996;335:369-76.
Green D, Kwaan HC, Ruiz G. Impaired fibrinolysis in sickle cell disease. Relationship to crisis and infection. Thromb Diath Haemorrh 1970;24:10-5.
Platt OS, Thorington BD, Brambilla DJ, Milner PF, Rosse WF, Vichinsky E, et al
. Pain in sickle cell disease. Rates and risk factors. N Engl J Med 1991;325:11-6.
Leslie J, Langler D, Serjeant GR, Serjeant BE, Desai P, Gordon YB. Coagulation changes during the steady state in homozygous sickle cell disease in Jamaica. Br J Haematol 1975;30:159-66.
Lard LR, Mul FPJ, Haas M, Roos D, Duits AJ. Neutrophil activation in sickle cell disease. J Leucocyte Biol 1999;66:411-5.
Saunthararajah Y, Vichinsky EP. Sickle cell disease, clinical features and management. In: Hoffman R, editor. Textbook of hematology, Basic principles and practice. 5th
ed. Churchill Livinstone Elsevier publishers; 2009. p. 577-99.
[Table 1], [Table 2], [Table 3]