Impact of renal failure on the outcome of dengue viral infection

Dengue haemorrhagic fever in chronic kidney disease and heart failure: challenges in fluid management

Dengue haemorrhagic fever (DHF) is recognized to have high mortality in patients with chronic kidney disease (CKD) and heart failure (HF). They are at high risk of shock during the ascending limb of the critical phase of DHF, fluid overload during convalescence and bleeding throughout the entire illness. Physiological changes and medications used in CKD/HF make the diagnosis and monitoring of DHF difficult. Treatment with standard fluid regimens also poses a challenge due to the propensity for fluid overload. As a result, standard dengue guidelines do not provide recommendations on fluid management regimens in DHF with CKD/HF. This article provides a narrative review on the existing evidence for management of DHF in patients with volume-changed states such as HF, CKD and nephrotic/ nephritic syndromes. It will explore the relevant diagnostic and therapeutic dilemmas, acknowledge the challenges for developing guidelines and recommend strategies to improve fluid management in these groups of patients.

Dengue virus infection among renal transplant recipients in Singapore: a 15-year, single-centre retrospective review

INTRODUCTION

Dengue is a mosquito-borne viral infection endemic in Singapore. Its impact on renal transplantation is limited to small case series. We aimed to characterise the clinical presentation and outcomes of dengue infection among renal transplant recipients in Singapore.

METHODS

We conducted a 15-year retrospective review of dengue in renal transplant patients treated at Singapore General Hospital between January 2005 and October 2019. The diagnosis of dengue was made if there were a compatible clinical syndrome and a positive dengue diagnostic assay (dengue non-structural 1 antigen, immunoglobulin M or reverse transcriptase-polymerase chain reaction).

RESULTS

Of the 31 patients diagnosed with dengue, 18 (58.1%) were deceased donor recipients. The median age was 52 (interquartile range [IQR] 40-61) years; 16 (51.6%) were females. The median time to diagnosis was 99 (IQR 18-169) months from transplant. The most common clinical symptoms were fever (87.1%), myalgia (41.9%), gastrointestinal symptoms (38.7%) and headache (25.8%). Nineteen (61.3%) patients had dengue without warning signs, nine (29.0%) had dengue with warning signs, three (9.7%) had severe dengue and 30 (96.8%) were hospitalised. Seventeen (54.8%) patients had graft dysfunction, 16 (94.1%) of whom had recovery of graft function. One (3.2%) patient required dialysis and subsequently died. There were two cases of donor-derived infections (DDIs) with favourable outcomes.

CONCLUSION

Our experience with dengue in renal transplant recipients is concordant with published data. Although graft dysfunction is common, it is often transient with favourable outcomes. Outpatient management may be considered for mild infections. Although dengue DDIs are uncommon, more stringent donor screening may be considered in endemic regions.

Prevalence of acute kidney injury among dengue cases: a systematic review and meta-analysis

Numerous studies have shown a correlation between dengue virus (DENV) infection and kidney disease. However, there is no existing meta-analysis on the prevalence of kidney diseases in the dengue population. A thorough systematic review and meta-analysis were undertaken to determine the prevalence of renal problems in people with DENV infection in order to fill this knowledge gap. A rigorous electronic literature search was carried out up to 25 January 2023 in a number of databases, including ProQuest, EBSCOhost, Scopus, PubMed and Web of Science. The search aimed to find articles that reported on the prevalence of kidney diseases in patients with DENV infection. Using the modified Newcastle-Ottawa Scale, the quality of the included studies was assessed. The meta-analysis included a total of 37 studies with 21 764 participants reporting on the prevalence of acute kidney injury (AKI) in individuals with DENV infection. The pooled prevalence of AKI in dengue patients was found to be 8% (95% confidence interval 6 to 11), with high heterogeneity across studies. The studies included are of moderate quality. The study revealed a high AKI prevalence in dengue patients, underlining the need for regular renal examination to detect AKI early and reduce hospitalization risk. Further research is needed to understand the dengue-kidney relationship and develop effective management strategies.

