ACUTE RENAL FAILURE IN SEVERE MALARIA Dr Saroj
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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% • Common in adults than children, recent trends- high incidence • Diagnosed when sr. creat. >3 mg/dl or urine output <400 ml/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. Two different settingsa) 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 • 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
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
Pathology & Pathogenesis 3 • ARF- mediated thro’ several mechanisms 1. Effect of p. RBC 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 p. RBC according to need of microcirculation- slugish circulation- renal ischemia
Pathology & Pathogenesis 4 2. Hypovolumia may occur due to Fever (hyperpyrexia), sweating, decreased intake of fluid, vomiting etc. 3. DIC 4. Increased plasma viscosity due to infection 5. Release of chemical mediators- TNF, cachectin, cytokines, interleukines etc causesvasoconstriction, increased vascular permiability, catecholamine release(SIADH ) hemoconcentrarion, shock & tubular necrosis 6. Hyperbilirubinaemia due to hemolysis, Black water fever in G 6 PD deficiency patients is also associated with ARF
CLINICAL FEATURES ARF in severe malaria is common in adults, rare in children Two subsets of presentationsa. ARF as a component of multi organ failure present since admission- poor prognosis, associated with anemia, jaundice, hypoglycemia, acidosis or coma b. Present as a sole complication- appears at a later stage when other complications subsided/treated – prognosis is good
CLINICAL FEATURES 2 • Diagnosis suspected when urine output <400 ml/24 hrs & confirmed when sr. creatinine >3 mg/dl in adults & >1. 5 mg/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 • Differentiation of prerenal & established ARF is important for management- sp. gr. of urine is >1. 020 & <1. 010 respectively • Vulnerable group of patientsa) 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 • • Hypo & hyper volumia Hyperparasitemia Hemoconcentration Hyperbilirubinemia Hyperpyrexia Hyperkalemia Hyponatremia
LAB. INVESTIGATIONS & MONITORING • Peripheral smear for diagnosis & parasite clearance • Blood urea, creat. , bilirubin, SGPT, Na, K, HCO 3, PH • Urine sp. Gr. • ECG & chest X-ray when indicated
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 • Meticulous record of fluid requirementfluid 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 • If the 24 hr urine output is <400 ml & the patient is clinically dehydrated. Fluid challenge – 20 ml/kg of Normal saline over one hr. Monitor fluid overload after each 200 ml by- Chest auscultation, JVP, CVP at 0 & +5 Urine output should be 20 ml/hour
TREATMENT 4 • If no urine after fluid therapy. Diuretic challenge: Iv loop diuretic- Inj Furosemide in incremental dose 40 -100 -200 -400 mg at ½ hour interval • If no improvement. Dopamine challenge: Inj dopamine slow iv infusion at 2. 5 to 5 mcg/kg/min
RESPONSE • 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 • • No benefit in oliguric patients No recovery in anuric patients Delay in decision for dialysis Complications of Dopamine- Gangrene, Ototoxicity
CAUTION 2 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
Antimalarial Drugs • • - Qunine Can be given safely in pregnancy & ARF Initial dose of qunine -10 mg/kg 8 hrly Reduction after 48 hrs No dose adjustment during HD Artemisinine No modification is required in ARF
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(HCO 3 <15 meq/l)
Haemodialysis • Advantages - Efficient method • Disadvantages - Only in selected centers - Expertise - Lag time
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 • 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
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