Коагулопатия при COVID-19
https://doi.org/10.18093/0869-0189-2020-30-5-645-657
Аннотация
Нарушения гемостаза играют важную роль в патогенезе и клинических проявлениях COVID-19. Целью работы явилось подробное рассмотрение патогенеза, клинических проявлений, методов диагностики и лечения коронавирус-индуцированной коагулопатии (КИК). При дебюте COVID-19 выявляется гиперкоагуляция, а коагулопатия потребления, синдром диссеминированного внутрисосудистого свертывания (ДВС) регистрируются обычно на поздних стадиях заболевания. В патогенезе гиперкоагуляции при COVID-19 играют роль провоспалительные цитокины, гиперфибриногенемия, повышенное содержание в крови фактора Виллебранда, фактора VIII, нейтрофильных внеклеточных ловушек, активация тромбоцитов, выработка антифосфолипидных антител, микровезикулы. В лабораторных показателях выявляются повышенные плазменные концентрации D-димера, фибриногена, увеличение протромбинового времени и уменьшение количества тромбоцитов. Кумулятивная частота тромботических осложнений колеблется от 21 до 31 %. Факторами риска тромбозов являются пребывание в отделении интенсивной терапии, лейкоцитоз и высокая концентрация D-димера в плазме. Дифференциальный диагноз КИК следует проводить с ДВС-синдромом, сепсис-индуцированной коагулопатией, антифосфолипидным, гемофагоцитарным синдромами, тромботической микроангиопатией, гепарин-индуцированной тромоцитопенией. Возможно сочетание КИК с сепсисом, антифосфолипидным синдромом, гемофагоцитарным синдромом, тромботической микроангиопатией, гепарин-индуцированной тромбоцитопенией.
Основной терапией является лечение низкомолекулярными гепаринами. Приводятся рекомендации по лечению.
Ключевые слова
Об авторе
Г. М. ГалстянРоссия
Галстян Геннадий Мартинович – д. м. н., заведующий отделением реанимации и интенсивной терапии
125167, Москва, Новый Зыковский проезд, 4
тел.: (495) 612-48-59
Список литературы
1. Uddin M., Mustafa F., Rizvi T.A. et al. SARS-CoV-2/ COVID-19: Viral genomics, epidemiology, vaccines, and therapeutic interventions. Viruses. 2020; 12 (5): 526. DOI: 10.3390/v12050526.
2. Ashour H.M., Elkhatib W.F., Rahman M. et al. Insights into the recent 2019 novel coronavirus SARS-CoV-2 in light of past human coronavirus outbreaks. Pathogens. 2020; 9 (3): 1–15. DOI: 10.3390/pathogens9030186.
3. Guglielmetti G., Quaglia M., Sainaghi P.P. et al. “War to the knife” against thromboinflammation to protect endothelial function of COVID-19 patients. Crit. Care. 2020; 24 (1): 1–4. DOI: 10.1186/s13054-020-03060-9.
4. Wu C., Chen X., Cai Y. et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern. Med. 2020; 180 (7): 934. DOI: 10.1001/jamainternmed.2020.0994.
5. Zhao Y., Zhao Z., Wang Y. et al. Single-cell RNA expression profiling of ACE2, the receptor of SARS-CoV-2. bioRxiv. [Preprint. Posted: 2020, Apr. 9]. DOI: 10.1101/2020.01.26.919985.
6. Udugama B., Kadhiresan P., Kozlowski H.N. et al. Diagnosing COVID-19: The disease and tools for detection. ACS Nano. 2020; 14 (4): 3822–3835. DOI: 10.1021/acsnano.0c02624.
7. Marongiu F., Grandone E., Barcellona D. Pulmonary thrombosis in 2019-nCoV pneumonia? J. Tromb. Haemost. 2020; 18 (6): 1511–1513. DOI: 10.1111/jth.14818.
8. Iba T., Levy J.H., Connors J.M. et al. The unique characteristics of COVID-19 coagulopathy. Crit. Care. 2020; 24 (1): 360. DOI: 10.1186/s13054-020-03077-0.
9. Chang J.C. Sepsis and septic shock: endothelial molecular pathogenesis associated with vascular microthrombotic disease. Thromb. J. 2019; 17 (1): 10. DOI: 10.1186/s12959-0190198-4.
10. Iba T., Miki T., Hashiguchi N. et al. Is the neutrophil a “prima donna” in the procoagulant process during sepsis? Crit. Care. 2014; 18 (4): 230. DOI: 10.1186/cc13983.
11. Yang S., Qi H., Kan K. et al. Neutrophil extracellular traps promote hypercoagulability in patients with sepsis. Shock. 2017; 47 (2): 132–139. DOI: 10.1097/SHK.0000000000000741.