Clinical and laboratory profile of Expanded Dengue Syndrome: experience of 2019 outbreak from Dhaka, Bangladesh

BACKGROUND OBJECTIVES

Bangladesh is afflicted with periodic dengue outbreak every few years and one of the worst upsurges was recorded in 2019 during which there was an increasing trend of dengue with unusual symptoms which were not so common before. This study aims to describe the experience of three tertiary care centres of Dhaka regarding the clinical and laboratory, hospital outcome and management profile of the Expanded Dengue Syndrome (EDS) cases admitted from the 2019 outbreak.

METHODS

The current work was a cross-sectional observational study which took place from August 1 to December 31 2019 at three major tertiary care centres in Dhaka, Bangladesh. Out of total 2017 screened dengue cases, 49 met the inclusion criteria and 39 were enrolled after taking informed written consent. Data was analysed using Microsoft Excel and Graph pad prism 9.3.1. A probability value of p<0.05 was considered statistically significant.

RESULTS

Out of the 39 cases, majority were male (79.49%) with median (±IQR) age of 33(±9) years. Hypertension (4; 10.26%) was the most commonly associated co-morbidity. Among the systemic manifestations, most prevalent was hepatitis (38.49%) followed by encephalopathy (12.82%). Majority of the patients were suffering from primary infection (85%). Case fatality rate was 15.38%. Hepatitis and meningoencephalitis were the predominant cause of death. This study records the only known case report of Acute respiratory dress syndrome (ARDS) complicating dengue from Bangladesh. None of the patients from our cohort were managed by steroids. Only two (5.13%) out of 39 cases received antibiotics.

INTERPRETATION CONCLUSION

In the year 2019, an unusual rise in EDS cases with about 15.4% fatalities were observed in this study. Hepatitis was the most common presentation and cause of death. Here, we report the first ARDS case encountered in Bangladesh. Despite the multifaceted presentation of EDS, indiscriminate use of antibiotics and steroid was minimal. Early recognition of multifarious features of EDS is important for choosing the targeted treatment option which can avert many deaths. The results of this study underline the necessity for more in-depth research into the risk factors that are contributing to mortality in EDS cases.

Multisystem Failure in Fatal Dengue: Associations between the Infectious Viral Serotype and Clinical and Histopathological Findings

Dengue is the most important arthropod-borne viral infection of humans. However, its viral pathogenesis is still unknown. The information collected from dengue fatal cases is crucial for understanding the complex interactions between virulence and host factors. This study aimed to establish possible associations between the clinical characteristics, histopathological changes, replication, and tissue location of viral serotypes in dengue fatal cases. Clinical and histopathological characterizations, antigen localization in tissue, and detection of the infecting serotype and replication using real-time polymerase chain reaction were all performed on the dengue fatal cases. The majority of the cases involved people under the age of 20. Bleeding (48.3%), abdominal pain (44.8%), myalgia (52.9%), and headache (48.3%) were the most common clinical manifestations in the cases. There was multiorgan pathology, with histopathological changes primarily in the liver, spleen, and lung. Similarly, the viral antigen was found primarily in these organs; however, there were no associations between tissue changes, viral location, infecting serotypes, and replication processes. Dengue infection should be considered a multiorgan disease, the outcome of which is possibly not associated with the infecting viral serotype.

In-hospital mortality predictors among hospitalized adults and those with chronic kidney disease with dengue

BACKGROUND

Accurately identifying risk factors that predict fatality in dengue is crucial for patient triage and clinical management. Our objective was to identify predictors of death associated with dengue and investigate the clinical characteristics and risk factors among patients with chronic kidney disease (CKD) who died from dengue.

METHODS

A multicenter longitudinal observation study conducted from 2008 to 2019.

