Mus Micro hauv Leptospirosis raum Kab Mob Ⅲ

7. Kev Ntsuas thiab Kev Tuag

Cov kab mob loj heev ntawm leptospirosis suav txog 10% ntawm tag nrho cov xwm txheej qhia [12]. Yog tsis muaj kev lees paub ntxov thiab kev kuaj mob, daim ntawv mob hnyav feem ntau tshwm sim nrog ntau lub cev tsis ua haujlwm sai, suav nrogmob raum tsis ua haujlwm, mob hepatic tsis ua hauj lwm, thiabmob encephalopathy. Hauv cov kev tshawb fawb feem ntau, kev tuag yog ntau dua 10-15% hauv cov neeg mob Weil's kab mob thiab ntau dua 50% hauv cov neeg mob pulmonary hemorrhage [99]. Qhov tseem ceeb, kev tuag tsis tshua muaj tshwm sim hauv cov neeg mob uas tsis muaj AKI. Muaj qee qhov kev tshawb fawb uas tau nthuav tawm cov kev pheej hmoo ntawm kev tuag muaj feem xyuam nrog lub hnub nyoog, kev puas siab puas ntsws thaum lub sijhawm kuaj mob,txawv txav repolarization yam ntxwvntawm electrocardiography, thiab thrombocytopenia [100–102]. Raws li kev tshawb fawb yav dhau los [103], thrombocytopenia yog sib raug zoo nrog qhov tshwm sim ntawm AKI thiab tau piav qhia hauv txhua qhov xwm txheej anicteric nrog AKI. Thrombocytopenia nrog AKI kuj tshwm sim ntawm nws tus kheej ntawm kev nthuav tawm intravascular coagulation thiab tej zaum yuav ua ke nrog mob endotoxemia [104]. Yog li, thrombocytopenia tej zaum yuav yog ib qho cim ntawm ib qho mob hnyavleptospirosis mob raum. Cov lus xaus hais txog leptospirosis-txog CKD tseem muaj teeb meem. AKI tuaj yeem ua rau tus neeg mob ua rautxhim kho CKD thiab kab mob raum kawg, tab sis tsis ntev los no luam tawm kev tshuaj xyuas tau sib cav tias tsis muaj kev sib raug zoo ntawm leptospirosis thiab CKD [49].

Nws yuav siv sij hawm ntev npaum li cas rau CISTANCHE los ua haujlwm rau cov neeg mob raum mob raum?