12. Østerud B., Bjørklid E. The tissue factor pathway in disseminated intravascular coagulation. Semin. Thromb. Hemost. 2001; 27 (6): 605–617. DOI: 10.1055/s-2001-18866.
13. Галстян Г.М., Кречетова А.В., Васильев С. и др. Система фибринолиза при сепсисе у больных в состоянии миелотоксического агранулоцитоза. Анестезиология и реаниматология. 2012; 57 (2): 41–47.
14. Wada H., Thachil J., Di Nisio M. et al. Guidance for diagnosis and treatment of disseminated intravascular coagulation from harmonization of the recommendations from three guidelines. J. Thromb. Haemost. 2013; 11 (4): 761–767. DOI: 10.1111/jth.12155.
15. Iba T., Di Nisio M., Levy J.H. et al. New criteria for sepsisinduced coagulopathy (SIC) following the revised sepsis definition: A retrospective analysis of a nationwide survey. BMJ Open. 2017; 7 (9): e017046. DOI: 10.1136/bmjopen2017-017046.
16. Takeda M., Moroi R., Harada T. et al. Relationship between protein C and antithrombin III deficiencies in sepsis without disseminated intravascular coagulation status. Ctit. Care. 2008; 12 (Suppl. 5): P40. DOI: 10.1186/cc7073.
17. Spiezia L., Boscolo A., Poletto F. et al. COVID-19-related severe hypercoagulability in patients admitted to intensive care unit for acute respiratory failure. Thromb. Haemost. 2020; 120 (6): 998–1000. DOI: 10.1055/s-0040-1710018.
18. Panigada M., Bottino N., Tagliabue P. et al. Hypercoagulability of COVID-19 patients in intensive care unit. A report of thromboelastography findings and other parameters of hemostasis. J. Thromb. Haemost. 2020; 18 (7): 1738–1742. DOI: 10.1111/jth.14850.
19. Yang M., Ng M.H.L., Li C.K. et al. Thrombopoietin levels increased in patients with severe acute respiratory syndrome. Thromb. Res. 2008; 122 (4): 473–477. DOI: 10.1016/j.thromres.2007.12.021.
20. Varga Z., Flammer A.J., Steiger P. et al. Endothelial cell infection and endotheliitis in COVID-19. Lancet. 2020; 395 (10234): 1417–1418. DOI: 10.1016/S0140-6736(20)30937-5.
21. Zuo Y., Yalavarthi S., Shi H. et al. Neutrophil extracellular traps in COVID-19. JCI Insight. 2020; 5 (11): e138999. DOI: 10.1172/jci.insight.138999.
22. Gould T.J., Vu T.T., Swystun L.L. et al. Neutrophil extracellular traps promote thrombin generation through platelet-dependent and platelet-independent mechanisms. Arter. Thromb. Vasc. Biol. 2014; 34 (9): 1977–1984. DOI: 10.1161/ATVBAHA.114.304114.
23. Zuo Y., Zuo M., Yalavarthi S. et al. Neutrophil extracellular traps and thrombosis in COVID-19. medRxiv. [Preprint. Posted: 2020, May 29]. DOI: 10.1101/2020.04.30.20086736.
24. Zhang Y., Xiao M., Shulan Zhang S. et al. Coagulopathy and antiphospholipid antibodies in patients with Covid-19. N. Engl. J. Med. 2020; 38 (1): 1–3. DOI: 10.1056/nejmc2007575.
25. Harzallah I., Debliquis A., Drénou B. Lupus anticoagulant is frequent in patients with Covid-19. J. Thromb. Haemost. 2020; 18 (8): 2064–2065. DOI: 10.1111/JTH.14867.
26. Helms J., Tacquard C., Severac F. et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020; 46 (6): 1089–1098. DOI: 10.1007/s00134-020-06062-x.
27. Guan W.J., Ni Z.Y., Hu Y. et al. Clinical characteristics of coronavirus disease 2019 in China. N. Engl. J. Med. 2020; 382 (18): 1708–1720. DOI: 10.1056/NEJMoa2002032.
28. Huang C., Wang Y., Li X. et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020; 395 (10223): 497–506. DOI: 10.1016/S01406736(20)30183-5.
29. Tang N., Li D., Wang X. et al. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J. Thromb. Haemost. 2020; 18 (4): 844–847. DOI: 10.1111/jth.14768.
30. Lodigiani C., Iapichino G., Carenzo L. et al. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb. Res. 2020; 191: 9–14. DOI: 10.1016/j.thromres.2020.04.024.
31. Zhang L., Yan X., Fan Q. et al. D-dimer levels on admission to predict in-hospital mortality in patients with Covid-19. J. Thromb. Haemost. 2020; 18 (6): 1324–1329. DOI: 10.1111/jth.14859.