RESULTS

A total of 1272 patients (113 who died and 1186 who recovered) diagnosed with dengue were included. Old age, CKD, and an elevated white blood cell count at hospital presentation were identified as independent predictors of in-hospital mortality among individuals infected with the dengue virus. In a subgroup analysis of 138 patients with CKD infected with dengue virus, 64 (46.3%) patients died, with 46 (33.3%) patients dying within 7 days after symptom onset. Among 64 fatal dengue patients with CKD, 34.4% were in stages 2 and 3 of kidney disease, 51.5% were in stages 4 and 5, and 14.1% had end stage renal disease as per the classification by Kidney Disease Improving Global Outcomes. Multivariate analysis revealed that initial altered consciousness, pulmonary edema, and leukocytosis during hospitalization were independently associated with in-hospital mortality in CKD patients infected with the dengue virus. Leukocytosis during hospitalization and severe hepatitis were independent risk factors for death within 7 days after dengue illness onset in CKD patients.

CONCLUSIONS

This study offers valuable insights into predictors linked to fatality in dengue and reinforces the importance of optimizing patient triage to improve the quality of care.

Associations of air pollutant concentrations with longitudinal kidney function changes in patients with chronic kidney disease

This longitudinal cohort study investigated the associations of air pollutant exposures, including CO, NO, NO₂, NO_x, O₃, PM₁₀, PM_2.5, and SO₂, with long-term kidney function changes in patients with chronic kidney disease (CKD). We enrolled 447 CKD patients who took part in a universal hospital pre-ESRD care program during 2011-2015. The daily average air pollutant exposures and temperature were estimated for each patient, with different levels of air pollutant concentrations defined by 5-knot and restricted cubic spline function. Predicted annual estimated glomerular filtration (eGFR) slope values by one mixed model were considered as the study outcome. The average age of the study population was 77.1 ± 12.6 years, and the median annual eGFR decreased by 2.1 ml/min/1.73 m² per year from 30 ml/min/1.73 m² at baseline during a mean follow-up time of 3.4 years. The univariable and multivariable analyses revealed no significant linear and non-linear associations between 5-knot air pollutant concentrations and annual eGFR slope. In addition, the visualized spline effect plots show insignificant variation patterns in annual eGFR slope values with increased air pollutant concentrations. These results encourage more extensive studies to clarify the causal relationships and mechanisms of long-term specific air pollutant exposures and longitudinal kidney function change, especially in CKD populations.

Mechanism of Immune Evasion in Mosquito-Borne Diseases

In recent decades, mosquito-borne illnesses have emerged as a major health burden in many tropical regions. These diseases, such as malaria, dengue fever, chikungunya, yellow fever, Zika virus infection, Rift Valley fever, Japanese encephalitis, and West Nile virus infection, are transmitted through the bite of infected mosquitoes. These pathogens have been shown to interfere with the host's immune system through adaptive and innate immune mechanisms, as well as the human circulatory system. Crucial immune checkpoints such as antigen presentation, T cell activation, differentiation, and proinflammatory response play a vital role in the host cell's response to pathogenic infection. Furthermore, these immune evasions have the potential to stimulate the human immune system, resulting in other associated non-communicable diseases. This review aims to advance our understanding of mosquito-borne diseases and the immune evasion mechanisms by associated pathogens. Moreover, it highlights the adverse outcomes of mosquito-borne disease.

Risk Factors for Mortality in Patients with Dengue: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate risk factors for mortality in dengue.

METHODS

Systematic review and meta-analysis searching MEDLINE, Embase, SciELO, LILACS Bireme, and OpenGrey to identify eligible observational studies of patients with dengue, of both genders, aged 14 years or older, that analyzed risk factors associated with mortality and reported adjusted risk measures with their respective confidence intervals (CIs). We estimated the pooled weighted mean difference and 95% CIs with a DerSimonian and Laird random-effects model. Methodological quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

Of 1,170 citations reviewed, 18 papers, with a total of 25,851 patients, were included in the systematic review and 12 in the meta-analysis. Severe hepatitis (OR 29.222, 95% CI: 3.876-220.314), dengue shock syndrome (OR 23.575, 95% CI 3.664-151.702), altered mental status (OR 3.76, 95% CI 1.67-8.42), diabetes mellitus (OR 3.698, 95% CI 1.196-11.433), and higher pulse rate (OR 1.039, 95% CI 1.011-1.067) are associated with mortality in patients with dengue. All studies included were classified as having a high quality.

