The Danish Disseminated Intravascular Coagulation (DANDIC) Cohort Study: Incidence and Prognosis

Abstract

Introduction: Disseminated intravascular coagulation (DIC) is a serious condition with poor prognosis and limited treatment options. Despite being a devastating disorder, data on the incidence and prognosis remains limited. Previous studies are more than 10 years old, were limited to selected patients e.g., patients admitted to university hospitals, and were unable to track transitions in sites of care. In this study, we examined the incidence and prognosis, including time trends, of DIC. Methods: Potential DIC cases were identified from the hospital laboratory database by coagulation biomarkers in the Central Denmark Region, Denmark. Patients were eligible for inclusion if they were above 18 years of age and had an International Society on Thrombosis and Haemostasis (ISTH) DIC score of five or higher or a Japanese Association for Acute Medicine (JAAM) DIC score of four or higher. An underlying disease compatible with DIC was also required for inclusion and was assessed by medical chart review. The underlying diseases were infection, malignant disorder, obstetric complications, trauma, cardiac arrest, and other less common conditions. Exclusion criteria were other conditions affecting the coagulation system. 6748 medical charts were reviewed, and 2565 patients were included in the cohort from January 2013 to December 2020. Incidence rates were computed by the number of cases per year divided with the midyear population in the Central Denmark Region and were age and sex standardized to the year 2020. Survival was determined by Kaplan-Meier estimates. Results: Out of the 2565 patients, the median age was 64 years (25th-75th percentile, 48-74 years) and 1439 (56.1%) were male. At inclusion 1055 patients had an ISTH DIC score of 5-6, 145 an ISTH DIC score of 7-8, 2014 a JAAM DIC score of 4-6 and 302 a JAAM DIC score of 7-8. The overall incidence rate per 100,000 person-years declined from 33.1 in 2013 [95% confidence interval (CI), 29.6 to 36.8] to 24.0 in 2020 [95% CI, 21.1 to 27.1]. Overall 30-day survival remained relatively unchanged at 65.0% in 2013 [95% CI, 59.9% to 70.6%] and 58.7% in 2020 [95% CI, 52.9% to 65.0%]. The incidence rate of patients with an ISTH score of 5-6 at baseline was 14.1 in 2013 [95% CI, 11.8 to 16.5] and 10.8 in 2020 [95% CI, 8.9 to 12.8]. The incidence rate of patients with an ISTH score of 7-8 at baseline remained nearly constant at 1.4 in 2013 [95% CI, 0.7 to 2.1] and 1.2 in 2020 [95% CI, 0.6 to 2.0]. Thirty-day survival was 56.2% [95% CI, 53.3% to 59.3%] for patients with an ISTH DIC score of 5-6 and 33.8% [95% CI, 26.9% to 42.4%] for patients with an ISTH DIC score of 7-8. Patients with JAAM DIC scores of 4-6 at baseline showed a decline in incidence rate from 25.8 in 2013 [95% CI, 22.7 to 29.9] to 19.4 in 2020 [95% CI, 16.8 to 22.1]. However, the incidence rate of patients with JAAM DIC scores of 7-8 remained steady at 3.6 in 2013 [95% CI, 2.4 to 4.8] and 2.3 in 2020 [95% CI, 1.4 to 3.2]. Patients with a JAAM DIC score of 4-6 at baseline had a 30-day survival rate of 62.2% [95% CI, 60.0% to 64.3%] while patients with a JAAM DIC score of 7-8 had a lower 30-day survival of 53.6% [95% CI, 48.3% to 59.6%]. Conclusion: The overall incidence of DIC declined during the study period, but overall mortality remained unchanged. The incidence rate was higher among patients with a low baseline ISTH or JAAM DIC score than among patients with a high baseline score. Survival rate was also higher for patients with a low DIC score at baseline, suggesting that DIC score at baseline may be a predictor of survival.