恶性疟合并溶血尿毒综合征的诊疗探讨

Diagnosis and treatment of hemolytic uremic syndrome in cases with Falciparum malaria

目的探讨恶性疟引起的溶血尿毒综合征（HUS）的诊断及治疗要点。方法对本院2008至2014年13例恶性疟引起的溶血尿毒综合征患者的临床特点、辅助检查及治疗情况进行回顾性分析。结果入组患者中男性12例,女性1例,年龄22~60岁,均符合恶性疟疾合并溶血尿毒综合征的诊断。其中10例合并脑型疟,1例合并消化道出血,2例出现呼吸循环衰竭。经抗疟原虫治疗、激素治疗、补液对症治疗以及呼吸机、血液透析滤过等,入组的13例患者中1例死亡,1例自动出院,11例治愈出院,其中5例因急性肾功能衰竭行血液透析滤过治疗肾功能恢复,随访11例治愈患者均未出现慢性肾功能损害,2例病例出现再燃。结论疟疾的早期诊断及治疗,对控制溶血及阻止脏器损害具有重要作用;大剂量长疗程使用蒿甲醚可增强抗疟原虫效果,早期应用激素可有效阻止溶血,减轻肾脏损害,对严重溶血、急性肾功能衰竭病例应及时采取血液透析滤过治疗,以降低病死率。

Objective To explore the clinical features and therapeutic strategy for hemolytic uremic syndrome（HUS） associated with falciparum malaria. Methods The medical records of 13 patients with HUS who were admitted to Beijing Ditan Hospital, Capital Medical University from 2008 to 2014 were reviewed, retrospectively. The clinical features, auxiliary examination results and therapeutic strategy were assessed, respectively. Results Among the 13 cases, 12 cases were male and 1 was female; ages of the 13 patients were ranged from 22 to 60 years old. Every patient conformed to the diagnosis of HUS associated with falciparum malaria. There were 10 patients developed cerebral malaria, one case was secondary to gastrointestinal bleeding and 2 patients had respiratory and circulatory failure. After treatments of anti-malaria, hormone therapy, ventilator-assisted and continuous venovenous hemodiafiltration（CVVHDF）, etc, one patient died, one patient was discharged by his own accord, and 11 patients were cured with no chronic renal damage. Five patients with acute renal failure were recovered by CVVHDF. During the follow up visiting, two of them recrudesced. Conclusions Early diagnosis and treatment of malaria play important roles in hemolysis and organ damage. High-dose, long period of treatment with the artemether can strengthen resistance to malaria. Early application of hormone could prevent hemolysis and alleviate kidney damage effectively. In order to reduce mortality, patients who have severe hemolysis or acute renal failure should be treated with hemodiafiltration therapy in time.