CONCLUSIONS

Proper identification and management of these risk factors should be considered to improve patient outcomes and reduce the hidden burden of this neglected tropical disease. Future well-designed studies are needed to investigate the association of other clinical, radiological, and laboratorial findings with mortality in dengue, as well as to develop prognostic models based on the risk factors found in our study.

Acute kidney injury associated with dengue virus infection: a review

Acute kidney injury (AKI) is one of the least studied complications of dengue, but it carries high mortality rates and prolonged hospital stay. Due to the severity of this complication, the risk of developing chronic kidney disease (CKD) and the increasing number of dengue cases reported worldwide, particularly in the tropical and subtropical regions of Africa, Southeast Asia and South America, including Brazil, we embarked on this narrative review, aimed to update the epidemiology of AKI associated with dengue, elucidate the main pathophysiological mechanisms of AKI caused by the dengue virus infection, as well as discuss useful information on the prevention and management of AKI in patients with dengue.

Severe dengue in adults and children, Ouagadougou (Burkina Faso), West Africa, October 2015–January 2017

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Severe dengue was common in this sudy.

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In contrast to multiple prior studies, the risk of severe dengue was greater for patients with primary dengue compared to those with secondary infection.

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Additional risk factors for severe dengue included age, male sex, haemoglobin S, diabetes, and hypertension.  Case mapping showed that dengue cases were more concentrated  in sectors located in the centre of the city and close to the health centres.

Introduction

Although dengue is the most common arbovirus infection worldwide, studies of severe dengue in Africa are lacking, and risk factors for severe dengue have been insufficiently described. This study was conducted in the context of the 2016 dengue epidemic in Burkina Faso to determine the prevalence of severe dengue, identify factors associated with severe dengue, and perform mapping of dengue cases in the country's capital, Ouagadougou.

Methods

This cross-sectional study was conducted from November 2015 to January 2017. Data were collected in 15 public and private health centres, and included sociodemographic, clinical and patient outcome variables. Dengue was diagnosed using SD Bioline Dengue Duo rapid diagnostic tests. Data were analysed using Epi-Info Version 7. Logistic regression was used to identify predictors of severe dengue. P<0.05 was considered significant. Dengue case mapping was performed using Geographic Information System software (ArcGIS).

Results

Of the 811 patients who tested positive for dengue, 609 (75%) had early dengue (AgNS1 positive) and 272 (33.5%) had severe dengue. Patient age ranged from 1 to 83 years (median 30.5 years) and 393 (48.3%) were female. Renal failure (13.1%) and severe bleeding (10.6%) were the most common signs of severe dengue. Risk factors for severe dengue included age, male sex, haemoglobin S, diabetes, hypertension, and primary dengue. Dengue cases were more concentrated  in sectors located in the centre of the city and close to the health centres.

Conclusion

Dengue is increasingly common in Africa and factors associated with severity should be sought systematically as soon as a patient tests positive. Additional studies are needed to determine if the factors found to be associated with severity can be used to identify patients at risk for dengue-related complications, and to provide early and specialized management to reduce morbidity and mortality related to dengue in Africa.

Brazilian Dengue Virus Type 2-Associated Renal Involvement in a Murine Model: Outcomes after Infection by Two Lineages of the Asian/American Genotype

Dengue virus type 2 (DENV-2) is, traditionally, the most studied serotype due to its association with explosive outbreaks and severe cases. In Brazil, almost 20 years after the first introduction in the 1990s, a new lineage (Lineage II) of the DENV-2 Asian/American genotype emerged and caused an epidemic with severe cases and hospitalizations. Severe dengue includes multiple organ failure, and renal involvement can be potentially related to increased mortality. In order to better understand the role of DENV infection in renal injury, here we aimed to investigate the outcomes of infection with two distinct lineages of DENV-2 Asian/American genotype in the kidney of a murine model. BALB/c mice were infected with Lineages I and II and tissues were submitted to histopathology, immunohistochemistry, histomorphometry and ultrastructural analysis. Blood urea nitrogen (BUN) was detected in blood sample accessed by cardiac puncture. A tendency in kidney weight increase was observed in mice infected with both lineages, but urea levels, on average, were increased only in mice infected with Lineage II. The DENV antigen was detected in the tissue of mice infected with Lineage II and morphological changes were similar to those observed in human dengue cases. Furthermore, the parameters such as organ weight, urea levels and morphometric analysis, showed significant differences between the two lineages in the infected BALB/c, which was demonstrated to be a suitable experimental model for dengue pathophysiology studies in kidneys.

