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Lintner Rivera M, Prager R, Gushu MB, June S, Phiri T, Salameh JP, Johnson HC, Taylor T, O'Brien NF. Point-of-care Ultrasound to Assess Hemodynamic Contributors to Acute Kidney Injury in Pediatric Patients With Cerebral Malaria: A Pilot Study. Pediatr Infect Dis J 2023; 42:844-850. [PMID: 37409812 DOI: 10.1097/inf.0000000000004021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
BACKGROUND Acute kidney injury is common in severe malaria and is independently associated with mortality. The pathogenesis of acute kidney injury (AKI) in severe malaria remains incompletely understood. Ultrasound-based tools such as point-of-care ultrasound (POCUS), ultrasound cardiac output monitors (USCOMs) and renal arterial resistive index (RRI) can be used to detect hemodynamic and renal blood flow abnormalities contributing to AKI in malaria. METHODS We conducted a prospective study of Malawian children with cerebral malaria to determine the feasibility of using POCUS and USCOM to characterize hemodynamic contributors to severe AKI (Kidney Disease: Improving Global Outcomes stage 2 or 3). The primary outcome was feasibility (completion rate of study procedures). We also assessed for differences in POCUS and hemodynamic variables for patients with or without severe AKI. RESULTS We enrolled 27 patients who had admission cardiac and renal ultrasounds and USCOM. Completion rates were high for cardiac (96%), renal (100%) and USCOM studies (96%). Severe AKI occurred in 13 of 27 patients (48%). No patients had ventricular dysfunction. Only 1 patient in the severe AKI group was determined to be hypovolemic ( P = 0.64). No significant differences in USCOM, RRI or venous congestion parameters were detected among patients with and without severe AKI. Mortality was 11% (3/27) with the 3 deaths occurring in the severe AKI group ( P = 0.056). CONCLUSIONS Ultrasound-based cardiac, hemodynamic and renal blood flow measurements appear to be feasible in pediatric patients with cerebral malaria. We were unable to detect hemodynamic or renal blood flow abnormalities contributing to severe AKI in cerebral malaria. Larger studies are needed to corroborate these findings.
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Affiliation(s)
- Michael Lintner Rivera
- From the Department of Pediatrics, Division of Critical Care Medicine, University of Maryland Children's Hospital, Baltimore, MD
| | - Ross Prager
- Critical Care Medicine, Schulich Medicine and Dentistry, Western University, London Health Sciences Center, London, Ontario, Canada
| | | | - Sylvester June
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, Blantyre, Malawi
| | - Tusekile Phiri
- Queen Elizabeth Central Hospital, The Blantyre Malaria Project, Blantyre, Malawi
| | - Jean-Paul Salameh
- Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Hunter C Johnson
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Terrie Taylor
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, E. Lansing, MI
| | - Nicole F O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
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Duangchan T, Kotepui M, Sukati S, Rattanapan Y, Wangdi K. A Systematic Review and Meta-Analysis of the Proportion Estimates of Disseminated Intravascular Coagulation (DIC) in Malaria. Trop Med Infect Dis 2023; 8:289. [PMID: 37368707 DOI: 10.3390/tropicalmed8060289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/01/2023] [Accepted: 05/19/2023] [Indexed: 06/29/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is a potentially life-threatening condition that causes systemic coagulation to be turned on and coagulation factors to be used up. However, the evidence for DIC in malaria patients is still not clear, and small case series and retrospective studies have shown varying results. This meta-analysis was intended for the evaluation of the evidence of DIC among malaria patients using a meta-analysis approach. The protocol for the systematic review was registered at PROSPERO as CRD42023392194. Studies that investigated DIC in patients with malaria were searched in Ovid, Scopus, Embase, PubMed, and MEDLINE. The pooled proportion with 95% confidence intervals (CI) of DIC among malaria patients was estimated using a random-effects model. A total of 1837 articles were identified, and 38 articles were included in the meta-analysis. The overall proportion of DIC in malaria was 11.6% (95% CI: 8.9%-14.3%, I2: 93.2%, 38 studies). DIC in severe falciparum malaria and fatal malaria was 14.6% (95% CI: 5.0-24.3%, I2: 95.5%, 11 studies) and 82.2% (95% CI: 56.2-100%, I2: 87.3, 4 studies). The estimates of DIC among severe malaria patients who had multi-organ dysfunction with bleeding, cerebral malaria, acute renal failure, and ≥2 complications were 79.6% (95% CI: 67.1-88.2%, one study), 11.9% (95% CI: 7.9-17.6%, one study), 16.7% (95% CI: 10.2-23.3%, ten studies), and 4.8% (95% CI: 1.9-7.7%, nine studies), respectively. The proportion estimates of DIC among the patients with malaria depended on the Plasmodium species, clinical severity, and types of severe complications. The information from this study provided useful information to guide the management of malaria patients. Future studies are needed to investigate the association between Plasmodium infection and DIC and to understand the mechanism of malaria-induced DIC.
