Snakebite Associated Thrombotic Microangiopathy and Recommendations for Clinical Practice

Snakebite is a significant and under-resourced global public health issue. Snake venoms cause a variety of potentially fatal clinical toxin syndromes, including venom-induced consumption coagulopathy (VICC) which is associated with major haemorrhage. A subset of patients with VICC develop a thrombotic microangiopathy (TMA). This article reviews recent evidence regarding snakebite-associated TMA and its epidemiology, diagnosis, outcomes, and effectiveness of interventions including antivenom and therapeutic plasma-exchange. Snakebite-associated TMA presents with microangiopathic haemolytic anaemia (evidenced by schistocytes on the blood film), thrombocytopenia in almost all cases, and a spectrum of acute kidney injury (AKI). A proportion of patients require dialysis, most survive and achieve dialysis free survival. There is no evidence that antivenom prevents TMA specifically, but early antivenom remains the mainstay of treatment for snake envenoming. There is no evidence for therapeutic plasma-exchange being effective. We propose diagnostic criteria for snakebite-associated TMA as anaemia with >1.0% schistocytes on blood film examination, together with absolute thrombocytopenia (<150 × 109/L) or a relative decrease in platelet count of >25% from baseline. Patients are at risk of long-term chronic kidney disease and long term follow up is recommended.

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Long-Term Therapeutic Plasma Exchange to Prevent End-Stage Kidney Disease in Adult Severe Resistant Henoch-Schonlein Purpura Nephritis

Case Reports in Nephrology ◽

10.1155/2015/269895 ◽

2015 ◽

Vol 2015 ◽

pp. 1-5

Author(s):

Patrick Hamilton ◽

Olumide Ogundare ◽

Ammar Raza ◽

Arvind Ponnusamy ◽

Julie Gorton ◽

...

Keyword(s):

Renal Function ◽

Kidney Disease ◽

Plasma Exchange ◽

Kidney Injury ◽

Term Treatment ◽

Therapeutic Plasma Exchange ◽

End Stage Kidney Disease ◽

Long Term Treatment ◽

End Stage

A 27-year-old man presented with a palpable purpuric skin rash and joint and abdominal pain in April 2010. He had acute kidney injury and his creatinine quickly deteriorated to 687 μmol/L, with associated nephrotic range proteinuria. Kidney biopsy showed crescentic Henoch-Schonlein nephritis. He was treated with intravenous cyclophosphamide and prednisolone despite which his renal function deteriorated; he required haemodialysis for a short duration and seven sessions of therapeutic plasma exchange (TPE). Renal function improved, but after discharge from hospital he suffered 2 further relapses, each with AKI, in 4 months. Cyclophosphamide was not effective and therefore Rituximab was introduced. He initially had a partial response but his renal function deteriorated despite continued therapy. TPE was the only treatment that prevented rapid renal functional deterioration. A novel long-term treatment strategy involving regular TPE every one to two weeks was initiated. This helped to slow his progression to end-stage kidney disease over a 3-year period and to prolong the need for renal replacement therapy over this time.

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Media Awareness and Screen Time Reduction in Children, Youth or Families: A Systematic Literature Review

Child Psychiatry & Human Development ◽

10.1007/s10578-021-01281-9 ◽

2021 ◽

Author(s):

Hanno Krafft ◽

Katja Boehm ◽

Silke Schwarz ◽

Michael Eichinger ◽

Arndt Büssing ◽

...

Keyword(s):

Screen Time ◽

Positive Influence ◽

Cochrane Library ◽

Public Health Issue ◽

Global Public Health ◽

Screen Media ◽

Long Term Follow Up ◽

And Behavior

AbstractExcessive use of screen media is a global public health issue and especially extensive screen exposure during very early childhood. This review was conducted in order to update previous reviews on the effectiveness of interventions to reduce screen time. An electronic literature search was carried out in MEDLINE, COCHRANE LIBRARY and CINAHL for articles indexed from June 2011 until October 2019. The search identified 933 publications of which 11 publications were included in this review. There are studies showing interventions with a positive influence on reduction of screen time and the participants’ awareness and behavior concerning the use of screen media, as well as studies without such effects. No intervention was identified to be superior. This warrants further investigation of potentially effective combinations of intervention components and long-term follow-up.

