Efferent therapy in cases of malaria

V. A. Voinov
Pulmonology Clinic of Pavlov State Medical University, St. Petersburg, Russia.

Today, like 150 years ago, malaria remains one of the most common diseases in the
world, every year affecting up to 500 million people. Of the four species of malaria, tropical is
characterized as the most severe, and deaths caused by it make up 98% of all deaths from
malaria [1]. In India, malaria causes deaths of more than 15,000 children per year [2], and in sub-
Saharan Africa - more than 200,000 children [3].
The severity of the clinical course of falciparum malaria (FM) is due to many reasons,
including the presence of specific toxic factors (e.g. cytotoxic substance Megreta) in this species
of parasites (Plasmodium falciparum), manifestation of tissue anaphylaxis, often associated with
more pronounced immunoreactive properties of the waste products of this type of plasmodium.
The released substance in the blood activate macrophages and lead to the release of pro-
inflammatory cytokines (TNF, IL1, IL2), which determine the severity of endotoxemia.
Complications, often leading to death, develop mostly with FM. Most common of these
are: development of a cerebral form with cerebral malaria coma, severe hemoglobinuric fever,
malarial algid, acute renal failure, in rare cases - pulmonary edema and malarial hepatitis. All of
them in one way or another are the result of severe endotoxemia.
Brain damage - malarial coma may be accompanied by swelling of the brain, especially
dangerous for children, often (20%) resulting in death.
Acute renal failure is the result of intense hemolysis, hemoglobinuria, followed with
impaired renal microcirculation and tubular necrosis.
Toxic shock is accompanied by clinic of malaria algid accompanied by severe vascular
insufficiency with a fall in blood pressure and dehydration.
Toxic shock is accompanied by acute respiratory failure, which according to the current
views is respiratory distress syndrome of adults (ARDS), which is clinically manifested by toxic
pulmonary edema.
Observed are severe disorders of biochemical homeostasis. Activation of proteolysis is
accompanied by accumulation of toxic medium weight oligopeptides. Disorders of lipid
peroxidation lead to the accumulation of their toxic end products, such as malondialdehyde and
diene conjugates, with the suppression of antioxidant activity (superoxide dismutase).
FM is particularly dangerous for pregnant women. Severe placental sequestration of
parasites with a massive fibrinoid deposition in the basal plate of the fruit part of the placenta
breaks flow of oxygen to the fetus, with the development of a chronic hypoxia and intrauterine
growth retardation. There is high frequency of antenatal fetal death. With live births there is
severe asphyxia (with Apgar score 5-6), and the period of early neonatal adaptation is
characterized with high frequency moderate or severe lesions of central nervous system.
Frequently observed are signs of intrauterine infection and the development of septic
complications [3, 4].
Malaria is typically characterized by immunosuppression, which often leads to a variety
of bacterial superinfection. Unconscious patients can be subjected to aspiration pneumonia.
Possible is the development and sepsis caused by gram-negative microflora, including
salmonella.

All of the above is the reason for application of efferent therapy for detoxification,
because any other way to rid the body of accumulated toxic substances is impossible. In addition,
intensive therapy of malaria with quinine drugs alone may lead to hearing loss due to the
selective action of a pair of cranial nerves. Also reinforced are toxic lesions of eye (keratitis,
iritis, iridocyclitis, and optic neuritis).
Most acceptable methods of efferent therapy (extracorporeal detoxication) are
hemosorbtion (hemocarboperfusion) and plasmapheresis.
Hemosorbtion allows you to selectively remove from circulation not only toxic
molecules with the presence of "free radicals" in their structure, but also the parasites with their
high adhesive activity. In addition, with FM on the surface of red blood cells there are "bumps",
containing high molecular weight protein, which interacts with receptors of endothelium of
venules and capillaries, provides adhesion of red blood cells with a delay in small vessels of the
brain, lungs, kidneys, liver, increasing their toxic damage. These "excited" red cells containing
Plasmodium falciparum, begin to stick to the healthy red blood cells, forming rosettes. This
adhesion of red cells to the endothelium and the rosette are the basis of the pathogenesis of
falciparum malaria. Therefore, it is hoped that the adsorption on activated surface of
hemosorbent and removal of such pathologically excited red cells should be helpful. This
procedure should help to smooth all the clinical manifestations of malaria and prevent its
complications.
Plasmapheresis helps to remove plasma from the body with all its toxic substances,
regardless of whether they are "free radicals" and of increased adhesive activity. In addition,
plasmapheresis allows you to extract an excessive amount of "free hemoglobin," accumulating in
the destruction of red cells (hemolysis) and threatening to develop renal disease in its excretion
in the urine. In addition, the removal of "toxic pressure" from immune system should help its
recovery. This is also helped by replacement of extracted plasma with fresh frozen donor plasma
with all the normal components of the immune defense.
 Plasmapheresis is well established in cases of toxicosis of pregnant women, which is
particularly important for patients with malaria. This procedure should also contribute to the
elimination of toxic complications in the development of the fetus and the birth of a healthy
child.
Both procedures of extracorporeal detoxification - both hemosorbtion and plasmapheresis
- are most appropriately carried out using the Russian device Hemofenix, low priming volume
of which ensures safety of such procedures, even in critical conditions of patients with unstable
hemodynamics, including pregnant women and young children. "Single needle" connection,
automatic dosing of anticoagulant, effective protection against entrance of air into the patient's
blood vessels and portable nature of the equipment ensures safe conduct of procedures during
travel to other medical facilities [5].
Sources
1. Shkurba A.V. Ovcharenko P.A. [Peculiarities of tropical malaria, its complications and
their treatment] // Clinical Immunology. Allergology. Infectology (Rus). - 2010. - 5-6. P. 15-
19.
2. Dhingra N., Jha P., Sharma V.P. et al. Adult and child malaria mortality in India //
Lancet. 2010. V.20, 376. P.9754.
3. Eilese T.P., Larsen D., Steketee R.W. Protective efficacy of interventions for preventing
malaria mortality in children in Plasmodium falciparum endemic areas // Int. J. Epidemiol.
2010. V 39, (suppl. 1). P. i88-i101.
4. Abdurakhmanov F.M. Abdurakhimova M.M. Abdurakhmanova F.M. [The course and
outcome of pregnancy with malaria] // Russian Journal of the obstetrician-gynecologist (Rus). -
2005. - 5, P. .25-27.
5. Voinov V.. [Efferent therapy. Membrane plasmapheresis]. ., 2010. 365 p. (Rus).