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Affiliation(s)
- Thitinat Duangchan
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
- Hematology and Transfusion Science Research Center, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
| | - Manas Kotepui
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
| | - Suriyan Sukati
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
- Hematology and Transfusion Science Research Center, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
| | - Yanisa Rattanapan
- Medical Technology, School of Allied Health Sciences, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
- Hematology and Transfusion Science Research Center, Walailak University, Tha Sala, Nakhon Si Thammarat 80160, Thailand
| | - Kinley Wangdi
- Department of Global Health, National Centre for Epidemiology and Population Health, College of Health and Medicine, Australian National University, Canberra 2601, Australia
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Schuermans A, Van den Eynde J, Mekahli D, Vlasselaers D. Long-term outcomes of acute kidney injury in children. Curr Opin Pediatr 2023; 35:259-267. [PMID: 36377251 DOI: 10.1097/mop.0000000000001202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) affects up to 35% of all critically ill children and is associated with substantial short-term morbidity and mortality. However, the link between paediatric AKI and long-term adverse outcomes remains incompletely understood. This review highlights the most recent clinical data supporting the role of paediatric AKI as a risk factor for long-term kidney and cardiovascular consequences. In addition, it stresses the need for long-term surveillance of paediatric AKI survivors. RECENT FINDINGS Recent large-scale studies have led to an increasing understanding that paediatric AKI is a significant risk factor for adverse outcomes such as hypertension, cardiovascular disease and chronic kidney disease (CKD) over time. These long-term sequelae of paediatric AKI are most often observed in vulnerable populations, such as critically ill children, paediatric cardiac surgery patients, children who suffer from severe infections and paediatric cancer patients. SUMMARY A growing body of research has shown that paediatric AKI is associated with long-term adverse outcomes such as CKD, hypertension and cardiovascular disease. Although therapeutic pathways tailored to individual paediatric AKI patients are yet to be validated, we provide a framework to guide monitoring and prevention in children at the highest risk for developing long-term kidney dysfunction.