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Therapeutic Plasma Exchange Application in Children Requires Individual Decision

Journal of Pediatric Intensive Care ◽

10.1055/s-0040-1714098 ◽

2020 ◽

Author(s):

Gürkan Atay ◽

Demet Demirkol

Keyword(s):

Plasma Exchange ◽

Vascular Access ◽

Pediatric Patients ◽

Demyelinating Disease ◽

Pediatric Intensive Care ◽

Therapeutic Plasma Exchange ◽

Transplantation Rejection ◽

Access Problems ◽

Uremic Syndrome

AbstractTherapeutic plasma exchange (TPE) is a treatment administered with the aim of removing a pathogenic material or compound causing morbidity in a variety of neurologic, hematologic, renal, and autoimmune diseases. In this study, we aimed to assess the indications, efficacy, reliability, complications, and treatment response of pediatric patients for TPE. This retrospective study analyzed data from 39 patients aged from 0 to 18 years who underwent a total of 172 TPE sessions from January 2015 to April 2018 in a tertiary pediatric intensive care unit. Indications for TPE were, in order of frequency, macrophage activation syndrome (28.2%, n = 11), renal transplantation rejection (15.4%, n = 6), liver failure (15.4%, n = 6), Guillain–Barre's syndrome (15%, n = 6), hemolytic uremic syndrome (7.7%, n = 3), acute demyelinating disease (7.7%, n = 3), septic shock (5.1%, n = 2), and intoxication (5.1%, n = 2). No patient had any adverse event related to the TPE during the procedure. The TPE session was ended prematurely in one patient due to insufficient vascular access and lack of blood flow (2.6%). In the long term, thrombosis due to the indwelling central catheter occurred (5.1%, n = 2). TPE appears to be an effective first-stage or supplementary treatment in a variety of diseases, may be safely used in pediatric patients, and there are significant findings that its area of use will increase. In experienced hands and when assessed carefully, it appears that the rate of adverse reactions and vascular access problems may be low enough to be negligible.

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Earlier intervention for acute kidney injury: evaluation of an outreach service and a long-term follow-up

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfu316 ◽

2014 ◽

Vol 30 (2) ◽

pp. 239-244 ◽

Cited By ~ 18

Author(s):

M. E. Thomas ◽

A. Sitch ◽

J. Baharani ◽

G. Dowswell

Keyword(s):

Acute Kidney Injury ◽

Kidney Injury ◽

Outreach Service ◽

Long Term Follow Up

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Fifteen-minute consultation: how to identify and treat children with acute kidney injury

Archives of Disease in Childhood - Education and Practice ◽

10.1136/archdischild-2020-319928 ◽

2021 ◽

pp. edpract-2020-319928

Author(s):

Maura Scott ◽

Grace McCall

Keyword(s):

Acute Kidney Injury ◽

Fluid Management ◽

Kidney Injury ◽

Case Presentation ◽

Mortality And Morbidity ◽

Fluid Status ◽

Close Observation ◽

Long Term Follow Up

Acute kidney injury (AKI) is under-recognised in children and neonates. It is associated with increased mortality and morbidity along with an increased incidence of chronic kidney disease in adulthood. It is important that paediatricians are able to recognise AKI quickly, enabling prompt treatment of reversible causes. In this article, we demonstrate an approach to recognising paediatric AKI, cessation of nephrotoxic medication, appropriate investigations and the importance of accurately assessing fluid status. The mainstay of treatment is attempting to mimic the kidneys ability to provide electrolyte and fluid homeostasis; this requires close observation and careful fluid management. We discuss referral to paediatric nephrology and the importance of long-term follow-up. We present an approach to AKI through case-presentation.

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Abstract 15934: Higher Midlife Serum Levels of Kidney-injury Molecule-1 (KIM-1) are Associated With Incident Fatal CHD Over Very Long-term Follow-up Among Men

Circulation ◽

10.1161/circ.132.suppl_3.15934 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Rachel H Mackey ◽

Greg G Grandits ◽

Lewis H Kuller ◽

Joel Estis ◽

John A Todd ◽

...

Keyword(s):