Ntau cov kev tshawb fawb tau tshawb fawb txog lub luag haujlwm ntawm biomarkers hauv kev kwv yees kev txhim kho ntawm AKI, txawm hais tias tam sim no tsis muaj kev pom zoo rau kev pom zoo ntawm kev siv biomarkers hais txog.niaj hnub kev kho mob[105]. Ib qho tseem ceeb tshaj plaws biomarkers rau AKI yog neutrophil gelatinase-associated lipocalin (NGAL). Ntau qhov kev tshawb fawb yav dhau los tau siv NGAL ua tus cim ntxov ntawm AKI thiab ua qhov kev kwv yees tau tshwm sim [106,107]. Srisawat et al. [107] tau tshuaj xyuas lub luag haujlwm ntawm NGAL ua tus cim ntxov thiab cov txiaj ntsig kwv yees ntawm leptospirosis-txuas nrog AKI hauv ntau lub chaw tshawb fawb uas muaj 113 tus neeg mob leptospirosis thoob plaws Thaib teb. Nws tsim nyog sau cia tias AKI tau tsim hauv 41 ntawm 113 tus neeg mob (37 feem pua). Cov neeg mob uas tsim AKI muaj ntau cov zis thiab ntshav NGAL ntau dua li cov uas tsis muaj. Lub cheeb tsam nyob rau hauv tus neeg txais kev khiav hauj lwm yam ntxwv (ROC) nkhaus rau cov zis thiab ntshav NGAL theem txuam nrog AKI yog 0.91 thiab 0.92, feem. Hauv qhov xwm txheej tshwj xeeb no, txawm li cas los xij, tsis muaj leej twg tau tshwm sim los ua lub luag haujlwm tseem ceeb ua tus kwv yees ntawm lub raum rov qab. Tej zaum, inhomogeneous kuaj (mob vs. convalescent kuaj) tuaj yeem teeb meem qhov tshwm sim. Activating transcription factor 3 (ATF3), ib qho kev hloov pauv uas cuam tshuam nrog kev tiv thaiv apoptosis lossis cov txheej txheem tiv thaiv kab mob thaum lub sij hawm kis kab mob yuav yog ib qho kev nthuav molecule nyob rau hauv cov nqe lus ntawm leptospirosis nrog AKI [108]. Hauv kev teeb tsa sepsis-AKI, tso zis ATF3 tau nce nyob rau tib hnub ntawm cov ntshav creatinine nce ntxiv uas pom tau tias muaj txiaj ntsig ntawm cov zis AFT3 dhau ntawm cov zis NGAL hauv kev kwv yees AKI [109]. Urinary ATF3 tsis tau nce ua ntej cov ntshav creatinine, tso zis ATF3 tab sis tsis tso zis NGAL yuav yog ib qho zoo ntxiv biomarker rau kev txhawb nqa qhov pib ntawm AKI hauv cov xwm txheej uas tsuas yog nce ntxiv ntawm cov ntshav creatinine, suav nrog leptospirosis ntsig txog AKI.

8. Kev kho mob

8.1. Kev kho mob tshwj xeeb rau Leptospirosis

Kev kho mob ntawmleptospirosis cuam tshuam rau lub raum kab mobfeem ntau yog nyob ntawm cov tsos mob, tshwj xeeb tshaj yog nyob rau theem pib ntawm tus kab mob. Yog li ntawd, kev paub ntxov ntxov thiab kev kuaj mob ntawm tus kab mob leptospirosis raum yog qhov tseem ceeb tshaj plaws uas ua rau muaj txiaj ntsig zoo. Hauv cov mob leptospirosis hnyav, cov tshuaj tua kab mob hauv cov hlab ntsha uas pom zoo yuav tsum tau muab tshuaj sai thaum lub sijhawm kuaj mob; cov no suav nrog 0.5–1 g ampicillin txhua 6 h, 1 g ceftriaxone txhua 12 h, lossis 1 g cefotaxime txhua 6 h. Qhov tseem ceeb, ib txoj kev tshawb fawb los ntawm Thaib teb tau qhia tias kev tswj hwm ntawm 1.5 lab units ntawm cov tshuaj sodium penicillin G txhua txhua 6 teev yog sib npaug zoo rau ceftriaxone hauv cov neeg mob uas mob leptospirosis hnyav [110]. Kev noj ib hnub ib zaug muaj qhov txiaj ntsig ntxiv ntawm kev tswj hwm intramuscular hauv qhov chaw kho mob sab nraud uas yog lwm txoj hauv kev tswj hwm txoj hlab ntshav. Txawm li cas los xij, cov neeg laus laus uas muaj tus kab mob pib ntxov yuav tsum tau txais 100 mg ntawm doxycycline ob zaug ib hnub lossis 500 mg ntawm azithromycin txhua hnub. Kev kho tshuaj tua kab mob tau zoo nyob rau hauv 7-10 hnub ntawm kev txhaj tshuaj, tab sis kev txhaj tshuaj ntawm 5 lab units / hnub ntawm benzylpenicillin yuav tsum tau muab tshuaj rau 5 hnub nkaus xwb. Cov neeg mob uas tsis hnov ​​​​mob lossis ua xua rau cov tshuaj penicillin tuaj yeem muab 250 mg erythromycin plaub zaug hauv ib hnub rau 5 hnub lossis 100 mg doxycycline ob zaug ib hnub rau 10 hnub. Tetracycline yog contraindicated rau cov menyuam yaus, cov poj niam cev xeeb tub, thiab cov neeg mob raum tsis txaus [111].

