Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia.
Expert Rev Clin Pharmacol. 2023 Jan-Jun;16(6):559-574. doi: 10.1080/17512433.2023.2220963. Epub 2023 Jun 15.
Snakebite is a neglected public health issue causing death and disability, disproportionately affecting tropical and subtropical resource poor countries globally. Snakebite-associated thrombotic microangiopathy (TMA) occurs in a subset of snakebites and is associated with acute kidney injury (sometimes requiring renal replacement therapy) and a risk of chronic kidney disease.
This expert review synthesizes current evidence on therapeutic interventions in snakebite-associated TMA via PubMed search for cohort studies and randomized controlled trials (RCTs) in snakebite-associated TMA from 1970 to October 2022.
There are no interventional RCTs in snakebite-associated TMA. Recent cohort studies from Sri Lanka, India, and Australia report clinical and laboratory endpoint outcomes for intervention with antivenom and therapeutic plasma-exchange (TPE). TPE is a resource intense and costly treatment using large volumes of blood donor plasma. There is no consistent evidence supporting TPE in snakebite-associated TMA with respect to patient survival, dialysis-free survival, or hospital length of stay. Antivenom is the standard of care for patients with snake envenoming, but there is no specific evidence of benefit in snakebite-associated TMA. Emerging new therapies in snakebite more broadly are untested in snakebite-associated TMA. RCTs are needed to improve the evidence for treatment of snakebite-associated TMA.
蛇咬伤是一个被忽视的公共卫生问题，可导致死亡和残疾，在全球范围内，不成比例地影响着热带和亚热带资源匮乏的国家。蛇咬伤相关的血栓性微血管病（TMA）发生在一部分蛇咬伤中，与急性肾损伤（有时需要肾脏替代治疗）和慢性肾脏病风险相关。
本文通过对 1970 年至 2022 年 10 月间 PubMed 中关于蛇咬伤相关 TMA 的队列研究和随机对照试验（RCT）进行检索，综合了当前关于蛇咬伤相关 TMA 治疗干预的证据。
目前尚无关于蛇咬伤相关 TMA 的干预性 RCT。来自斯里兰卡、印度和澳大利亚的最近队列研究报告了抗蛇毒血清和治疗性血浆置换（TPE）干预的临床和实验室终点结局。TPE 是一种资源密集型和昂贵的治疗方法，需要使用大量的献血者血浆。没有一致的证据支持 TPE 在蛇咬伤相关 TMA 中对患者存活率、无透析存活率或住院时间有影响。抗蛇毒血清是蛇咬伤患者的标准治疗方法，但在蛇咬伤相关 TMA 中没有具体的益处证据。在更广泛的蛇咬伤中出现的新兴新疗法在蛇咬伤相关 TMA 中尚未经过测试。需要 RCT 来提高蛇咬伤相关 TMA 治疗的证据水平。