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Affiliation(s)
- Art Schuermans
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven
| | - Jef Van den Eynde
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven
| | - Djalila Mekahli
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven
- Department of Pediatric Nephrology, University Hospitals Leuven
| | - Dirk Vlasselaers
- Department of Intensive Care Medicine, University Hospitals Leuven
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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4
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Tembo D, Mwanza S, Mwaba C, Dallah I, wa Somwe S, Seydel KB, Birbeck GL. Risk factors for acute kidney injury at presentation among children with CNS malaria: a case control study. Malar J 2022; 21:310. [PMID: 36316704 PMCID: PMC9624036 DOI: 10.1186/s12936-022-04327-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 10/18/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Recent research has established that acute kidney injury (AKI) is a common problem in severe paediatric malaria. Limited access to kidney diagnostic studies in the low resources settings where malaria is common has constrained research on this important problem. METHODS Enrolment data from an ongoing clinical trial of antipyretics in children with central nervous system (CNS) malaria, CNS malaria being malaria with seizures or coma, was used to identify risk factors for AKI at presentation. Children 2-11 years old with CNS malaria underwent screening and enrollment assessments which included demographic and anthropomorphic data, clinical details regarding the acute illness, and laboratory studies including creatinine (Cr), quantitative parasite count (qPC), quantitative histidine rich protein 2 (HRP2), lactate, and bilirubin levels. Children with a screening Cr > 106 µmol/l were excluded from the study due to the potential nephrotoxic effects of the study drug. To identify risk factors for AKI at the time of admission, children who were enrolled in the study were categorized as having AKI using estimates of their baseline (i.e. before this acute illness) kidney function and creatinine at enrollment applying the Kidney Disease: Improving Global Outcome (KDIGO) 2012 guidelines. Logistic regressions and a multivariate model were used to identify clinical and demographic risk factors for AKI at presentation among those children enrolled in the study. RESULTS 465 children were screened, 377 were age-appropriate with CNS malaria, 22 (5.8%) were excluded due to Cr > 106 µmol/l, and 209 were enrolled. Among the 209, AKI using KDIGO criteria was observed in 134 (64.1%). One child required dialysis during recovery. Risk factors for AKI in both the logistic regression and multivariate models included: hyperpyrexia (OR 3.36; 95% CI 1.39-8.12) and age with older children being less likely to have AKI (OR 0.72; 95% CI 0.62-0.84). CONCLUSION AKI is extremely common among children presenting with CNS malaria. Hyperpyrexia with associated dehydration may contribute to the AKI or may simply be a marker for a more inflammatory systemic response that is also affecting the kidney. Appropriate fluid management in children with CNS malaria and AKI may be challenging since generous hydration to support kidney recovery could worsen malaria-induced cerebral oedema in this critically ill population. Trial registration https://clinicaltrials.gov/ct2/show/NCT03399318.
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Affiliation(s)
- Derby Tembo
- Department of Paediatrics and Child Health, Chipata Central Hospital, Chipata, Zambia
| | - Suzanna Mwanza
- Department of Paediatrics and Child Health, Chipata Central Hospital, Chipata, Zambia
| | - Chisambo Mwaba
- grid.12984.360000 0000 8914 5257Dept. of Paediatric & Child Health, University of Zambia School of Medicine, Lusaka, Zambia
| | - Ifunanya Dallah
- grid.16416.340000 0004 1936 9174Department of Neurology, University of Rochester, Rochester, NY 14642 USA
| | - Somwe wa Somwe
- University Teaching Hospitals, Neurology Research Office, Lusaka, Zambia
| | - Karl B. Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi ,grid.17088.360000 0001 2150 1785Dept. of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI USA
| | - Gretchen L. Birbeck
- grid.12984.360000 0000 8914 5257Dept. of Paediatric & Child Health, University of Zambia School of Medicine, Lusaka, Zambia ,grid.16416.340000 0004 1936 9174Department of Neurology, University of Rochester, Rochester, NY 14642 USA ,University Teaching Hospitals Children’s Hospital, Lusaka, Zambia
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Batte A, Berrens Z, Murphy K, Mufumba I, Sarangam ML, Hawkes MT, Conroy AL. Malaria-Associated Acute Kidney Injury in African Children: Prevalence, Pathophysiology, Impact, and Management Challenges. Int J Nephrol Renovasc Dis 2021; 14:235-253. [PMID: 34267538 PMCID: PMC8276826 DOI: 10.2147/ijnrd.s239157] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/26/2021] [Indexed: 01/02/2023] Open
Abstract
