Misra D P, Das S, Pattnaik M, Singh S C, Jena R K
Postgraduate Department of Medicine, SCB Medical College, Cuttack.
J Assoc Physicians India. 2011 Sep;59:552-6.
The present study was designed to assess hepatic and renal dysfunction in Plasmodium falciparum malaria, and evaluate if such abnormalities had any bearing with the hemorrheological dysfunction.
Sixty consecutive patients of Plasmodium falciparum malaria with hepatic and renal dysfunction (Group A) and twenty consecutive cases of uncomplicated falciparum malaria (Group B) were studied. Patients with past history of alcoholism, jaundice, chronic renal failure, bleeding diathesis or coagulopathy were excluded from the study. Laboratory investigations done were liver and renal function tests, complete blood count and coagulation profile. The data collected was analysed to inter - correlate parameters of hepatic, renal and hemorrheological dysfunction.
In Group A, all had rigor and chill, icterus while 57% had oliguria and hepatomegaly, 37% splenomegaly, with less than 2% having overt bleeding diathesis. On evaluation, in Group A, 57% had acute renal failure, mean value of bilirubin was 13.91 (+/- 12.53) mg/dL, ALT 76.92 (+/- 37.48) IU/ml, AST 135.32 (+/- 97.33) IU/ml, mean PT was 13.03 (+/- 2.22) seconds, mean aPTT was 31.69 +/- 6.76 seconds, FDP by D-dimer was raised in 53% and LDH was raised in 78% respectively. In Group B mean PT was 11.93 (+/- 1.51) seconds, mean APTT was 29.39 +/- 2.89 seconds and FDP by D-dimer was raised in 30% respectively. Thrombocytopenia was seen in 26% cases in Group A and 15% cases in Group B. On analysis, in Group B, there was statistically significant negative correlation of total platelet count with serum AST (p = .010) and serum ALT (p = .036), serum ALP with BT (p = .036), but positively with CT (p = .006) and aPTT (p = .036). In Group A, serum bilirubin was found to have significant negative correlation with haemoglobin (p = .019),positive correlation with aPTT (p = .037), urea (p = .000) and serum creatinine (p = .000), serum ALP Positively with serum urea (p = .025) and serum creatinine (p = .037), serum urea negatively with haemoglobin(p = .015), so also did serum creatinine (p = .025),prothrombin time positively with serum urea(p = 0.037) and serum creatinine (p = 0.013), serum FDP positively with serum urea (p = 0.038) and serum creatinine (p = 0.022), bleeding time positively with serum AST(p = .002).
Despite less than 2% of patients in Group A having clinically overt bleeding diathesis, raised FDP (53%), prolonged aPTT (67%), low total platelet count (26%) and anemia (87%) were found in a significant number of patients, suggesting subclinical DIC. Therefore patients with Plasmodium falciparum malaria have high incidence of subclinical haemorrheological disorders which do not amount to overt DIC but adversely affect renal function contributing to acute renal failure.
本研究旨在评估恶性疟原虫疟疾患者的肝肾功能障碍，并评估这些异常是否与血液流变学功能障碍有关。
对60例连续的伴有肝肾功能障碍的恶性疟原虫疟疾患者（A组）和20例连续的无并发症恶性疟患者（B组）进行研究。有酗酒、黄疸、慢性肾衰竭、出血倾向或凝血病既往史的患者被排除在研究之外。进行的实验室检查包括肝肾功能测试、全血细胞计数和凝血指标。对收集到的数据进行分析，以相互关联肝、肾和血液流变学功能障碍的参数。
A组患者均有寒战和发冷、黄疸，57%有少尿和肝肿大，37%有脾肿大，不到2%有明显的出血倾向。评估发现，A组中57%有急性肾衰竭，胆红素平均值为13.91（±12.53）mg/dL，谷丙转氨酶（ALT）76.92（±37.48）IU/ml，谷草转氨酶（AST）135.32（±97.33）IU/ml，凝血酶原时间（PT）平均值为13.03（±2.22）秒，活化部分凝血活酶时间（aPTT）平均值为31.69±±6.76秒，53%的患者D-二聚体检测的纤维蛋白降解产物（FDP）升高，78%的患者乳酸脱氢酶（LDH）升高。B组PT平均值为11.93（±1.51）秒，aPTT平均值为29.39±2.89秒，30%的患者D-二聚体检测的FDP升高。A组26%的病例和B组15%的病例出现血小板减少。分析发现，B组中，血小板总数与血清AST（p = 0.010）和血清ALT（p = 0.036）、血清碱性磷酸酶（ALP）与出血时间（BT，p = 0.036）呈统计学显著负相关，但与凝血时间（CT，p = 0.006）和aPTT（p = 0.036）呈正相关。在A组中，血清胆红素与血红蛋白呈显著负相关（p = 0.019），与aPTT呈正相关（p = 0.037）、与尿素（p = 0.000）和血清肌酐（p = 0.000）呈正相关，血清ALP与血清尿素（p = 0.025）和血清肌酐（p = 0.037）呈正相关，血清尿素与血红蛋白呈负相关（p = 0.015），血清肌酐也是如此（p = 0.025），凝血酶原时间与血清尿素（p = 0.037）和血清肌酐（p = 0.013）呈正相关，血清FDP与血清尿素（p = 0.038）和血清肌酐（p = 0.022）呈正相关，出血时间与血清AST呈正相关（p = 0.002）。
尽管A组中不到2%的患者有临床明显的出血倾向，但大量患者出现FDP升高（53%）、aPTT延长（67%）、血小板总数降低（26%）和贫血（87%），提示存在亚临床弥散性血管内凝血（DIC）。因此，恶性疟原虫疟疾患者亚临床血液流变学紊乱的发生率很高，虽未达到明显的DIC，但对肾功能有不利影响，可导致急性肾衰竭。
