KARAKTERISTIKE I LEČENJE KOAGULOPATIJE UDRUŽENE SA COVID-19

Predrag Miljić

doi:10.5937/mp72-33067

Prof. dr Predrag Miljić Klinika za hematologiju, Univerzitetski klinički centar Srbije, Medicinski fakultet Univerziteta u Beogradu

DOI: https://doi.org/10.5937/mp72-33067

Ključne reči: COVID-19, koagulopatija, tromboza, D-dimer, antikoagulansi

Sažetak

Koagulopatija udružena sa COVID-19 predstavlja tromboinflamatorno stanje i jedan je od najvažnijih uzroka morbiditeta i mortaliteta u ovoj bolesti. Pojava koagulopatije korelira sa intenzitetom inflamatornog odgovora na infekciju SARS-Cov-2 virusom, a njeno prisustvo se karakteriše laboratorijskim pokazateljima hiperkoagulabilnosti krvi i klinički izraženim protrombogenim stanjem. Iako mehanizam koagulopatije nije potpuno razjašnjen, smatra se da disregulisani i prenaglašeni imunološki odgovor posredovan inflamatornim citokinima, aktiviranje komplementa, aktiviranje leukocita sa oslobađanjem slobodnih nukleinskih kiselina i histona u cirkulaciju, hipoksija i oštećenje endotela imaju veoma važnu ulogu u njenom nastanku i progresiji. Tromboze se mogu javiti u svim delovima cirkulatornog sistema pri čemu su najčešće lokalizovane u mikrocirkulaciji pluća i venskom delu vaskulature. U većem broju studija je pokazano da se prisustvo trombne embolije pluća može dokazati objektivnm metodama kod približno 15% COVID-19 bolesnika koji se leče u jedinicama intenzivne nege, dok je učestalost ukupnog venskog tromboembolizma u ovoj grupi bolesnika preko 20% uprkos primeni antitrombozne profilakse. Iako znatno ređe u odnosu na trombozu vena, kod COVID-19 bolesnika javljaju se i tromboze u araterijskom sistemu, najčešće u vidu infarkta miokarda, ishemijskog šloga i okluzije perifernih arterija. Oštećenje endotela pod dejstvom virusa ili inflamatornog odgovora, aktiviranje trombocita i koagulacionog sistema sa taloženjem fibrina dovodi do opsežnih tromboza u mirkocirkulaciji pluća i drugih tkiva i direktno doprinosi pojavi respiratrne insuficijencije, ARDS-a ili funkcionalne slabosti drugih organa. Stoga koagulopatija u COVID-19 predstavlja integralni deo patofiziološkog mehanizma bolesti i doprinosi njenom kliničkom ispoljavanju i progresiji. Osnovna laboratorijska karakteristika COVID-19 koagulopatije su povišene vrednosti D-dimera u krvi koji nastaje u procesu razgradnje istaloženog fibrina pod dejstvom fibrinolitičkih enzima u mikrocirkulaciji pluća i drugih organa. Zbog toga vrednosti D-dimera odražavaju intenzitet inflamatornog dogovora u plućima i imaju prognostički značaj u prepoznavanju bolesnika sa rizikom od pojave ozbiljnih komplikacija i nepovoljnog toka bolesti. Za razliku od diseminovane intravaskularne koagulacije u sepsi, teška trombocitopenija i hipofibrinogenemija kao i klinički ispoljena sklonost krvarenju su retki u COVID-19 koagulopatiji. Zbog visoke učestalosti i važne uloge koagulopatije u morbiditetu i mortalitetu, primena antikoagulantne profilakse je preporučena kod svih hospitalizovanih COVID-19 bolesnika. Međutim, optimalan način lečenja koagulopatije i intenzitet antitrombozne profilakse nisu još uvek definisani i predstavljaju u ovom momentu predmet intenzivnih istraživanja.

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