THE PROGNOSTIC IMPORTANCE OF PLASMA D-DIMER LEVELS IN PATIENTS WITH COMMUNITY ACQUIRED PNEUMONIA C. NAZ, F. ALATAS, G.AK, H. YILDIRIM, M. METİNTAS, S. ERGINEL Eskisehir Osmangazi University Deparment of Chest Diseases, Eskisehir, TURKEY
INTRODUCTION and AIM d-Dimer results from the fibrin breakdown after fibrinolytic system activation. Circulating d-Dimer levels can be measured easily, and elevated levels have been detected in patients with DIC, severe sepsis, thromboembolic events, pregnancy, liver disease, surgery, and trauma.
Previous studies have supported the fact that coagulation system is associated with acute and chronic lung injury. Intraalveolar activation of the coagulation cascade is lead to fibrin deposition in the pulmonary interstitium and alveoli.
In parenchymal lung, and pleural disease, a transitional fibrin neomatrix constitutes part of the acute inflammatory response, and appears to initiate a sequence of events that leads to tissue remodeling. Little is known about the relationship between d-Dimer levels and clinical outcomes of patients CAP.
The aim of our study is to investigate the value of plasma d-dimer levels as a prognostic index in patients with CAP.
MATERIALS - METHODS The patients admitted to our hospital and diagnosed as CAP were included in this study. Exclusion criteria included neutropenia due to chemotherapy, malignancy, admission to a hospital within the previous 10 days, high probability of a pulmonary embolism, recent surgical operation and trauma story.
Patients underwent standard evaluation that included medical history, physical examination , CXR, and ECG. Blood samples for culture, CBC and CRP determination and a sputum sample for Gram staining and culture were collected before the antibiotic treatment.
Patients were classified according to ATS,PSI, CURB, CURB 65, CRB, CRB65 criteria. d-dimer levels were measured on the day of collection by automated quantitative latex system. D-dimer measurements were repeated on the third and twentieth day of treatment. A value of >500 ng/mL was considered to be a positive d-Dimer level. The statistical evaluation of data was done by SPSS 10.0 package program.
RESULTS Mean age: 59 years (range:18-86) Before treatment levels of d-Dimer (median ± SD): 2553 ± 1786 ng/ml (298-8000).
Demografic factors and d-dimer levels (median ± SD) Presence Absence Age > 65 2370 ± 1641,5 (n=38) 2010 ± 1910,9 (n=29) Male gender 2148 ± 1516,9 (n=50) 1543 ± 2464,3 (n=17) CHF 2247 ± 1312,7 (n=16) 2020 ± 1922,0 (n=51) CVD 3110 ± 1850,6 (n=5) 2040 ± 1791,5 (n=62) DM 1860 ± 1401,9 (n=11) 2225 ± 1849,0 (n=56) Confusion 3330 ± 1495,1 (n=6) 2020 ± 1785,4 (n=61) RR>30 min 3110 ± 1688,4 (n=7) 2030 ± 1803,3 (n=60) Pulse>125 min 3110 ± 1339,1 (n=7) 2010 ± 1822 (n=60) Systolic BP<90 3500 ± 1542,0 (n=3) 2040 ± 1804,8 (n=64) Diastolic BP<60 2645 ± 1461,8 (n=4) 2040 ± 1814,5 (n=63) Ph<7.35 2194 ± 1708,8 (n=9) 2030 ± 1812,1 (n=58) PaO2<60 mmHg 2511 ± 1955,8 (n=31) 1827 ± 1538,8 (n=36)* BUN> 30mg/dL 2455 ± 1243,9 (n=18) 1935 ± 1954,7 (n=49) Na<130 mmol/L 2146 ± 682,9 (n=3) 2040 ± 1023,7 (n=64) Glucose>250mg/dL 1320 ± 732,4 (n=3) 2093 ± 1813,4 (n=64) Hematocrit<%30 3259 ± 1747,7 (n=9) 2010 ± 1780 (n=58) Bilateral İnfiltration 2040 ± 1271,6 (n=26) 2146 ± 2053,1(n=41) * p=0.04
No correlation was observed between d-Dimer levels before treatment and clinical and radiological findings and CRP levels. No statistically significant difference was observed between the before treatment d-Dimer levels of outpatient and hospitalized patients. No significantly difference was observed between d-Dimer levels of patients that require the change of treatment or not.
The median d-dimer levels of patients treated with mechanical ventilator (n=9) was 1935ng/ml. The median d-dimer levels of patients who did not require mechanical ventilation was 2093 ng/ml (p=0,593).
The sensitivity and specificity for the determination of bad prognosis were 89% and 33% respectively, when the cut-off level was taken ≥1290 ng/ml for d-dimer.
No statistically significant difference was observed between d-dimer levels and prognostic scores that are used for the follow-up of CAP patients ATS: p=0,807 PSI: p=0,393 CURB: p=0,432 CURB 65: p=0,238 CRB: p=0,543 CRB65: p=0,617
CONCLUSION d-dimer levels are increased in CAP cases. Series determination of d-dimer levels may have a valuable parameter in the follow up of response to treatment. However, it is insufficient for the determination of prognosis. This result may be due to the low numbered patient series; therefore, new studies with larger cohort should be valuable.