Acute kidney injury (AKI) is emerging as a complication of increasing clinical importance associated with substantial morbidity and mortality in African children with severe malaria. Using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria to define AKI, an estimated 24–59% of African children with severe malaria have AKI with most AKI community-acquired. AKI is a risk factor for mortality in pediatric severe malaria with a stepwise increase in mortality across AKI stages. AKI is also a risk factor for post-discharge mortality and is associated with increased long-term risk of neurocognitive impairment and behavioral problems in survivors. Following injury, the kidney undergoes a process of recovery and repair. AKI is an established risk factor for chronic kidney disease and hypertension in survivors and is associated with an increased risk of chronic kidney disease in severe malaria survivors. The magnitude of the risk and contribution of malaria-associated AKI to chronic kidney disease in malaria-endemic areas remains undetermined. Pathways associated with AKI pathogenesis in the context of pediatric severe malaria are not well understood, but there is emerging evidence that immune activation, endothelial dysfunction, and hemolysis-mediated oxidative stress all directly contribute to kidney injury. In this review, we outline the KDIGO bundle of care and highlight how this could be applied in the context of severe malaria to improve kidney perfusion, reduce AKI progression, and improve survival. With increased recognition that AKI in severe malaria is associated with substantial post-discharge morbidity and long-term risk of chronic kidney disease, there is a need to increase AKI recognition through enhanced access to creatinine-based and next-generation biomarker diagnostics. Long-term studies to assess severe malaria-associated AKI’s impact on long-term health in malaria-endemic areas are urgently needed.
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Affiliation(s)
- Anthony Batte
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Zachary Berrens
- Department of Pediatrics, Pediatric Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kristin Murphy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ivan Mufumba
- CHILD Research Laboratory, Global Health Uganda, Kampala, Uganda
| | | | - Michael T Hawkes
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea L Conroy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
Because of the lack of early recognition and referral, the incidence of pediatric acute kidney injury (AKI) in Asia still is underestimated. Although each diagnostic criteria has its own merits, the Kidney Disease Improving Global Outcomes classification now is widely accepted. In Asia, the spectrum of pediatric AKI is wide-ranging, from pediatric AKI in highly sophisticated tertiary-care pediatric intensive care units in resource-rich regions due to advanced procedures such as transplantation, cardiac surgery, and other hospital-acquired causes, to primary care preventable causes, such as infectious diseases, snakebite, and so forth in rural parts of the developing world. The development and application of novel biomarkers, concepts such as the Renal Angina Index and advanced renal replacement therapy have revolutionized the era of treating AKI, but the cost and feasibility are the key determinants, especially in rural areas. In view of availability and expenses, peritoneal dialysis should be the first choice in less-developed areas, however, because of various barriers, it still needs more effort. Effective educational steps to both medical carers and families are needed urgently.
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Affiliation(s)
- Ruochen Che
- Department of Nephrology, State Key Laboratory of Reproductive Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China; Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China
| | - Mohammed Mazheruddin Quadri
- Department of Nephrology, State Key Laboratory of Reproductive Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China; Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China
| | - Aihua Zhang
- Department of Nephrology, State Key Laboratory of Reproductive Medicine, Children's Hospital of Nanjing Medical University, Nanjing, China; Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China.
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7
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Brown DD, Solomon S, Lerner D, Del Rio M. Malaria and acute kidney injury. Pediatr Nephrol 2020; 35:603-608. [PMID: 30706124 DOI: 10.1007/s00467-018-4191-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 12/19/2018] [Accepted: 12/28/2018] [Indexed: 10/27/2022]
Abstract
Malaria is a parasitic infection transmitted by mosquitos, resulting in significant morbidity and mortality. It affects 212 million worldwide, causing death in up to 303,000 children annually. In the USA, up to 1700 people are affected yearly. Although the prevalence in developed countries is less than in developing countries, travelers from low transmission areas, and those from endemic areas who later return, are very susceptible to malaria and its complications. Severe malaria can cause significant multiorgan dysfunction including acute kidney injury (AKI). The pathogenesis is not clearly understood but proposed mechanisms include acute tubular necrosis (ATN) due to impediments in renal microcirculation, infection-triggered proinflammatory reactions within the kidney, and metabolic disturbances. Providers must consider malarial infection in cases of AKI in someone with a travel history, as early recognition and treatment are crucial to improving outcomes. This article will review malaria-induced AKI in order to provide a better understanding of this infection's effect on the kidneys.
