COVID-19 and coagulation: bleeding and thrombotic manifestations of SARS-CoV-2 infection
COVID-19 and coagulation: bleeding and thrombotic manifestations of SARS-CoV-2 infection
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DOI：
10.1182/blood.2020006520
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发表时间：
2020-07-23
期刊：
影响因子：
20.3
通讯作者：
Rosovsky, Rachel P.
中科院分区：
文献类型：
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作者：
Al-Samkari, Hanny;Leaf, Rebecca S. Karp;Rosovsky, Rachel P.
2019冠状病毒病（COVID-19）患者的D-二聚体水平升高。早期报告描述了高静脉血栓栓塞（VTE）和弥散性血管内凝血（DIC）的发生率，但数据有限。这项多中心回顾性研究描述了400名住院COVID-19患者（144名危重患者）的止血和血栓并发症的发生率和严重程度，这些患者主要接受标准剂量的预防性抗凝治疗。比较有和无凝血相关并发症患者的凝血和炎症参数。多变量logistic模型检验了这些标记物在预测凝血相关并发症、危重病和死亡中的效用。影像学证实的VTE发生率为4.8%（95%置信区间[CI]，2.9-7.3），总体血栓性并发症发生率为9.5%（95% CI，6.8-12.8）。总出血率和大出血率分别为4.8%（95% CI，2.9-7.3）和2.3%（95% CI，1.0-4.2）。在危重患者中，影像学证实的VTE和大出血发生率分别为7.6%（95% CI，3.9-13.3）和5.6%（95% CI，2.4-10.7）。初次就诊时D-二聚体升高可预测住院期间凝血相关并发症（D-二聚体>2500 ng/mL，血栓形成的校正比值比[OR]为6.79 [95% CI，2.39-19.30];出血的校正比值比[OR]为3.56 [95% CI，1.01-12.66]）、危重病和死亡。在住院期间，在最初表现时预测血栓形成的其他标志物包括血小板计数>450 3 109/L（校正OR，3.56 [95% CI，1.27-9.97]），C反应蛋白（CRP）>100 mg/L（校正OR，2.71 [95%CI，1.26-5.86]）和红细胞沉降率（ESR）>40 mm/h（校正OR，2.64 [95%CI，1.07-6.51]）。ESR、CRP、纤维蛋白原、铁蛋白和降钙素原在有血栓性并发症的患者中高于无血栓性并发症的患者。DIC、临床相关的血小板减少症和纤维蛋白原减少是罕见的，与显著的出血表现相关。鉴于观察到的出血率，需要进行随机试验来确定COVID-19患者强化抗凝预防的任何潜在益处。（血。2020;136（4）：489-500）
Patients with coronavirus disease 2019 (COVID-19) have elevated D-dimer levels. Early reports describe high venous thromboembolism (VTE) and disseminated intravascular coagulation (DIC) rates, but data are limited. This multicenter retrospective study describes the rate and severity of hemostatic and thrombotic complications of 400 hospital-admitted COVID-19 patients (144 critically ill) primarily receiving standard-dose prophylactic anti-coagulation. Coagulation and inflammatory parameters were compared between patients with and without coagulation-associated complications. Multivariable logistic models ex-amined the utility of these markers in predicting coagulation-associated complications, critical illness, and death. The radiographically confirmed VTE rate was 4.8% (95% con-fidence interval [CI], 2.9-7.3), and the overall thrombotic complication rate was 9.5% (95% CI, 6.8-12.8). The overall and major bleeding rates were 4.8% (95% CI, 2.9-7.3) and 2.3% (95% CI, 1.0-4.2), respectively. In the critically ill, radiographically confirmed VTE and major bleeding rates were 7.6% (95% CI, 3.9-13.3) and 5.6% (95% CI, 2.4-10.7), respectively. Elevated D-dimer at initial presentation was predictive of coagulation-associated com-plications during hospitalization (D-dimer >2500 ng/mL, adjusted odds ratio [OR] for thrombosis, 6.79 [95% CI, 2.39-19.30]; adjusted OR for bleeding, 3.56 [95% CI, 1.01-12.66]), critical illness, and death. Additional markers at initial presentation predictive of thrombosis during hospitalization included platelet count >450 3 109/L (adjusted OR, 3.56 [95% CI, 1.27-9.97]),C-reactive protein (CRP) >100 mg/L (adjusted OR, 2.71 [95% CI, 1.26-5.86]), and erythrocyte sedimentation rate (ESR) >40 mm/h (adjusted OR, 2.64 [95% CI, 1.07-6.51]). ESR, CRP, fi-brinogen, ferritin, and procalcitonin were higher in patients with thrombotic complications than in those without. DIC, clinically relevant thrombocytopenia, and reduced fibrinogen were rare and were associated with significant bleeding manifestations. Given the observed bleeding rates, randomized trials are needed to determine any potential benefit of intensified anticoagulant prophylaxis in COVID-19 patients. (Blood. 2020;136(4):489-500)