32. Yin S., Huang M., Li D., Tang N. Difference of coagulation features between severe pneumonia induced by SARS-CoV2 and non-SARS-CoV2. J. Thromb. Thrombolysis. [Preprint. Posted: 2020, Apr. 3]. DOI: 10.1007/s11239-020-02105-8.
33. Huang C., Wang Y., Li X. et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020; 395 (10223): 497–506. DOI: 10.1016/S01406736(20)30183-5.
34. Ranucci M., Ballotta A., Di Dedda U. et al. The procoagulant pattern of patients with COVID-19 acute respiratory distress syndrome. J. Thromb. Haemost. 2020; 18 (7): 17471751. DOI: 10.1111/jth.14854.
35. Lippi G., Plebani M., Henry B.M. Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A meta-analysis. Clin. Chim. Acta. 2020; 506: 145–148. DOI: 10.1016/j.cca.2020.03.022.
36. Министерство здравоохранения Российской Федерации. Временные методические рекомендации: Профилактика, диагностика и лечение новой коронавирусной инфекции (COVID-19). Версия 7 (03.06.2020). Доступно на: https://static-0.rosminzdrav.ru/system/attachments/attaches/000/050/584/original/03062020_%D0%9CR_COVID19_v7.pdf
37. Thachil J., Tang N., Gando S. et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J. Thromb. Haemost. 2020; 18 (5): 1023–1026. DOI: 10.1111/jth.14810.
38. Jing-Chun S., Gang W., Wei Z. et al. Chinese expert consensus for diagnosis and treatment of coagulation dysfunction in COVID-19. Mil. Med. Res. 2020; 7 (1): 335–344. DOI: 10.1186/s40779-020-00247-7.
39. Fraissé M., Logre E., Pajot O. et al. Thrombotic and hemorrhagic events in critically ill COVID-19 patients: A French monocenter retrospective study. Crit. Care. 2020; 24 (1): 1–4. DOI: 10.1186/s13054-020-03025-y.
40. Paranjpe I., Fuster V., Lala A. et al. Association of treatment dose anticoagulation with in-hospital survival among hospitalized patients with COVID-19. J. Am. Coll. Cardiol. 2020; 76 (1): 122–124. DOI: 10.1016/j.jacc.2020.05.001.
41. Klok F.A., Kruip M.J.H.A., van der Meer N.J.M. et al. Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis. Thromb. Res. 2020; 191: 148–150. DOI: 10.1016/j.thromres.2020.04.041.
42. Leonard-Lorant I., Delabranche X., Severac F. et al. Acute pulmonary embolism in COVID-19 patients on CT angiography and relationship to D-Dimer levels. Radiology. 2020; 296 (3): e189–191. DOI: 10.1148/radiol.2020201561.
43. Tavazzi G., Civardi L., Caneva L. et al. Thrombotic events in SARS-CoV-2 patients: an urgent call for ultrasound screening. Intensive Care Med. 2020; 46 (6): 1121–1123. DOI: 10.1007/s00134-020-06040-3.
44. Middeldorp S., Coppens M., van Haaps T.F. et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19. J. Thromb. Haemost. 2020; 18 (8): 1995–2002. DOI: 10.1111/jth.14888.
45. Oudkerk M., Büller H.R., Kuijpers D. et al. Diagnosis, prevention, and treatment of thromboembolic complications in COVID-19: Report of the National Institute for Public Health of the Netherlands. Radiology. 2020; 297 (1): e216–222. DOI: 10.1148/radiol.2020201629.
46. Wichmann D., Sperhake J.P., Lütgehetmann M. et al. Autopsy findings and venous thromboembolism in patients with COVID-19. Ann. Intern. Med. 2020; 173 (4): 268–277. DOI: 10.7326/m20-2003.
47. Ramachandra S., Zaid F., Aggarwal A. et al. Recent advances in diagnostic and therapeutic guidelines for primary and secondary hemophagocytic lymphohistiocytosis. Blood Cells Mol. Dis. 2017; 64: 53–57. DOI: 10.1016/j.bcmd.2016.10.023.
48. Mehta P., McAuley D.F., Brown M. et al. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020; 395 (10229): 1033–1034. DOI: 10.1016/S0140-6736(20)30628-0.
49. Loscocco G.G. Secondary hemophagocytic lymphohistiocytosis, HScore and COVID-19. Int. J. Hematol. 2020; 112 (1): 125–126. DOI: 10.1007/s12185-020-02895-w.
50. Azoulay E., Knoebl P., Garnacho-Montero J. et al. Expert statements on the standard of care in critically Ill adult patients with atypical hemolytic uremic syndrome. Chest. 2017; 152 (2): 424–434. DOI: 10.1016/j.chest.2017.03.055.
