Efferent therapy in cases of malaria

Today, like 150 years ago, malaria remains one of the most common diseases in the world, every year affecting up to 500 million people. Of the four species of malaria, tropical is characterized as the most severe, and deaths caused by it make up 98% of all deaths from malaria [1]. In India, malaria causes deaths of more than 15,000 children per year [2], and in sub-Saharan Africa - more than 200,000 children [3].

The severity of the clinical course of falciparum malaria (FM) is due to many reasons, including the presence of specific toxic factors (e.g. cytotoxic substance Megreta) in this species of parasites (Plasmodium falciparum), manifestation of tissue anaphylaxis, often associated with more pronounced immunoreactive properties of the waste products of this type of plasmodium. The released substance in the blood activate macrophages and lead to the release of pro-inflammatory cytokines (TNF, IL1β, IL2), which determine the severity of endotoxemia.

Complications, often leading to death, develop mostly with FM. Most common of these are: development of a cerebral form  with cerebral malaria coma, severe hemoglobinuric fever, malarial algid, acute renal failure, in rare cases - pulmonary edema and malarial hepatitis. All of them in one way or another are the result of severe endotoxemia.

Brain damage - malarial coma may be accompanied by swelling of the brain, especially dangerous for children, often (20%) resulting in death.

Acute renal failure is the result of intense hemolysis, hemoglobinuria, followed with impaired renal microcirculation and tubular necrosis.
Toxic shock is accompanied by clinic of malaria algid accompanied by severe vascular insufficiency with a fall in blood pressure and dehydration.

Toxic shockis accompanied byacute respiratory failure, which according tothe current viewsisrespiratory distress syndromeof adults(ARDS),which is clinically manifestedby toxicpulmonary edema.

Observedare severe disordersof biochemicalhomeostasis.Activation ofproteolysisis accompanied by accumulationof toxicmedium weightoligopeptides.Disordersoflipid peroxidationlead to the accumulationoftheirtoxicendproducts, such asmalondialdehydeand dieneconjugates,with the suppressionofantioxidantactivity (superoxide dismutase).

FM is particularly dangerousfor pregnant women. Severeplacentalsequestrationof parasiteswith a massivefibrinoiddepositioninthe basal plateof the fruit part of theplacentabreaks flow ofoxygento the fetus,with the development ofachronic hypoxiaand intrauterine growth retardation. There is highfrequency ofantenatalfetal death.Withlive birthsthere is severeasphyxia (with Apgar score5-6), and the periodof earlyneonataladaptationis characterized withhigh frequencymoderate or severe lesions of central nervous system. Frequentlyobserved aresigns ofintrauterine infectionand the developmentof septiccomplications [3, 4].

Malariais typically characterized byimmunosuppression,which often leadsto a varietyof bacterial superinfection. Unconsciouspatientscan be subjected toaspiration pneumonia. Possible is the developmentandsepsis caused bygram-negativemicroflora,includingsalmonella.

All of the aboveis the reasonfor application ofefferenttherapy fordetoxification,becauseany otherway to ridthe body ofaccumulatedtoxic substancesis impossible.In addition, intensive therapy of malariawithquininedrugsalone maylead tohearing lossdue tothe selective actionofa pairof cranialnerves.Also reinforced aretoxic lesionsof eye(keratitis, iritis, iridocyclitis, and optic neuritis).

Most acceptable methods of efferent therapy (extracorporeal detoxication) are hemosorbtion (hemocarboperfusion) and plasmapheresis.

Hemosorbtionallows you to selectivelyremove fromcirculationnot onlytoxic moleculeswith the presenceof "freeradicals"in their structure, but also theparasiteswith theirhighadhesive activity. In addition, withFMon the surfaceof red blood cellsthere are "bumps", containing high molecular weight protein, which interacts with receptors ofendotheliumof venulesand capillaries,provides adhesionof red blood cellswith a delayinsmall vessels ofthe brain, lungs, kidneys, liver, increasing their toxic damage. These "excited" red cells containingPlasmodium falciparum,begin tostickto the healthyred blood cells, forming rosettes. Thisadhesionof red cellsto the endothelium andthe rosetteare the basisof the pathogenesis offalciparum malaria. Therefore,it is hopedthat the adsorptiononactivated surfaceofhemosorbentandremoval of suchpathologicallyexcitedred cellsshouldbe helpful.This procedure shouldhelp to smoothall the clinicalmanifestations ofmalariaand preventitscomplications.

Plasmapheresishelps to removeplasmafrom the bodywith allits toxicsubstances, regardless of whether they are"free radicals"and of increasedadhesive activity. In addition, plasmapheresisallows you to extractan excessive amountof "freehemoglobin," accumulatingin the destruction ofred cells (hemolysis) and threateningto develop renal diseasein itsexcretion inthe urine.In addition, the removal of "toxicpressure"from immunesystemshould helpits recovery.Thisis also helped byreplacementof extractedplasmawith fresh frozen donor plasmawith all the normalcomponents of the immunedefense.

Plasmapheresisis well establishedin cases of toxicosisof pregnant women,which is particularly importantfor patients with malaria.This procedure shouldalso contribute tothe eliminationof toxiccomplicationsin the development ofthe fetus and thebirth of a healthychild.

Both procedures ofextracorporeal detoxification- bothhemosorbtionand plasmapheresis-are most appropriatelycarried out usingthe Russian device«Hemofenix»,lowpriming volumeof which ensures safetyof such procedures, even in critical conditionsof patients withunstable hemodynamics, including pregnant women and young children. "Single needle" connection, automatic dosingof anticoagulant, effective protection against entrance ofair into thepatient'sblood vesselsand portablenature ofthe equipmentensures safeconduct of proceduresduring travel toother medical facilities [5].

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