Risk Factor ◽

Limit Of Detection ◽

Kidney Injury ◽

Multiple Risk Factor ◽

Serum Samples ◽

Increased Risk ◽

Long Term Follow Up ◽

Kidney Injury Molecule 1

Introduction: Higher levels of kidney-injury molecule-1 (KIM-1) measured in urine are associated with presence and progression of acute renal disease. A recent study reported similar results for KIM-1 measured in blood. Hypothesis: We hypothesized that KIM-1 measured in stored serum from middle-aged men who participated in the Multiple Risk Factor Intervention Trial (MRFIT) would differentiate very long-term risk of fatal CHD vs. survival to a mean age of 80 over approximately 30 year follow-up. Methods: We conducted a nested case-control study within MRFIT, which in 1973-76 randomized 12,866 high risk but CVD free men ages 35-57 to risk factor intervention vs. usual care. Serum samples were collected at baseline and stored for future use. The trial concluded in 1982 but long-term mortality follow-up was ascertained through 2005 using the National Death Index. From MRFIT participants with stored serum from baseline, we sampled 100 men who died of CHD (mean age 47.3 at baseline and 73.9 at death), and 100 men who survived to 2005 (mean age =48.4 at baseline and 80.1 in 2005.) KIM-1 was assayed from stored serum samples using high sensitivity single-molecule counting technology (Erenna ® Immunoassay System, Singulex), with limit of detection (LoD)=0.5 pg/ml, and lower limit of quantification (LLoQ)=2.0 pg/ml. Results were compared between cases and controls using Wilcoxon rank tests and logistic regression. Results: Inter-assay %CVs were 8%. Median KIM-1 was higher for smokers vs. non-smokers and for men with vs. without hypertension, but was not associated with high cholesterol. KIM-1 was significantly higher in cases (183 pg/ml (IQR: 137-239) versus controls, (161 pg/ml (IQR:109-212), p=0.03; OR (95%CI)for Q4 versus Q1 was 2.26 (1.02 - 5.02) Adjusted for age and smoking the OR(95%CI) of fatal CHD for Q4 vs. Q1 was 2.34 (1.02- 5.37), and further adjusted for diastolic BP and serum cholesterol at baseline, was 2.0 (95% CI: 0.8-4.7). Conclusions: Higher serum KIM-1 levels at midlife were associated with a ∼2-fold increased risk of fatal CHD vs. survival over ∼30 years of follow-up. This is the first report of a longitudinal association of circulating KIM-1 levels with fatal CHD in long-term follow-up.

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Carfilzomib associated thrombotic microangiopathy initially treated with therapeutic plasma exchange

Journal of Clinical Apheresis ◽

10.1002/jca.21371 ◽

2014 ◽

Vol 30 (5) ◽

pp. 308-310 ◽

Cited By ~ 25

Author(s):

Matthew R. Sullivan ◽

Alexey V. Danilov ◽

Frederick Lansigan ◽

Nancy M. Dunbar

Keyword(s):

Plasma Exchange ◽

Thrombotic Microangiopathy ◽

Therapeutic Plasma Exchange

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Policies for tackling health inequities in migrants in an irregular situation: learning from Italy

European Journal of Public Health ◽

10.1093/eurpub/ckz186.031 ◽

2019 ◽

Vol 29 (Supplement_4) ◽

Author(s):

F Sesti ◽

A Rosano ◽

D Ingleby ◽

G Baglio ◽

R Bell ◽

...

Keyword(s):

Public Health ◽

Health Care ◽

Health Policies ◽

Public Health Issue ◽

Global Public Health ◽

Integration Policy ◽

Access To Health Services ◽

Human Right ◽

Access To Health

Abstract Issue With increasing of numbers of people moving in Europe and around the world, the health of migrants has become a key global public-health issue. Migrants in an irregular situation (MIS) represent an important part of the migration phenomenon, whether they have become irregular by entering a country without authorisation or by overstaying a visa, including whose applied unsuccessfully for asylum. Description of the problem Overstaying of visas is not unusual in EU countries and during 2015 and 2016 in particular, many countries experienced a large number of unauthorised entrants. Health policies for MIS are increasingly a matter of concern. Using the 2015 Migrant Integration Policy Index Health strand (MIPEX HS) it is possible to conduct an analysis of health policies, focusing on access to health services by MIS. Results Among the 34 European countries covered by the MIPEX HS, Italy’s overall score of 65 is exceeded only by Switzerland (70) and Norway (67). Averaging the indicators of access for MIS, Italy obtains the highest score (83), followed by Denmark, France, the Netherlands, Romania, Spain, Sweden and Switzerland with 67. Its score for legal entitlements to health care is 75 (the same as Sweden), while reporting of MIS to the immigration authorities is prohibited and there are no sanctions against helping them. However, legislation introduced by the new government in 2018 has restricted some of their rights. Lessons Current migration to Europe requires dealing with short-term health needs as well as strengthening public health and health systems in the long term. This presentation will discuss the lessons that can be learned from the comparative analysis of health policies for MIS using the MIPEX HS. Key messages Affordable health care is a human right, which should not be denied to any migrant. Policy analysis plays a key role in identifying interventions for promoting health equity.

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