8.2. Sepsis thiab lub cev tsis ua haujlwm hauv Leptospirosis

Sepsis hauv leptospirosis, nrog lossis tsis muaj kev poob siab, tuaj yeem tshwm sim raws li kev nthuav qhia txawv txawv, feem ntau hauv nroog [29]. Zoo ib yam li kev tswj hwm sepsis, kev kho mob sepsis hauv leptospirosis yog raws li kev tswj hwm sai ntawm cov tshuaj tua kab mob kom raug thiab kev saib xyuas zoo tshaj plaws [112]. Yog li ntawd, kev tswj cov kua dej yog lub hauv paus ntawm sepsis resuscitation. Hauv cov neeg mob uas muaj cov tshuaj tiv thaiv dej (tsawg dua 40% ntawm cov neeg mob septic), cov kab mob stroke nce 10-15% tom qab kev sib tw ua kua (250-500 mL), ua raws li Frank-Starling txoj cai (raws li preload nce, qhov mob stroke ntim nce mus txog thaum qhov kev pom zoo preload tiav) [113]. Nrog rau qhov zoo tshaj plaws preload, kev tswj hwm cov kua dej ntxiv tsis ua kom cov hlab ntsha tawg, tab sis ua rau cov hlab ntsha siab, venous siab, pulmonary hydrostatic siab, thiab natriuretic peptide (cov kua hloov pauv inducer los ntawm qhov chaw intravascular mus rau qhov chaw interstitial). Nce venous siab (thiab lub raum subcapsular siab) txo cov glomerular filtration rate (GFR) ntawm lub raum. Raws li Acute Dialysis Quality Initiative (ADQI), kev kho kua dej hauv sepsis tau muab faib ua kev cawm (siab-ntim resuscitation), optimization, stabilization, thiab de-escalation [114] nyob ntawm tus neeg mob. Nyob rau theem de-escalation, yuav txo tau tag nrho cov kua dej, diuretics, thiab/los yog lub raum hloov kho (RRT) yuav tsim nyog. Rau cov kua dej muaj pes tsawg leeg, ib txwm saline (los yog 0.9% NaCl; cov tshuaj uas tsis yog lub cev) tuaj yeem ua rau hyperchloremic metabolic acidosis uas ua rau lub raum ntshav qis [115]. Synthetic hydroxyethyl starch muaj peev xwm nephrotoxic [115]. Txawm hais tias ib txwm saline tam sim no yog lub ntsiab hloov cov kua dej siv hauv sepsis-AKI vim nws muaj nrog tus nqi tsim nyog thoob ntiaj teb, qhov txwv ntim ntawm cov kua qaub ib txwm nrog ib feem ntawm lwm cov kua dej npaj yuav tau txais txiaj ntsig.

Txawm hais tias acidosis feem ntau tshwm sim hauv cov neeg mob sepsis, kev kho bicarbonate tsis pom zoo tshwj tsis yog cov ntshav pH qis dua 7.15 vim tias sodium bicarbonate infusion ua rau hypernatremia, hypervolemia, intracellular hloov ntawm calcium-induced hypocalcemia, intracellular acidosis, thiab tsis muaj oxygen xa mus [116] . Hauv qhov sib piv, cov tswv yim rau kev txhim kho cov ntaub so ntswg perfusion (kev txhawb nqa ua pa kom zoo, thiab kho cov kua qaub ib txwm muaj nrog lwm cov kev daws teeb meem sib npaug) yuav tsum tau txiav txim siab. Tris-hydroxy methyl aminomethane (THAM), lub hauv paus tsis muaj zog nrog intracellular diffusion uas yogexcreted los ntawm lub raum, tau hais los txo cov kua qaub hauv lub cev tab sis ua rau hyperkalemia, hypoglycemia, pseudo hyponatremia, thiab nce osmole qhov sib txawv, tshwj xeeb tshaj yog rau cov neeg mob uas twb muaj lawm.lub raum tsis ua haujlwm[117]. Vim tias qhov txo qis hauv cov hlab ntsha yog qhov ua rau muaj qhov ua rau lub raum tsis zoo thiab lub raum raug mob hauv sepsis, norepinephrine rov zoo li qub capillary tshaj tawm, pom lub siab, thiab txhais tau tias cov hlab ntsha siab, thiab ua rau kom lub raum medullary ncig tsis muaj lub raum ntshav hloov pauv, ua rau lub raum ua haujlwm tau zoo, siv. raws li thawj kab tshuaj rau septic shock.

