蛇咬伤相关性血栓性微血管病：系统评价临床特征、结局及干预作用的方案。
Snakebite associated thrombotic microangiopathy: a protocol for the systematic review of clinical features, outcomes, and role of interventions.
机构信息
Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.
出版信息
Syst Rev. 2019 Aug 22;8(1):212. doi: 10.1186/s13643-019-1133-2.
BACKGROUND
Thrombotic microangiopathy is an uncommon complication of snake envenoming associated with a subset of snakebite cases presenting with venom-induced consumption coagulopathy. It presents with microangiopathic haemolytic anaemia and thrombocytopenia. Available studies are predominantly small retrospective observational studies only. Renal end organ injury appears common. It has variably been likened to either thrombotic thrombocytopenic purpura or atypical haemolytic uraemic syndrome. Many studies report acute kidney injury, with dialysis required in a subset of patients. Some studies suggest a role for treatment with plasmapheresis. Interpretation of the literature is complicated by variable nomenclature and historically poor case definitions of both venom-induced consumption coagulopathy and thrombotic microangiopathy associated with snake envenoming.
METHODS
The main objective of this systematic review is to synthesise the worldwide experience of snakebite-associated thrombotic microangiopathy with respect to its features and outcomes, and collate any evidence for the role of plasmapheresis as treatment. A predetermined case definition of confirmed or suspected snakebite with either blood film evidence of microangiopathic haemolytic anaemia or histological evidence of thrombotic microangiopathy will be used. This case definition will determine the search terms and study inclusion criteria. Relevant studies will be identified by electronic database, published conference abstracts, and grey literature search. This systematic review will be performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The quality of included studies will be assessed by a proposed tool for evaluating the methodological quality of case reports and case series. Results will be reported by a descriptive synthesis with a focus on the presenting features; outcomes of acute kidney injury, dialysis-free survival, other end organ damage, and overall survival; and any evidence of a role for treatment with plasmapheresis. The quality of accumulated evidence will be assessed via the Grading of Recommendations, Assessment, Development, and Evaluations framework.
DISCUSSION
It is anticipated that eligible studies will consist of small observational studies. Evidence gathered from this review will provide the first broader understanding of the clinical features, outcomes, prognosis, and management of snakebite-associated thrombotic microangiopathy.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42019121436.
背景
血栓性微血管病是蛇咬伤的一种罕见并发症，与一些表现为毒液诱导的消耗性凝血病的蛇咬伤病例有关。它表现为微血管性溶血性贫血和血小板减少症。现有的研究主要是小的回顾性观察研究。肾脏终末器官损伤似乎很常见。它与血栓性血小板减少性紫癜或非典型溶血尿毒综合征有一定的相似性。许多研究报告了急性肾损伤，一些患者需要透析。一些研究表明，血浆置换治疗有一定作用。由于毒液诱导的消耗性凝血病和蛇咬伤相关的血栓性微血管病的命名不规范，历史上病例定义较差，因此文献的解读变得复杂。
方法
本系统评价的主要目的是综合全世界蛇咬伤相关血栓性微血管病的经验，包括其特征和结局，并整理血浆置换治疗作用的证据。将使用预先确定的确诊或疑似蛇咬伤病例定义，该定义包括血涂片微血管性溶血性贫血的证据或组织学血栓性微血管病的证据。该病例定义将确定搜索词和研究纳入标准。将通过电子数据库、已发表的会议摘要和灰色文献搜索来确定相关研究。本系统评价将根据系统评价和荟萃分析的首选报告项目清单进行和报告。将使用拟议的评估病例报告和病例系列方法学质量的工具来评估纳入研究的质量。结果将通过描述性综合报告，重点关注临床表现；急性肾损伤、无透析生存、其他终末器官损伤和总体生存的结局；以及血浆置换治疗作用的任何证据。通过推荐评估、发展和评估框架来评估累积证据的质量。
讨论
预计合格的研究将由小的观察性研究组成。从本次审查中收集的证据将首次提供更广泛的关于蛇咬伤相关血栓性微血管病的临床特征、结局、预后和管理的理解。
系统评价注册
PROSPERO CRD42019121436。
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