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Affiliation(s)
- Denver D Brown
- Department of Pediatric Nephrology at The Children's Hospital at Montefiore, 3326 Bainbridge Ave, Bronx, NY, 10029, USA.
| | - Sonia Solomon
- Department of Pediatric Nephrology at The Children's Hospital at Montefiore, 3326 Bainbridge Ave, Bronx, NY, 10029, USA
| | - Daniele Lerner
- Department of Pediatric Nephrology at The Children's Hospital at Montefiore, 3326 Bainbridge Ave, Bronx, NY, 10029, USA
| | - Marcela Del Rio
- Department of Pediatric Nephrology at The Children's Hospital at Montefiore, 3326 Bainbridge Ave, Bronx, NY, 10029, USA
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Hickson MR, Conroy AL, Bangirana P, Opoka RO, Idro R, Ssenkusu JM, John CC. Acute kidney injury in Ugandan children with severe malaria is associated with long-term behavioral problems. PLoS One 2019; 14:e0226405. [PMID: 31846479 PMCID: PMC6917349 DOI: 10.1371/journal.pone.0226405] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/26/2019] [Indexed: 11/25/2022] Open
Abstract
Background Acute kidney injury (AKI) is a risk factor for neurocognitive impairment in severe malaria (SM), but the impact of AKI on long-term behavioral outcomes following SM is unknown. Methods We conducted a prospective study on behavioral outcomes of Ugandan children 1.5 to 12 years of age with two forms of severe malaria, cerebral malaria (CM, n = 226) or severe malarial anemia (SMA, n = 214), and healthy community children (CC, n = 173). AKI was defined as a 50% increase in creatinine from estimated baseline. Behavior and executive function were assessed at baseline and 6, 12, and 24 months later using the Child Behavior Checklist and Behavior Rating Inventory of Executive Function, respectively. Age-adjusted z-scores were computed for each domain based on CC scores. The association between AKI and behavioral outcomes was evaluated across all time points using linear mixed effect models, adjusting for sociodemographic variables and disease severity. Results AKI was present in 33.2% of children with CM or SMA at baseline. Children ≥6 years of age with CM or SMA who had AKI on admission had worse scores in socio-emotional function in externalizing behaviors (Beta (95% CI), 0.52 (0.20, 0.85), p = 0.001), global executive function (0.48 (0.15, 0.82), p = 0.005) and behavioral regulation (0.66 (0.32, 1.01), p = 0.0002) than children without AKI. There were no behavioral differences associated with AKI in children <6 years of age. Conclusions AKI is associated with long-term behavioral problems in children ≥6 years of age with CM or SMA, irrespective of age at study enrollment.