Rau qhovKev hloov pauv sai ntawm AKI(vim ncaj qha co toxins, hypotension, thiab hypovolemia ntawm leptospirosis), cov ntsiab lus ntawm kev kho lub raum hloov (RRT); Cov lus qhia, lub sijhawm, kev hloov pauv, thiab kev xa tawm yuav tsum tau siv. Raws li qhov tshwm sim, cov lus qhia RRT feem ntau, "AEIOU"; Acidosis, Electrolyte cuam tshuam, Intoxication, kua dej ntau dhau, thiab Uremia yuav tsum tau siv ua metabolic acidosis hnyav, kua dej ntau dhau, thiab uremia yog peb qhov RRT sab saum toj qhia hauv leptospirosis. Rau RRT kev hloov pauv, kev lim ntshav txhua hnub tuaj yeem muab cov txiaj ntsig zoo tshaj plaws rau kev lim ntshav hauv ib hnub hauv qhov mob hnyav leptospirosis (Weil's Syndrome) [118] thiab kev lim ntshav extracorporeal (kev kho nqus nrog polymyxin B lossis lwm yam cytokine absorbents) yuav muaj txiaj ntsig [119], tshwj xeeb tshaj yog rau kev txhim kho hemodynamic [120], tab sis tseem ua tsis tiav. Yog li ntawd, cov biomarkers tsim nyog rau ntau yam (piv txwv li, kev ntxhov siab, kev raug mob, kev ua haujlwm tsis zoo, thiab kev rov qab los) rau kev xaiv txoj kev kho mob yog qhov xav tau sai. Ntawm lawv, lub hauv paus tshaj (BE) uas qis dua −5 tej zaum yuav cuam tshuam nrog kev ua tiav ntawm kev txhawb nqa lub raum tsis ua haujlwm los ntawm peb cov kev paub dhau los (cov ntaub ntawv tsis tau tshaj tawm). Ntawm qhov tod tes, hauv cov kab mob leptospirosis ntsig txog mob siab tsis ua haujlwm, cov txheej txheem txhawb nqa lub cev tsis ua rau muaj txiaj ntsig zoo hauv kev tshawb fawb soj ntsuam thiab kev txhawb nqa lub raum tsis pom zoo hauv AKI-superimposed mob siab mob siab [121]. Txawm li cas los xij, kev txhawb nqa rau lub raum tsuas yog txiav txim siab tsuas yog hauv cov neeg mob uas muaj qhov ua rau rov qab los [122].

9. Cov lus xaus

leptospirosis ntsig txog AKI; Piv txwv li, ncaj qha Leptospira nephrotoxicity, hyperbilirubinemia, rhabdomyolysis, thiab sepsis. Cov xwm txheej no ua rau muaj neeg tuag coob thiab muaj tus mob morbidity. Yog li ntawd, qhov kev tsis txaus siab ntawm leptospirosis ua raws li kev kho mob raws sijhawm, tshwj xeeb tshaj yog nrog cov tshuaj tua kab mob tsim nyog nrog rau kev saib xyuas zoo tshaj plaws, tuaj yeem txhim kho cov teeb meem hauv cov kab mob hnyav.

Cov ntaub ntawv

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