Coagulopathy is a global public health problem, which results in mortality and morbidity (5). Thrombocytopenia, vWD, and hemophilia are the leading causes of coagulopathy (5). The effect of bleeding disorder in Africa and Ethiopia is considered a public health problem (6, 22). Hence, this study was aimed to assess the prevalence and associated risk factors of coagulopathy among bleeding diathesis participants attending at University of Gondar Specialized Referral Hospital.
The finding of this study showed that the overall prevalence of coagulopathy was (65.9%; 95% CI: 61.16, 70.64). This result is considered a high public health problem. The reason may be associated with the type of study participants included in this study. More than half (55.2%) of them were with different types of chronic diseases. From this liver disease, cardiac disease, and diabetes Miletus (DM) was the majority of them. These diseases are directly associated with coagulopathy (12, 23–27). Coagulopathy due to liver disease is as a result of all coagulation factors involved in the generation of a fibrin clot, and thrombopoietin is produced by liver cells (28). Also, coagulopathy due to DM is mostly related to thrombocytopenia. In contrast, glycation of hemoglobin, prothrombin, fibrinogen, and other proteins involved in the clotting mechanism results in the hypercoagulable state (27). On the other hand, coagulopathy due to cardia disease is mostly related to medications that are given to the patients. The drugs that are associated with thrombocytopenia and prolonged coagulation test include glycoprotein IIb/IIIa receptor inhibitors, heparin, warfarin, and thienopyridines (29).
The current study was in agreement with a study conducted by Tapia et al in American which reported a 65.6% prevalence of bleeding disorder (13). In contrast, the prevalence of this study was higher than a study conducted in Egypt (23%) (7), India (53%) (30), and America (47%) (14). The possible reasons for the discrepancies might be associated with differences in the study population, study period, geographical variability, detection method, and implementation of different strategies to minimize the burden of coagulopathy in the region where studies have been conducted.
In this study, the prevalence of thrombocytopenia was (32%; 95% CI: 27.3, 36.7) which was nearly one out of three participants was with thrombocytopenia. Thrombocytopenia was commonly associated with bleeding diathesis patients. It can be caused by malnourishment, liver disease, bone marrow disease, sepsis, DIC, heparin, certain antibiotics, and different chronic diseases (27, 31). Most of the above causes were detected in the current study participants. This may be the reason for the moderate result of thrombocytopenia. The current study finding was higher than a study conducted by David et al in Canada which showed a 13.3% prevalence of thrombocytopenia (23). In contrast, this study finding was lower than the study conducted in America (47.6%) (32) and India (38%) (31). The variability may be related to differences in study population and variability in socio-economy.
In the current study, the prevalence of coagulopathy due to factor inhibitory and factor deficiency among prolonged coagulation tests were 78.9% (157/199), and 21.1% (42/199) respectively. This study indicated that four out of five individuals with prolonged coagulation tests were due to factor inhibitors. This might be related to the presence of chemicals, lupus anticoagulant, and specific immunoglobulin. Study participants in the current study were having different types of chronic diseases which may be the cause for the presence of high factor inhibitory. The prevalence of factor inhibitory (78.9%; 95% CI: 74.82, 82.89) was consistent with a study conducted by Kershaw et al in Australia 77% (20). On the other hand, the current study finding was higher compared to the study conducted in France (69%)(33), Italy ( 2.5%) (34), and Israel (67%) (35). These studies showed that higher level of factor inhibitors was detected than the factor deficiency. The variety of the result may be related to the type of study population used, study design, sample size, and all the above study were conducted on single factor deficiency type but this study was conducted on the presence of all type of factor deficiency as well as this study assessed presence of all type of inhibitory.
Coagulopathy is mostly associated with chronic diseases (23, 29, 36, 37), parasitic infection (38), and some viral agents (30). In this study cardiac disease, and other chronic diseases were significantly associated with coagulopathy. Study participants with cardiac disease were nearly eleven times more likely to develop coagulopathy than those without cardiac disease. This might be due to cardiac study participants might take different types of medication which might have an impact on the normal hemostasis process (26). Researchers conducted on the association of vWD factor deficiency with cardiovascular disease and asymptomatic carotid atherosclerosis By Seaman et al in America showed that the prevalence of the cardiovascular disease among VWF deficient participants was 5.8% (16). Similarly, research conducted in America by Mohamed et al among cardiac patients showed that cardiac disease is associated with thrombocytopenia in which 10.17% of the cardiac patients had thrombocytopenia (26). Both the above studies and the current study indicates that cardiac disease patients are a risk for prolonged coagulation test and thrombocytopenia.
In this study, other chronic diseases (nasal bleeding, anemia, DM, and liver disease) were statistically associated with coagulopathy. Those study participants who had other chronic disease were almost 7 times more likely to be coagulopathy than who had no other chronic diseases. The Liver disease had an association with coagulopathy because all coagulation factors and thrombopoietin are produced in the liver cells. Also, a study shows all 3 phases of hemostasis were reduced among liver disease patients (25). patients with liver disease had decreased synthesis of Vitamin K-dependent and independent clotting factors, reduced production of anticoagulants, platelet production abnormalities, and platelet consumption are the leading cause for prolonged coagulation test, and thrombocytopenia (39). Similarly, DM patients are a risk for thrombocytopenia. Thrombocytopenia due to DM patients is commonly related to medications given to patients like insulin and autoimmunity to bone marrow cells. Shortened coagulation tests were also detected in DM participants. Research conducted by Richard et al among Type-2 DM in America and with other previously published reports showed that shortened APTT and PT in diabetes patients compared to non-diabetic controls (27). Also, research conducted by Acang et al in Indonesia shows that type 2 DM study participants were exposed to hypercoagulability (36). Similarly, research conducted by Erem et al in Kuwait shows, the plasma levels of fibrinogen, antithrombin III, plasminogen activator inhibitor-1, VWF activity, and PT were found to be significantly increased in the type 2 DM patients compared with the healthy subjects (24).
The first major limitation of this study was being cross-sectional nature that does not allow us to observe causality in the relationship. Due to the constraint of resource, we did not perform advanced techniques which can assess specific factors and concentration technique to assess a small number of parasites. Moreover, recall bias might be a possible factor in the assessment of past events and exposures.