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On : Aug 07, 2014

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  • Slide 1 - ACUTE RENAL FAILURE IN SEVERE MALARIA Dr Saroj K Mishra Dr Kishore C Mahanta Ispat General Hospital, Rourkela Orissa India
  • Slide 2 - 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.>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
  • Slide 3 - INTRODUCTION Contd. 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.
  • Slide 4 - 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
  • Slide 5 - 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
  • Slide 6 - 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
  • Slide 7 - 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 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
  • Slide 8 - CLINICAL FEATURES ARF 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
  • Slide 9 - CLINICAL FEATURES 2 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
  • Slide 10 - 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 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
  • Slide 11 - CRITICAL DETERMINANTS Hypo & hyper volumia Hyperparasitemia Hemoconcentration Hyperbilirubinemia Hyperpyrexia Hyperkalemia Hyponatremia
  • Slide 12 - LAB. INVESTIGATIONS & MONITORING Peripheral smear for diagnosis & parasite clearance Blood urea, creat., bilirubin, SGPT, Na,K, HCO3,PH Urine sp. Gr. ECG & chest X-ray when indicated
  • Slide 13 - 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
  • Slide 14 - TREATMENT 2 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
  • Slide 15 - TREATMENT 3 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
  • Slide 16 - TREATMENT 4 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
  • Slide 17 - 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
  • Slide 18 - CAUTION No benefit in oliguric patients No recovery in anuric patients Delay in decision for dialysis Complications of Dopamine- Gangrene, Ototoxicity
  • Slide 19 - 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
  • Slide 20 - 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
  • Slide 21 - 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)
  • Slide 22 - Haemodialysis Advantages - Efficient method Disadvantages - Only in selected centers - Expertise - Lag time
  • Slide 23 - ppt slide no 23 content not found
  • Slide 24 - 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
  • Slide 25 - 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
  • Slide 26 - Thank you

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Tags : malaria | malaria disease | malaria treatment