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Affiliation(s)
- Meredith R. Hickson
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indiana, United States of America
- * E-mail:
| | - Paul Bangirana
- Department of Psychiatry, Makerere University of School of Medicine, Kampala, Uganda
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Makerere University School of Medicine, Kampala, Uganda
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University School of Medicine, Kampala, Uganda
- Centre of Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - John M. Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indiana, United States of America
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Conroy AL, Hawkes MT, Elphinstone R, Opoka RO, Namasopo S, Miller C, John CC, Kain KC. Chitinase-3-like 1 is a biomarker of acute kidney injury and mortality in paediatric severe malaria. Malar J 2018; 17:82. [PMID: 29448936 PMCID: PMC5815237 DOI: 10.1186/s12936-018-2225-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 02/07/2018] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Andrea L Conroy
- Department of Pediatrics, Indiana University School of Medicine, 1044 West Walnut St., Building 4, Indianapolis, IN, 46202, USA. .,Sandra Rotman Centre for Global Health, Toronto General Hospital, University Health Network, MaRS Centre, 101 College St. TMDT 10-360A, Toronto, ON, M5G 1L7, Canada. .,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Michael T Hawkes
- Division of Pediatric Infectious Diseases, 3-593 Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB, T6G1C9, Canada
| | - Robyn Elphinstone
- Sandra Rotman Centre for Global Health, Toronto General Hospital, University Health Network, MaRS Centre, 101 College St. TMDT 10-360A, Toronto, ON, M5G 1L7, Canada
| | - Robert O Opoka
- Department of Pediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Sophie Namasopo
- Department of Pediatrics, Jinja Regional Referral Hospital, P.O. Box 43, Jinja, Uganda
| | | | - Chandy C John
- Department of Pediatrics, Indiana University School of Medicine, 1044 West Walnut St., Building 4, Indianapolis, IN, 46202, USA
| | - Kevin C Kain
- Sandra Rotman Centre for Global Health, Toronto General Hospital, University Health Network, MaRS Centre, 101 College St. TMDT 10-360A, Toronto, ON, M5G 1L7, Canada.,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
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10
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Abdelraheem MB. Acute kidney injury in low- and middle-income countries: investigations, management and prevention. Paediatr Int Child Health 2017; 37:269-272. [PMID: 29216816 DOI: 10.1080/20469047.2017.1386816] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Acute kidney injury (AKI) is a relatively common condition, encountered in everyday paediatric clinical practice. It is an important cause of morbidity and mortality in children both inside and outside intensive care units. It is associated with prolonged hospital stay and progression to chronic kidney disease. The burden of AKI is particularly high in low- and middle-income countries where rural areas and smaller cities in the countryside predominate. Most of these areas suffer from poverty, poor sanitation, water quality and hygiene, lack of education and poor access to health care. AKI is preventable if it is detected sufficiently early and managed promptly. Improved nephrology services and the availability of cost-effective dialysis facilities in resource-limited settings should reduce morbidity and save many children's lives.
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Affiliation(s)
- Mohamed B Abdelraheem
- a Al Jalila Children's Speciality Hospital , Dubai , United Arab Emirates.,b Department of Paediatrics , University of Khartoum , Khartoum , Sudan
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11
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Cerdá J, Mohan S, Garcia-Garcia G, Jha V, Samavedam S, Gowrishankar S, Bagga A, Chakravarthi R, Mehta R. Acute Kidney Injury Recognition in Low- and Middle-Income Countries. Kidney Int Rep 2017; 2:530-543. [PMID: 29034358 PMCID: PMC5637391 DOI: 10.1016/j.ekir.2017.04.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) is increasingly common around the world. Because of the low availability of effective therapies and resource limitations, early preventive and therapeutic measures are essential to decrease morbidity, mortality, and cost. Timely recognition and diagnosis of AKI requires a heightened degree of suspicion in the appropriate clinical and environmental context. In low- and middle-income countries (LMICs), early detection is impaired by limited resources and low awareness. In this article, we report the consensus recommendations of the 18th Acute Dialysis Quality Initiative meeting in Hyderabad, India, on how to improve recognition of AKI. We expect these recommendations will lead to an earlier and more accurate diagnosis of AKI, and improved research to promote a better understanding of the epidemiology, etiology, and histopathology of AKI in LMICs.
