Clinical and laboratory predictors of death in African children with features of severe malaria: a systematic review and meta-analysis

Chitinase-3-like 1 is a biomarker of acute kidney injury and mortality in paediatric severe malaria

Background

Chitinase-3-like 1 (CHI3L1) is a glycoprotein elevated in paediatric severe malaria, and an emerging urinary biomarker of acute kidney injury (AKI). Based on the hypothesis that elevated CHI3L1 levels in malaria are associated with disease severity, the relationship between plasma CHI3L1 levels, AKI and mortality was investigated in Ugandan children enrolled in a clinical trial evaluating inhaled nitric oxide (iNO) as an adjunctive therapy for severe malaria.

Methods

Plasma CHI3L1 levels were measured daily for 4 days in children admitted to hospital with severe malaria and at day 14 follow up. AKI was defined using the Kidney Disease: Improving Global Outcomes consensus criteria. This is a secondary analysis of a randomized double-blind placebo-controlled trial of iNO versus placebo as an adjunctive therapy for severe malaria. Inclusion criteria were: age 1–10 years, and selected criteria for severe malaria. Exclusion criteria included suspected bacterial meningitis, known chronic illness including renal disease, haemoglobinopathy, or severe malnutrition. iNO was administered by non-rebreather mask for up to 72 h at 80 ppm.

Results

CHI3L1 was elevated in patients with AKI and remained higher over hospitalization (p < 0.0001). Admission CHI3L1 levels were elevated in children who died. By multivariable analysis logCHI3L1 levels were associated with increased risk of in-hospital death (relative risk, 95% CI 4.10, 1.32–12.75, p = 0.015) and all-cause 6 month mortality (3.21, 1.47–6.98, p = 0.003) following correction for iNO and AKI. Treatment with iNO was associated with delayed CHI3L1 recovery with a daily decline of 34% in the placebo group versus 29% in the iNO group (p = 0.012). CHI3L1 levels correlated with markers of inflammation (CRP, sTREM-1, CXCL10), endothelial activation (Ang-2, sICAM-1) and intravascular haemolysis (LDH, haem, haemopexin).

Conclusions

CHI3L1 is a novel biomarker of malaria-associated AKI and an independent risk factor for mortality that is associated with well-established pathways of severe malaria pathogenesis including inflammation, endothelial activation, and haemolysis.

Trial registration Clinicaltrials.gov, NCT01255215. Registered December 7th 2010

Electronic supplementary material

The online version of this article (10.1186/s12936-018-2225-5) contains supplementary material, which is available to authorized users.

Pathophysiology, clinical presentation, and treatment of coma and acute kidney injury complicating falciparum malaria

PURPOSE OF REVIEW

Cerebral impairment and acute kidney injury (AKI) are independent predictors of mortality in both adults and children with severe falciparum malaria. In this review, we present recent advances in understanding the pathophysiology, clinical features, and management of these complications of severe malaria, and discuss future areas of research.

RECENT FINDINGS

Cerebral malaria and AKI are serious and well recognized complications of severe malaria. Common pathophysiological pathways include impaired microcirculation, due to sequestration of parasitized erythrocytes, systemic inflammatory responses, and endothelial activation. Recent MRI studies show significant brain swelling in both adults and children with evidence of posterior reversible encephalopathy syndrome-like syndrome although targeted interventions including mannitol and dexamethasone are not beneficial. Recent work shows association of cell-free hemoglobin oxidation stress involved in the pathophysiology of AKI in both adults and children. Paracetamol protected renal function likely by inhibiting cell-free-mediated oxidative stress. It is unclear if heme-mediated endothelial activation or oxidative stress is involved in cerebral malaria.

SUMMARY

The direct causes of cerebral and kidney dysfunction remain incompletely understood. Optimal treatment involves prompt diagnosis and effective antimalarial treatment with artesunate. Renal replacement therapy reduces mortality in AKI but delayed diagnosis is an issue.

Technical and Alarm signs for referral in adult patients with acute febrile illness: A study from a tertiary care hospital in North India

Context

There is a huge burden of patients with acute febrile illness (AFI) during the post-monsoon season in India. It is very important to have a functioning triage system, whereby patients with high likelihood of developing a severe illness are referred to higher levels of care.

Aim

The objective of this study was to identify the alarm signs which would help in triaging of those patients with AFI without any specific diagnosis.

Methods

This was a retrospective review of records, whereby clinical and laboratory parameters of patients with AFI admitted in our tertiary care center between July 2016 and October 2016 were reviewed.

Statistical Analysis Used

Appropriate tests of significance were applied using SPSS 21(Chicago, IL, USA) to find statistically significant differences between those who required mechanical ventilation, intensive care, ionotropic support, or higher intravenous antibiotics and those who recovered with minimal supportive care.

Results

Presence of comorbidities, dyspnea, altered sensorium, features of myocarditis, hypotension, leukocytosis (>11,000/μL), and acute kidney injury were significantly associated with requirement of higher levels of care, while presence of arthralgia, serositis, and leucopenia indicated a higher likelihood of recovery with minimal support.

Conclusion

This article highlights the possibility of identification of simple alarm signs in patients with AFI which would indicate the need for higher levels of care.