Serum calcium: biomarker of clinical severity and prognosis in COVID 19 patients

The pathogen has been reported as a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The World Health Organization (WHO) has made the assessment that coronavirus disease 2019 (COVID-19) can be characterized as a pandemic because the disease is still spreading rapidly around the world, especially in the United States, Spain, and Russia.¹ The National Health Commission of China has issued a series of diagnosis and treatment recommendations and suggested classifying the disease into four grades: mild, moderate, severe and critical.²

Recent studies have reported the clinical characteristics and prognosis of the varied severity grades of COVID-19.³ The underlying mechanisms of the novel coronavirus leading to disease exacerbation and organ dysfunction remain to be further explored. Due to the high mortality and the lack of effective treatments in critically ill patients,⁴ early identification and prediction of these patients are crucial. What are the risk factors for severe illness or death⁵? How can we identify groups that are most likely to have poor outcomes so that we can focus prevention and treatment efforts⁵? These studies are needed.

However, fewer studies have been published that confirm an early and sensitive biomarker to estimate the disease severity and prognosis of COVID-19. During clinical work against the COVID-19 epidemic in Wuhan, observed a high incidence of hypocalcemia in critically ill patients. Therefore, authors hypothesized that serum calcium levels were associated with the disease severity and prognosis of patients with COVID-19.³

Sun et al³ investigated the correlations between serum calcium and clinical outcomes in patients with coronavirus disease 2019 (COVID-19). In this retrospective study, serum calcium levels, hormone levels and clinical laboratory parameters on admission were recorded. The clinical outcome variables were also recorded. Out of 241 patients, 180 (74.7%) had hypocalcemia on admission. The median serum calcium levels were 2.12 (IQR, 2.04-2.20) mmol/L, median parathyroid hormone (PTH) levels were 55.27 (IQR, 42.73-73.15) pg/mL, and median 25-hydroxy-vitamin D (VD) levels were 10.20 (IQR, 8.20-12.65) ng/mL. The serum calcium levels were significantly positively correlated with VD levels (P =0.004) but negatively correlated with PTH levels (P =0.048). Patients with lower serum calcium levels (especially ≤2.0 mmol/L) had worse clinical parameters, higher incidences of organ injury and septic shock, and higher 28-day mortality. The areas under the receiver operating characteristic curves of multiple organ dysfunction syndrome, septic shock, and 28-day mortality were 0.923 (P <0.001), 0.905 (P =0.001), and 0.929 (P <0.001), respectively.

Sun et al concluded that serum calcium was associated with the clinical severity and prognosis of patients with COVID-19. Hypocalcemia may be associated with imbalanced VD and PTH levels.

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References:

1. World Health Organization. Coronavirus disease (COVID-19) outbreak. https://www.who.int
2. National Health Commission of the People’s Republic of China home page. http://www.nhc.gov.cn
3. Sun JK, Zhang WH et al. Serum calcium as a biomarker of clinical severity and prognosis in patients with coronavirus disease 2019. Aging (Albany NY) 2020 Jun 30; 12(12): 11287–11295. doi: 10.18632/aging.103526
4. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DS, Du B, Li LJ, Zeng G, et al, andChina Medical Treatment Expert Group for Covid-19. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020; 382:1708–20. https://doi.org/10.1056/NEJMoa2002032 PMID:32109013
5. Lipsitch M, Swerdlow DL, Finelli L. Defining the epidemiology of covid-19 – studies needed. N Engl J Med. 2020; 382:1194–96.  https://doi.org/10.1056/NEJMp2002125 PMID:32074416