Social, health system and clinical determinants of fever mortality during an outbreak of dengue fever in Kerala, India

Background and Objectives:

The morbidity and mortality spectrum of the south Indian state of Kerala is dominated by chronic non-communicable diseases, yet febrile illnesses because of neglected tropical diseases and emerging viral infections are often reported. As fever deaths are mostly avoidable, understanding the determinants of mortality is essential for implementing preventive measures.

Methods:

A case-control study was done during an ongoing dengue outbreak in Thiruvananthapuram district, Kerala during 2017–18. Cases included all fever deaths from the line list of Integrated Disease Surveillance Program (IDSP). Data were obtained from hospital case records and by interviewing patients or care givers. The theoretical model for determinants of mortality was constructed at three levels namely sociodemographic factors, access to health care and health seeking behavior, and clinical determinants.

Results:

This study confirmed association of mortality with age above 40 years (P = 0.010, OR = 3.48), being heavy built (P = 0.029, OR = 13.25), clinical symptoms of breathlessness (P < 0.001, OR = 24.89), restlessness (P < 0.001, OR = 97.26), clinical signs of drowsiness (P = 0.024, OR = 7.97), hypotension (P < 0.001, OR = 42.22), complications such as ARDS (P = 0.047, OR = 171.56), and myocarditis (P = 0.012, OR = 16.59). A low occupation status of semiskilled work or less (P = 0.012, OR = 0.30), choosing a nearby hospital for treatment (P = 0.018, OR = 0.48) and shortening the time gap between onset of symptom and final diagnosis (P = 0.044, OR = 0.72) was found to be protective.

Conclusion:

Along with biological and clinical factors, distal determinants like social factors, health seeking behavior, and health system factors are associated with fever mortality.

Mortality among Hospitalized Dengue Patients with Comorbidities in Mexico, Brazil, and Colombia

Dengue patients with comorbidities may be at higher risk of death. In this cross-sectional study, healthcare databases from Mexico (2008–2014), Brazil (2008–2015), and Colombia (2009–2017) were used to identify hospitalized dengue cases and their comorbidities. Case fatality rates (CFRs), relative risk, and odds ratios (OR) for in-hospital mortality were determined. Overall, 678,836 hospitalized dengue cases were identified: 68,194 from Mexico, 532,821 from Brazil, and 77,821 from Colombia. Of these, 35%, 5%, and 18% were severe dengue, respectively. Severe dengue and age ≥ 46 years were associated with increased risk of in-hospital mortality. Comorbidities were identified in 8%, 1%, and 4% of cases in Mexico, Brazil, and Colombia, respectively. Comorbidities increased hospitalized dengue CFRs 3- to 17-fold; CFRs were higher with comorbidities regardless of dengue severity or age. The odds of in-hospital mortality were significantly higher in those with pulmonary disorders (11.6 [95% CI 7.4–18.2], 12.7 [95% CI 9.3–17.5], and 8.0 [95% CI 4.9–13.1] in Mexico, Brazil, and Colombia, respectively), ischemic heart disease (23.0 [95% CI 6.6–79.6], 5.9 [95% CI 1.4–24.6], and 7.0 [95% CI 1.9–25.5]), and renal disease/failure (8.3 [95% CI 4.8–14.2], 8.0 [95% CI 4.5–14.4], and 9.3 [95% CI 3.1–28.0]) across the three countries; the odds of in-hospital mortality from dengue with comorbidities was at least equivalent or higher than severe dengue alone (4.5 [95% CI 3.4–6.1], 9.6 [95% CI 8.6–10.6], and 9.0 [95% CI 6.8–12.0). In conclusion, the risk of death because of dengue increases with comorbidities independently of age and/or disease severity.

