Pathophysiology, clinical presentation, and treatment of coma and acute kidney injury complicating falciparum malaria.
Pathophysiology, clinical presentation, and treatment of coma and acute kidney injury complicating falciparum malaria.
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DOI：
10.1097/qco.0000000000000419
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发表时间：
2018-03
影响因子：
3.9
通讯作者：
Dondorp AM
中科院分区：
文献类型：
--
作者：
Plewes K;Turner GDH;Dondorp AM
脑损伤和急性肾损伤（阿基）是严重恶性疟疾成人和儿童死亡率的独立预测因子。在这篇综述中，我们介绍了最近的进展，了解这些并发症的严重疟疾的病理生理，临床特征和管理，并讨论了未来的研究领域。脑型疟疾和阿基是严重疟疾的严重和公认的并发症。常见的病理生理学途径包括由于寄生红细胞的隔离而导致的微循环受损、全身炎症反应和内皮活化。最近的MRI研究显示，成人和儿童均出现明显的脑肿胀，并有后部可逆性脑病综合征样综合征的证据，尽管包括甘露醇和地塞米松在内的靶向干预措施无效。最近的研究表明，无细胞血红蛋白氧化应激与成人和儿童阿基的病理生理学有关。对乙酰氨基酚可能通过抑制无细胞介导的氧化应激来保护肾功能。目前还不清楚血红素介导的内皮细胞活化或氧化应激是否参与脑型疟疾。脑和肾功能障碍的直接原因仍然不完全清楚。最佳治疗包括及时诊断和青蒿琥酯的有效抗疟治疗。肾脏替代治疗降低了阿基的死亡率，但延迟诊断是一个问题。
Cerebral impairment and acute kidney injury (AKI) are independent predictors of mortality in both adults and children with severe falciparum malaria. In this review, we present recent advances in understanding the pathophysiology, clinical features, and management of these complications of severe malaria, and discuss future areas of research. Cerebral malaria and AKI are serious and well recognized complications of severe malaria. Common pathophysiological pathways include impaired microcirculation, due to sequestration of parasitized erythrocytes, systemic inflammatory responses, and endothelial activation. Recent MRI studies show significant brain swelling in both adults and children with evidence of posterior reversible encephalopathy syndrome-like syndrome although targeted interventions including mannitol and dexamethasone are not beneficial. Recent work shows association of cell-free hemoglobin oxidation stress involved in the pathophysiology of AKI in both adults and children. Paracetamol protected renal function likely by inhibiting cell-free-mediated oxidative stress. It is unclear if heme-mediated endothelial activation or oxidative stress is involved in cerebral malaria. The direct causes of cerebral and kidney dysfunction remain incompletely understood. Optimal treatment involves prompt diagnosis and effective antimalarial treatment with artesunate. Renal replacement therapy reduces mortality in AKI but delayed diagnosis is an issue.