期刊
LANCET RHEUMATOLOGY
卷 4, 期 2, 页码 E135-E144出版社
ELSEVIER
DOI: 10.1016/S2665-9913(21)00322-2
关键词
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类别
资金
- National Institutes of Health
- National Cancer Institute
In patients with moderate-to-severe COVID-19 pneumonia, immunomodulatory therapy has overall benefits, while immunosuppression is not proven to be beneficial in mild cases or critical cases. Timely immunosuppression may have a window of opportunity, but caution should be exercised regarding RNAaemia. Immunomodulatory therapy can inhibit excessive immune responses and immunothrombosis.
In patients with moderate-to-severe COVID-19 pneumonia, an aberrant post-viral alveolitis with excessive inflammatory responses and immunothrombosis underpins use of immunomodulatory therapy (eg, corticosteroids and interleukin-6 receptor antagonism). By contrast, immunosuppression in individuals with mild COVID-19 who do not require oxygen therapy or in those with critical disease undergoing prolonged ventilation is of no proven benefit. Furthermore, a window of opportunity is thought to exist for timely immunosuppression in patients with moderateto-severe COVID-19 pneumonia shortly after clinical presentation. In this Viewpoint, we explore the shortcomings of a universal immunosuppression approach in patients with moderate-to-severe COVID-19 due to disease heterogeneity related to ongoing SARS-CoV-2 replication, which can manifest as RNAaemia in some patients treated with immunotherapy. By contrast, immunomodulatory therapy has overall benefits in patients with rapid SARS-CoV-2 clearance, via blunting of multifaceted, excessive innate immune responses in the lungs, potentially uncontrolled T-cell responses, possible autoimmune responses, and immunothrombosis. We highlight this therapeutic dichotomy to better understand the immunopathology of moderate-to-severe COVID-19, particularly the role of RNAaemia, and to refine therapy choices.
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