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Affiliation(s)
- Jorge Cerdá
- Department of Medicine, Division of Nephrology, Albany Medical College, Albany, New York, USA
- Correspondence: Jorge Cerdá, MD, MS, FACP, FASN, Division of Nephrology, Department of Medicine, Albany Medical College, Albany, NY 12209.Division of NephrologyDepartment of MedicineAlbany Medical CollegeAlbanyNY 12209
| | - Sumit Mohan
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Guillermo Garcia-Garcia
- Nephrology Service, Hospital Civil de Guadalajara “Fray Antonio Alcalde,” Hospital 278, Guadalajara, Mexico
| | - Vivekanand Jha
- George Institute for Global Health India, New Delhi and University of Oxford, Oxford, UK
| | | | | | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Ravindra Mehta
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
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Prasad R, Mishra OP. Acute Kidney Injury in Children with Plasmodium falciparum Malaria: Determinants for Mortality. Perit Dial Int 2016; 36:213-7. [PMID: 26429418 PMCID: PMC4803368 DOI: 10.3747/pdi.2014.00254] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 05/03/2015] [Indexed: 02/03/2023] Open
Abstract
UNLABELLED ♦ BACKGROUND Acute kidney injury (AKI) in P. falciparum malaria infection is an important morbidity in children. The purpose of the present study was done to observe the renal involvement, associated morbidities and outcome. ♦ METHODS Out of 156 patients with severe P. falciparum malaria, diagnosed on the basis of compatible clinical presentations and positive malarial parasites in the peripheral blood smear and/or histidine rich protein 2 antigen, 31 had AKI at presentation and were analyzed. ♦ RESULTS Of 31 (19.9%) patients with AKI, 4 were classified at risk, 11 injury, and 16 failure stage, as per pRIFLE criteria (pediatric version of RIFLE [R = risk, I = injury, F = failure, L = loss E = end-stage kidney disease]). Mean age of children with AKI was 7.7 ± 3.2 years. A significantly higher proportion of patients with AKI had hypoglycemia (41.9%), pulmonary edema (32.2%), and disseminated intravascular coagulation (DIC) (29.0%) compared to those without AKI (18.4%, 4.8%, and 3.2%, respectively). Twelve patients (38.7%) required peritoneal dialysis (PD), 8 (25.8%) died, and all were in failure stage. The non-survivors had significantly higher blood urea (p = 0.005) and serum creatinine levels (p = 0.042), lower glomerular filtration rate (p < 0.001), longer duration of illness (p = 0.003), and oliguria/anuria (p = 0.001) than survivors at admission. On logistic regression analysis, the disseminated intravascular coagulation (DIC), jaundice and parasite density (≥ 3+) were found to be significant factors contributing to mortality in children with AKI. ♦ CONCLUSIONS Acute kidney injury in falciparum malaria is one of the severe systemic complications. Duration of illness and presence of comorbidities adversely affected the outcome.
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Affiliation(s)
- Rajniti Prasad
- Division of Pediatric Nephrology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India
| | - Om P Mishra
- Division of Pediatric Nephrology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India
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Conroy AL, Hawkes M, Elphinstone RE, Morgan C, Hermann L, Barker KR, Namasopo S, Opoka RO, John CC, Liles WC, Kain KC. Acute Kidney Injury Is Common in Pediatric Severe Malaria and Is Associated With Increased Mortality. Open Forum Infect Dis 2016; 3:ofw046. [PMID: 27186577 PMCID: PMC4866565 DOI: 10.1093/ofid/ofw046] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 02/16/2016] [Indexed: 01/06/2023] Open
Abstract
Acute kidney injury is common in severe malaria and associated with short- and long-term mortality developing in 50% of cases after admission. Cystatin C and BUN are associated with the severity of AKI, are elevated at admission and predict mortality. Background. Acute kidney injury (AKI) is a well recognized complication of severe malaria in adults, but the incidence and clinical importance of AKI in pediatric severe malaria (SM) is not well documented. Methods. One hundred eighty children aged 1 to 10 years with SM were enrolled between 2011 and 2013 in Uganda. Kidney function was monitored daily for 4 days using serum creatinine (Cr). Acute kidney injury was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Blood urea nitrogen (BUN) and Cr were assessed using i-STAT, and cystatin C (CysC) was measured by enzyme-linked immunosorbent assay. Results. Eighty-one (45.5%) children had KDIGO-defined AKI in the study: 42 (51.9%) stage 1, 18 (22.2%) stage 2, and 21 (25.9%) stage 3. Acute kidney injury evolved or developed in 50% of children after admission of hospital. There was an increased risk of AKI in children randomized to inhaled nitric oxide (iNO), with 47 (54.0%) of children in the iNO arm developing AKI compared with 34 (37.4%) in the placebo arm (relative risk, 1.36; 95% confidence interval [CI], 1.03–1.80). Duration of hospitalization increased across stages of AKI (P = .002). Acute kidney injury was associated with neurodisability at discharge in the children receiving placebo (25% in children with AKI vs 1.9% in children with no AKI, P = .002). Mortality increased across stages of AKI (P = .006) in the placebo arm, reaching 37.5% in stage 3 AKI. Acute kidney injury was not associated with neurodisability or mortality at discharge in children receiving iNO (P > .05 for both). Levels of kidney biomarkers were predictive of mortality with areas under the curves (AUCs) of 0.80 (95% CI, .65–.95; P = .006) and 0.72 (95% CI, .57–.87; P < .001), respectively. Admission levels of CysC and BUN were elevated in children who died by 6 months (P < .0001 and P = .009, respectively). Conclusions. Acute kidney injury is an underrecognized complication in young children with SM and is associated with increased mortality.
