Acute renal failure in severe malaria
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ACUTE RENAL FAILURE IN SEVERE MALARIA. Dr Saroj K Mishra Dr Kishore C Mahanta Ispat General Hospital, Rourkela Orissa India. INTRODUCTION. Malaria is one of top 10 killer diseases in world ARF occurs in <1% of pf malaria, but mortality up to 45%

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Acute renal failure in severe malaria l.jpg


Dr Saroj K Mishra

Dr Kishore C Mahanta

Ispat General Hospital, Rourkela Orissa India

Introduction l.jpg

  • Malaria is one of top 10 killer diseases in world

  • ARF occurs in <1% of pf malaria, but mortality up to 45%

  • Common in adults than children, recent trends- high incidence

  • Diagnosed when sr. creat.>3mg/dl or urine output <400ml/24 hrs

  • Renal involvement varies from mild proteinuria to severe azotemia

  • Malarial ARF is associated with CM, Jaundice, Anaemia, ARDS/Pulm. edema & Hypoglycaemia

Introduction contd l.jpg

Two different settings-

  • ARF as a component of MOF – present at the time of admission,

    Often associated with poor prognosis.

    b) Present as a sole complication at a later stage of the course, when other complications subsided or treated,

    Often associated with recovery.

Pathology pathogenesis l.jpg
Pathology & Pathogenesis

  • In mild cases- not much change in renal parenchyma- may be minimal tubular degeneration, mild renal parenchymal change & presence of vacuoles

  • In severe cases- Tubular degeneration with distal tubular necrosis, Proximal tubules are often loaded with malarial pigments, Hb granules may be seen in the tubular cells

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Pathology & Pathogenesis 2

  • Most patients have little or no proteinuria & urinary sediment contains occasional granular and hyaline cast but no RBC.

  • Absence of hypertension, Rapid resolution without residual impairment & predominant in adults rather than children with urinary findings suggests- ARF results from ATN & not glomerulonephritis

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Pathology & Pathogenesis 3

  • ARF- mediated thro’ several mechanisms

    1.Effect of pRBC on microcirculation- knob like processes formation on surface of RBC which helps in anchoring the endothelium

    Cytoadherence- due to thrombospondin formation from vascular endothelium- specific to pf ( not in pv/pm) so ARF only in pf.

    Loss of deformability of pRBC according to need of microcirculation- slugish circulation- renal ischemia

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Pathology & Pathogenesis 4

2.Hypovolumia may occur due to Fever (hyperpyrexia), sweating, decreased intake of fluid, vomiting etc.


4.Increased plasma viscosity due to infection

5.Release of chemical mediators- TNF,cachectin, cytokines, interleukines etc causes- vasoconstriction, increased vascular permiability, catecholamine release(SIADH ) hemoconcentrarion, shock & tubular necrosis

6.Hyperbilirubinaemia due to hemolysis, Black water fever in G6 PD deficiency patients is also associated with ARF

Clinical features arf in severe malaria is common in adults rare in children l.jpg
CLINICAL FEATURESARF in severe malaria is common in adults, rare in children

Two subsets of presentations-

  • ARF as a component of multi organ failure present since admission- poor prognosis, associated with anemia, jaundice, hypoglycemia, acidosis or coma

  • Present as a sole complication- appears at a later stage when other complications subsided/treated – prognosis is good

Clinical features 2 l.jpg

  • Diagnosis suspected when urine output <400ml/24 hrs & confirmed when sr.creatinine >3mg/dl in adults & >1.5mg/dl in children

  • Patient may be anuric, oliguric, with normal urination or polyuric

  • Oliguric phase varies from few days to wks

  • Prerenal azotemia presents with signs of dehydration

  • Prolonged anuria/oliguria – volume over load due to decrease salt & water excretion

Clinical features 3 l.jpg

  • Differentiation of prerenal & established ARF is important for management- urine is >1.020 & <1.010 respectively

  • Vulnerable group of patients-

  • Pregnant women, b) high parasitemia,

    c) very high jaundice d) prolonged dehydration e) on NSAID therapy

  • Patients with pfr +ve to be screened for ARF

Critical determinants l.jpg

  • Hypo & hyper volumia

  • Hyperparasitemia

  • Hemoconcentration

  • Hyperbilirubinemia

  • Hyperpyrexia

  • Hyperkalemia

  • Hyponatremia

Lab investigations monitoring l.jpg

  • Peripheral smear for diagnosis & parasite clearance

  • Blood urea, creat., bilirubin, SGPT, Na,K,


  • Urine sp. Gr.

