Oliguric and non-oliguric acute renal failure in malaria in west zone of rajasthan, India-A comparative study

While acute renal failure (ARF) due to leptospiral infection is on decline, malaria has become the emerging cause of ARF[1,2]. Acute renal failure is one of the important manifestations of severe falciparum (pf) malaria, although it can occur rarely with vivax (pv) also[3]. Recently high incidence of ARF has been reported from various parts of the world including India both in cases of falciparum as well as vivax malaria[1-11]. It can occur as an isolated complication or as a component of multi-organ involvement[3]. Precise mechanism of ARF in malaria is not clearly known. Several hypothesis including mechanical obstruction caused by cytoadherence and sequestration of infected erythrocytes, immune-mediated glomerular pathology, alteration in renal and systemic homodynamics, release of cytokines, reactive oxygen intermediates and nitric oxide have been proposed. In addition to above, restricted blood flow to the kidneys due to less intake and increase loss of fluids can cause dehydration and renal ischemia[3,5,9]. Various histopathological alterations has been reported in the renal biopsy of malarial ARF include acute tubular necrosis, acute glomerulonephritis, Mesangioproliferative glomerulonephritis and nephrotic syndrome especially due to membranoproliferative glomerulonephritis in chronic malaria[3,9,12,13]. ARF in malaria is usually associated with oliguria and in severe cases even anuria. Occasionally ARF may be non-oliguric which make the diagnosis difficult unless serum creatinine is estimated[3]. Therefore this study was planned to evaluate renal functions in malaria and compare clinically and histopathologically oliguric ARF and nonoliguric ARF. Objective: To report a comparative clinical and histopathological study on oliguric and nonoliguric acute renal failure (ARF) in malaria. Method: 311 consecutive cases of malaria out of which 74 (23.79%) had ARF as per WHO criteria were conducted. Mean age was 32.58 (range 1560 years) and male: female was 2:1. Result: Most of the cases developed ARF within 10 d of onset. 18 cases (11 falciparum, 2 mixed, 5 vivax) presented with oliguric and 56 (41 falciparum, 6 mixed, 9 vivax) with non-oliguric renal failure. Associated major manifestations were jaundice (75.68%), cerebral malaria (41.89%), bleeding manifestations (32.43%), severe anemia (27.03%), hypotension (25.68%), multi-organ failure (18.92%), severe thrombocytopenia (12.16%), and ARDS (8.11%). Kidney biopsy (n=20) showed acute tubular necrosis (n=7), Mesangioproliferative glomerulonephritis (n=4) or both (n=9). Hemodialysis was done in 8 cases of oliguric renal failure out of which 4 survived (average no. of session 2.9). Conclusion: Most of the cases recovered within 3 weeks. Total mortality was 28.38% (n=21) and mortality was more in oliguric renal failure (72.22%) as compare to non-oliguric renal failure (14.29%). Journal of Acute Disease (2012)100-106