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Affiliation(s)
- Andrea L Conroy
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Canada; Department of Pediatrics, Indiana University, Indianapolis
| | - Michael Hawkes
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Canada; Division of Pediatric Infectious Diseases
| | - Robyn E Elphinstone
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health , University Health Network-Toronto General Hospital, University of Toronto , Canada
| | - Catherine Morgan
- Division of Pediatric Nephrology , University of Alberta , Edmonton, Canada
| | - Laura Hermann
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health , University Health Network-Toronto General Hospital, University of Toronto , Canada
| | - Kevin R Barker
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health , University Health Network-Toronto General Hospital, University of Toronto , Canada
| | | | - Robert O Opoka
- Department of Paediatrics and Child Health , Mulago Hospital and Makerere University , Kampala , Uganda
| | - Chandy C John
- Department of Pediatrics , Indiana University , Indianapolis
| | - W Conrad Liles
- Department of Medicine , University of Washington , Seattle
| | - Kevin C Kain
- Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, University of Toronto, Canada; Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Canada
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Anstey NM, Douglas NM, Poespoprodjo JR, Price RN. Plasmodium vivax: clinical spectrum, risk factors and pathogenesis. ADVANCES IN PARASITOLOGY 2013. [PMID: 23199488 DOI: 10.1016/b978-0-12-397900-1.00003-7] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Vivax malaria was historically described as 'benign tertian malaria' because individual clinical episodes were less likely to cause severe illness than Plasmodium falciparum. Despite this, Plasmodium vivax was, and remains, responsible for major morbidity and significant mortality in vivax-endemic areas. Single infections causing febrile illness in otherwise healthy individuals rarely progress to severe disease. Nevertheless, in the presence of co-morbidities, P. vivax can cause severe illness and fatal outcomes. Recurrent or chronic infections in endemic areas can cause severe anaemia and malnutrition, particularly in early childhood. Other severe manifestations include acute lung injury, acute kidney injury and uncommonly, coma. Multiorgan failure and shock are described but further studies are needed to investigate the role of bacterial and other co-infections in these syndromes. In pregnancy, P. vivax infection can cause maternal anaemia, miscarriage, low birth weight and congenital malaria. Compared to P. falciparum, P. vivax has a greater capacity to elicit an inflammatory response, resulting in a lower pyrogenic threshold. Conversely, cytoadherence of P. vivax to endothelial cells is less frequent and parasite sequestration is not thought to be a significant cause of severe illness in vivax malaria. With a predilection for young red cells, P. vivax does not result in the high parasite biomass associated with severe disease in P. falciparum, but a four to fivefold greater removal of uninfected red cells from the circulation relative to P. falciparum is associated with a similar risk of severe anaemia. Mechanisms underlying the pathogenesis of severe vivax syndromes remain incompletely understood.
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Affiliation(s)
- Nicholas M Anstey
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
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