  • ECG & chest X-ray when indicated

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TREATMENT (Guidelines)

  • Appropriate antimalarial at the earliest

  • Maintenance of fluid & electrolytes

  • Recording of intake output chart

  • Prevention of fluid overload & secondary infection including pneumonia

  • Treatment of acquired infection at the earliest keeping an open mind

Treatment 2 l.jpg

  • Meticulous record of fluid requirement- fluid intake, urine output –guides the administration of fluid, monitoring the improvement & most of all preventing fluid overload – a CVP line can be established

  • Daily sr creat estimation in severe pf malaria cases if possible

Treatment 3 l.jpg

  • If the 24hr urine output is <400ml & the patient is clinically dehydrated-

    Fluid challenge –

    20ml/kg of Normal saline over one hr.

    Monitor for fluid overload after each 200ml by- Chest auscultation, JVP,CVP at 0 & +5

    Urine output should be 20ml/hour

Treatment 4 l.jpg

  • If no urine after fluid therapy-

    Diuretic challenge:

    Iv loop diuretic- Inj Furosemide in incremental dose 40-100-200-400mg at ½ hour interval

  • If no improvement-

    Dopamine challenge:

    Inj dopamine slow iv infusion at

    2.5 to 5mcg/kg/min

Response l.jpg

  • 75%of oliguric & 5%of anuric responds with increased urine output

  • No improvement in sr creat level

  • False sense of improvement

  • Reduces the risk of volume overload

  • If ineffective further fluid is restricted

Caution l.jpg

  • No benefit in oliguric patients

  • No recovery in anuric patients

  • Delay in decision for dialysis

  • Complications of Dopamine- Gangrene, Ototoxicity

Caution 2 l.jpg

Avoid Nephrotoxic drug in ARF suspects-

  • ACE inhibitors & cyclooxygenase inhibitors (NSAIDs)- precipitate prerenal azotemia to ischemic ARF

  • Cephalosporines & Aminoglycosides

  • Assesment of renal function using urine output is dangerous in patients receiving Diuretics

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Antimalarial Drugs

  • Qunine

    - Can be given safely in pregnancy & ARF

    - Initial dose of qunine -10mg/kg 8hrly

    - Reduction after 48 hrs

  • No dose adjustment during HD

  • Artemisinine

  • No modification is required in ARF

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Indications for Dialysis

Clinical :

  • Uraemic symptoms- Nausea, Vomiting, Hiccough, Flapping tremors, Muscle twitching,& Convulsion

  • Fluid overload

  • Pericardial rub

  • Arrhythmia

    Laboratory: Rising creatinine, Hyperkalemia,

    (K >6.5), Acidosis(HCO3 <15meq/l)

Haemodialysis l.jpg

  • Advantages

    - Efficient method

  • Disadvantages

    - Only in selected centers

    - Expertise

    - Lag time

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Caution for conservative management of ARF in severe malaria

  • May develop critical signs at any odd hrs without giving a scope for dialysis

  • Many patients have been lost as dialysis is decided but institution is delayed

  • Sudden cardiac death may ensue in a patient who is improving due to pulmonary edema or hyperkalaemia

Prognosis l.jpg

  • Mortality among renal failure is 45% to 10% those without

  • Death increases 3 fold in presence of ARF

  • Very high mortality in presence of MOF

  • Mortality can be reduced to 10% if early & frequent Dialysis is instituted

  • Survival with PD is lower than HD