COVID-19: The crucial role of blood coagulation and fibrinolysis
COVID-19: The crucial role of blood coagulation and fibrinolysis
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DOI：
10.1007/s11739-020-02443-8
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发表时间：
2020-08-03
影响因子：
4.6
通讯作者：
Coccheri, Sergio
中科院分区：
文献类型：
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作者：
Coccheri, Sergio
最近关于COVID-19的文献中充斥着大量研究，这些研究往往给出临时或相互矛盾的结果，因此值得反思和重新考虑。事实上，这种新疾病的病理生理学知识仍在发展中，因此引发了讨论和解释。关于血液凝固和纤维蛋白溶解的作用，这些机制应被认为是至关重要的，特别是在严重的情况下。建议考虑血栓形成表现的两种不同表型：目前的“血栓栓塞型”也发生在其他类型的脓毒症中，以及弥漫性微血栓形成型，主要发生在肺部，但有时会延伸到其他器官。这两种类型都可能诱发严重疾病，并可能致命。微血栓形成模式，更具体地说是COVID-19，是由于凝血的大规模激活严格结合了高强度的炎症和免疫反应。这导致广泛的闭塞性血栓性微血管病，伴有肺泡破坏和阻塞性新血管生成。纤维蛋白溶解的参与，往往被忽视，赋予一个双重的激活/抑制过程，最终有利于纤维蛋白溶解关闭，加强微血栓的持久性。考虑到这些特殊的机制，似乎很明显，目前的抗血栓药物的预防和治疗效果不能想当然，因此需要新的具体和严格的对照试验。
The overflow of studies in the recent literature on COVID-19 often gives provisional or contradictory results and therefore deserves pauses of reflection and reconsideration. In fact, knowledges of pathophysiology of this new disease are still in development and hence originate discussions and interpretations. Regarding the role of blood coagulation and fibrinolysis, these mechanisms should be considered as crucial especially in severe cases. It is proposed to consider two distinct phenotypes of thrombotic manifestations: the current "thromboembolic type" also occurring in other kinds of sepsis, and the diffuse micro-thrombotic type, prevailing in the lungs but sometimes extending to other organs. Both types can induce severe disease and are potentially lethal. The micro-thrombotic pattern, more specific for COVID-19, results from a massive activation of coagulation strictly coupled with a hyper-intense inflammatory and immune reaction. This results in widespread occlusive thrombotic micro-angiopathy with destruction of alveoli and obstructive neoangiogenesis. The involvement of fibrinolysis, often neglected, confers a double faceted process of activation/inhibition, finally conducive to a fibrinolytic shutdown that reinforces persistence of micro-thrombi. Considering these peculiar mechanisms, it seems evident that both prophylactic and therapeutic effects of current anti-thrombotic drugs cannot be taken for granted and need therefore new specific and rigorous controlled trials.