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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 14  |  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


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 Publication5-Oct-2017

Correspondence Address:
Ibrahim U Kusfa
Department of Haematology and Blood Transfusion, Ahmadu Bello University Teaching Hospital, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_1_17

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  Abstract 

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 2017 Dec 18];14:92-5. Available from: http://www.njbcs.net/text.asp?2017/14/2/92/216044


  Introduction Top


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.[1] External exposure of phosphatidylserine (PS) alters the adhesive properties of sickle RBC [2] and appears to contribute to the hemostatic changes observed in sickle cell anemia (SCA).[3],[4] Several studies provide evidence of a relationship between PS exposure and the hemostatic changes.[4] However, the number of PS-positive sickle RBC is significantly correlated with plasma prothrombin fragments (F1.2) D-dimer levels.[3] 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.[1]

Patients with SCA have elevated plasma levels of D-dimers,[5],[6],[7] plasmin-antiplasmin (PAP) complexes and fibrinopeptide A in steady state.[4] 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.[7] 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 [1],[5] and that changes in coagulation activity in patients with SCA reflect the degree of disease severity of the hemoglobin disorder.[5]


  Materials and Methods Top


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 Top


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].
Figure 1: Box plot of D-dimer levels of all the study participants

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Table 1: D-dimer levels of participants with HbAA

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Table 2: D-dimer levels of the participants with HbSS

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  Discussion Top


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.,[8] Hagger et al.,[9],[10] and Francis RB [11] 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.[12] 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.[13]

However, in another study by Ekwere et al.,[14] 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.[15],[16] and Nsiri et al.[17] 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.[18]

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%.[19]

Reduced hemoglobin concentration (Hb) observed in this study among patients with SCA is similar to the studies reported separately by Ladu et al.,[20] Omoti,[21] and Chikhlikar et al.[22] 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

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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.,[20] Sagir,[23] and Okpala [24] 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.[13] 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.[25]

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.,[26] and other studies by Liesner et al.,[27] Walters et al.,[28]Hagger et al.,[9] Green et al.,[29] and Platt et al.,[30] respectively. Higher platelets count in patients with SCA may explain the cellular activation previously observed in SCA individuals.[31],[32] It may also be due to functional asplenia and chronic hemolysis.[33] 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 Top


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.

Limitations

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

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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