From the Department of Pediatrics, Division of Critical Care Medicine, University of Maryland Children's Hospital, Baltimore, MD.
Critical Care Medicine, Schulich Medicine and Dentistry, Western University, London Health Sciences Center, London, Ontario, Canada.
Pediatr Infect Dis J. 2023 Oct 1;42(10):844-850. doi: 10.1097/INF.0000000000004021. Epub 2023 Jul 6.
Acute kidney injury is common in severe malaria and is independently associated with mortality. The pathogenesis of acute kidney injury (AKI) in severe malaria remains incompletely understood. Ultrasound-based tools such as point-of-care ultrasound (POCUS), ultrasound cardiac output monitors (USCOMs) and renal arterial resistive index (RRI) can be used to detect hemodynamic and renal blood flow abnormalities contributing to AKI in malaria.
We conducted a prospective study of Malawian children with cerebral malaria to determine the feasibility of using POCUS and USCOM to characterize hemodynamic contributors to severe AKI (Kidney Disease: Improving Global Outcomes stage 2 or 3). The primary outcome was feasibility (completion rate of study procedures). We also assessed for differences in POCUS and hemodynamic variables for patients with or without severe AKI.
We enrolled 27 patients who had admission cardiac and renal ultrasounds and USCOM. Completion rates were high for cardiac (96%), renal (100%) and USCOM studies (96%). Severe AKI occurred in 13 of 27 patients (48%). No patients had ventricular dysfunction. Only 1 patient in the severe AKI group was determined to be hypovolemic ( P = 0.64). No significant differences in USCOM, RRI or venous congestion parameters were detected among patients with and without severe AKI. Mortality was 11% (3/27) with the 3 deaths occurring in the severe AKI group ( P = 0.056).
Ultrasound-based cardiac, hemodynamic and renal blood flow measurements appear to be feasible in pediatric patients with cerebral malaria. We were unable to detect hemodynamic or renal blood flow abnormalities contributing to severe AKI in cerebral malaria. Larger studies are needed to corroborate these findings.
严重疟疾中常发生急性肾损伤，且其与死亡率独立相关。严重疟疾所致急性肾损伤（AKI）的发病机制仍不完全清楚。即时床旁超声（POCUS）、超声心输出量监测仪（USCOM）和肾动脉阻力指数（RRI）等基于超声的工具可用于检测导致疟疾相关 AKI 的血流动力学和肾血流异常。
我们对马拉维患有脑型疟疾的儿童进行了一项前瞻性研究，以确定使用 POCUS 和 USCOM 来描述严重 AKI（肾脏病：改善全球预后阶段 2 或 3）的血流动力学病因的可行性。主要结局为可行性（研究程序完成率）。我们还评估了有无严重 AKI 的患者之间的 POCUS 和血流动力学变量的差异。
我们共纳入 27 例患者，这些患者均接受了入院时的心脏和肾脏超声及 USCOM 检查。心脏（96%）、肾脏（100%）和 USCOM 研究的完成率均较高（96%）。27 例患者中有 13 例（48%）发生严重 AKI。无一例患者存在心室功能障碍。仅在严重 AKI 组的 1 例患者中被确定为低血容量（P=0.64）。在有无严重 AKI 的患者之间，未发现 USCOM、RRI 或静脉充血参数存在显著差异。死亡率为 11%（3/27），其中 3 例死亡均发生在严重 AKI 组（P=0.056）。
即时床旁超声心脏、血流动力学和肾血流测量在患有脑型疟疾的儿科患者中似乎是可行的。我们未能检测到导致脑型疟疾中严重 AKI 的血流动力学或肾血流异常。需要更大规模的研究来证实这些发现。