51. Козловская Н.Л., Галстян Г.М., Степанюк В.Н. Сложные вопросы диагностики атипичного гемолитико-уремического синдрома в отделении реанимации и интенсивной терапии. Вестник анестезиологии и реаниматологии. 2019; 16 (4): 65–76. DOI: 10.21292/2078-5658-201916-4-65-76.
52. Sadler J.E. Pathophysiology of thrombotic thrombocytopenic purpura. Blood. 2017; 130 (10): 1181–1188. DOI: 10.1182/blood-2017-04-636431.
53. Magro C., Mulvey J.J., Berlin D. et al. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: A report of five cases. Transl. Res. 2020; 220: 1–13. DOI: 10.1016/j.trsl.2020.04.007.
54. Gavriilaki E., Brodsky R.A. Severe COVID-19 infection and thrombotic microangiopathy: success does not come easily. Br. J. Haematol. 2020; 189 (6): e227–230. DOI: 10.1111/bjh.16783.
55. Selleng K., Warkentin T.E., Greinacher A. Heparin-induced thrombocytopenia in intensive care patients. Crit. Care Med. 2007; 35 (4): 1165–1176. DOI: 10.1097/01.CCM.0000259538.02375.A5.
56. Al-Eidan F. Is the incidence trend of heparin-induced thrombocytopenia decreased by the increased use of low-molecular-weight-heparin? Mediterr. J. Hematol. Infect. Dis. 2015; 7 (1): e2015029. DOI: 10.4084/MJHID.2015.029.
57. Patell R., Khan A., Bogue T. et al. Heparin induced thrombocytopenia antibodies in COVID-19. Am. J. Hematol. 2020; 95 (10): e295–296. DOI: 10.1002/ajh.25935.
58. Thachil J. The versatile heparin in COVID-19. J. Thromb. Haemost. 2020; 18 (5): 1020–1022. DOI: 10.1111/jth.14821.
59. Vicenzi E., Canducci F., Pinna D. et al. Coronaviridae and SARS-associated coronavirus strain HSR1. Emerg. Infect. Dis. 2004; 10 (3): 413–418. DOI: 10.3201/eid1003.030683.
60. Mycroft-West C., Su D., Elli S. The 2019 coronavirus (SARS-CoV-2) surface protein (Spike) S1 receptor binding domain undergoes conformational change upon heparin binding. bioRxiv. [Preprint. Posted: 2020, Mar. 2]. DOI: 10.1101/2020.02.29.971093.
61. Casini A., Alberio L., Angelillo-Scherrer A. et al. Thromboprophylaxis and laboratory monitoring for in-hospital patients with COVID-19 – a Swiss consensus statement by the Working Party Hemostasis. Swiss Med. Wkly. 2020; 150: w20247. DOI: 10.4414/smw.2020.20247.
62. Tang N., Bai H., Chen X., et al. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J. Thromb. Haemost. 2020; 18 (5): 1094–1099. DOI: 10.1111/jth.14817.
63. Ayerbe L., Risco C., Ayis S. The association between treatment with heparin and survival in patients with COVID-19. J. Thromb. Thrombolysis. 2020; 50 (2): 298–301. DOI: 10.1007/s11239-020-02162-z.
64. New COVID-19 HOPE clinical trial recommendations introduced today may reduce or eliminate mechanical ventilation for coronavirus patients. BioSpace. Available at: https://www.biospace.com/article/releases/new-covid-19-hope-clinical-trial-recommendations-introduced-today-may-reduce-or-eliminate-mechanical-ventilation-for-coronavirus-patients/?keywords=new+covid+19+hope+clinical+trial+recommendations+introduced+today+may+reduce+or+eliminate+mechanical+ventilation+for+coronavirus+patients
65. Wang J., Hajizadeh N., Moore E.E. et al. Tissue plasminogen activator (tPA) treatment for COVID-19 associated acute respiratory distress syndrome (ARDS): A case series. J. Thromb. Haemost. 2020; 18 (7): 1752–1755. DOI: 10.1111/jth.14828.
66. Benamu E., Montoya J.G. Infections associated with the use of eculizumab: Recommendations for prevention and prophylaxis. Curr. Opini. Infect. Dis. 2016; 29 (4): 319–329. DOI: 10.1097/QCO.0000000000000279.
Рецензия
Для цитирования:
Галстян Г.М. Коагулопатия при COVID-19. Пульмонология. 2020;30(5):645-657. https://doi.org/10.18093/0869-0189-2020-30-5-645-657
For citation:
Galstyan G.M. Coagulopathy in COVID-19. PULMONOLOGIYA. 2020;30(5):645-657. https://doi.org/10.18093/0869-0189-2020-30-5-645-657