Acute renal failure in Falciparum malaria--increasing prevalence in some areas of India--a need for awareness

Abstract

Twenty-six cases (4.8%) from a total of 540 patients with acute renal failure (ARF) of diverse aetiology had ARF in association with falciparum malaria. Their ages ranged from 15 to 85 years (mean 31.2). Urinary sediment abnormalities and proteinuria (less than 1 g/24 h) were observed in 15 (57.7%) cases. The probable underlying factors leading to ARF were: volume depletion 17 (65.3%), intravascular haemolysis 8 (30.8%), hyperparasitaemia 8 (30.8%), cholestatic jaundice 6 (23%), and hypotension 5 (19.2%). Dialysis therapy was required in 15 patients (57.7%) as they had severe renal failure, and the remaining 11 patients improved with supportive measures. All patients received antimalarial therapy. The clinical course of ARF was consistent with acute tubular necrosis in 20 patients. Six cases were subjected to percutaneous renal biopsy. One patient showed histological features of necrotizing glomerulonephritis along with acute tubulointerstitial nephritis. The biopsies in the other five patients showed features of acute tubular necrosis in three, and acute interstitial oedema with patchy tubular necrosis in two. The mortality rate was 30.8%. Thus falciparum malaria, which has been an important cause of ARF in certain highly endemic zones of India, is showing an increasing prevalence in other parts such as Eastern Uttar Pradesh due to an imbalance between the increasing population and inadequate sanitary facilities, which further worsen during floods.

Outcome of malaria-associated acute kidney injury: a prospective study from a single center

“…24,25 In a previous study by Prakash et al, severe jaundice (serum bilirubin: 11.8-23.4 mg/dL) was observed in six (23%) patients, with biochemical evidence of cholestasis in all of them. 26 Cerebral symptoms were observed in 21.8% patients, similar observations have documented in past studies also. 3,18,27 AKI in malaria is usually oliguric and hypercatabolic, which may last for days to weeks.…”

“…Association of cerebral malaria with mortality have been reported previously also. 6,18,26 Raised LDH levels (p ¼ 0.019) and lower hemoglobin levels (p ¼ 0.015) significantly predicted mortality. Similarly, elevated AST (p50.001) and ALT (p ¼ 0.016) were significantly associated with mortality risk in our study.…”

“…18 Oligo-anuric AKI was the presentation in 44.5% of our cases, which is lower than 60-70% proportion of oliguric ARF reported in other studies. 6,18,26 Our speculation behind this lower incidence is that our study included only patients directly admitted in nephrology unit, which can handle fluid and electrolyte disturbances in more efficient manner, whereas, in other studies, patients referred from other medical and surgical units were also included.…”

Epidemiology of Acute Kidney Injury

“…Each year, 300 million people contract the disease, which will be responsible for more than 1 million yearly deaths in Africa alone (49,77). It is estimated that in 1% of cases (3000,000/yr), a combination of parasite and host factors will lead to severe malaria, jaundice, and AKI (42,78), a complication associated with 45% mortality (78); in areas of endemic malaria, the incidence of AKI may be Ͼ4% of malarial cases (42). Worldwide, the incidence of AKI as a result of malaria varies between 0.6 and 60% of malarial cases, depending on the region (43).…”

“…In developing countries, the most common causes of AKI are frequently associated with volume-responsive "prerenal" (39,40), obstetric (41), infectious (42,43), or toxic (25,44) mechanisms; thus, inexpensive, simple interventions such as education on oral rehydration (29,45), improved crosscultural interaction with traditional healers (46), change in obstetric management policies (47,48), or management of infection (49) may result in a dramatic reduction in the incidence and severity of AKI (29,42,(45)(46)(47)(48)(49). Given that in developing countries the costs of renal replacement therapies are prohibitively high (17,50 -52), prevention is often the only realistic way to decrease its severe impact on morbidity and mortality.…”