Predictors and Outcomes of Dengue-Associated Acute Kidney Injury

Dengue viral infections present with a wide clinical spectrum ranging from asymptomatic to severe manifestations with organ involvement. The term "expanded dengue syndrome" has been commonly used to illustrate the unusual or atypical manifestations; acute kidney injury (AKI) is one of the atypical manifestations of this syndrome. The use of heterogeneous criteria to determine the presence of AKI in dengue patients due to the vast diversity in populations led to difficulties in assessing the true incidence of dengue-associated AKI. This review presents a variable, but often high, frequency of dengue-associated AKI among vastly diverse populations with various disease severities. Dengue-associated AKI is not an uncommon complication, and its importance has often been neglected during the management of dengue patients. The risk factors and certain clinical and laboratory findings commonly reported among dengue patients with AKI should be considered to support a timely diagnosis and case management. This review highlights the need for clinicians to be aware of dengue-associated AKI to reduce the morbidity and mortality associated with this common and important tropical disease.

Clinical characteristics and risk factors for intracranial hemorrhage or infarction in patients with dengue

BACKGROUND

Intracranial hemorrhage (ICH) or infarction in dengue cases is rare but very challenging for clinicians. We report these uncommon complications of dengue patients and focused on the significant factors associated with ICH or infarction in dengue patients.

METHODS

This investigation was a retrospective study of 182 adult dengue patients who received brain computed tomography at three Taiwan hospitals during the 2014 and 2015 dengue outbreaks. This included 13 hemorrhage cases, 26 infarction cases and 143 cases without brain infarction or hemorrhage.

RESULTS

Among them, 13 (7.14%) suffered from ICH (6 had subdural hemorrhage, 3 had subarachnoid hemorrhage, 1 had subdural and subarachnoid hemorrhage, and 3 had intracerebral hemorrhage) and 26 (14.3%) had brain infarction. The overall mortality rate was 4/13 (30.8%) in the ICH group and 3/26 (11.5%) in the infarction group. The significant variables from the univariate analysis, including difference between 2014 and 2015, age, history of cerebrovascular accident, bone pain, arthralgia, dizziness, altered consciousness, and a higher Charlson comorbidity score. Multivariate analysis revealed that significant risk factors for ICH/infarction in dengue cases were the year of occurrence, 2014 vs. 2015 (p < 0.0001, OR = 25.027, 95% CI = 8.205-76.336), Charlson score >4 (p = 0.01, OR = 3.764, 95% CI = 1.364-10.386) and altered consciousness (p < 0.0001, OR = 6.3, 95% CI = 2.242-17.7). The factors physicians should notice in dengue endemic regions for brain infarction or ICH include altered consciousness and a Charlson score >4, especially in the year that a higher frequency of infarction/ICH was observed.

Prevalence, Characteristics, and Factors Associated with Acute Kidney Injury among Adult Dengue Patients in Vietnam

Acute kidney injury (AKI) is a serious and potentially lethal complication of dengue disease; however, the actual incidence in dengue patients in Vietnam is unknown. This study aimed to determine the prevalence, clinical and laboratory characteristics, and risk factors for AKI in adults with dengue. This is a multicenter, cross-sectional study conducted between January and December 2017 in 2,417 adult patients with dengue. Indicators of demographic, clinical, and laboratory findings were evaluated. The prevalence of dengue disease-associated AKI was 2.7% (64/2,417), and dengue patients with AKI had a higher mortality rate than patients without AKI (12.5% versus 0.6%; P < 0.01). Characteristics of AKI were more common in male gender (male: female was 6.1:1), a history of hypertension (7.8% versus 2.3%; P < 0.02), the situations of hemoconcentration (hematocrit > 44%; P < 0.008), hypovolemic shock (21.9% versus 6.8%; P < 0.01), organ failure (42.3% versus 2.3%; P < 0.01), or manifestations of myocarditis (20.3% versus 6.6%; P < 0.01), hyperbilirubinemia (28.7 ± 7.6 versus 12.0 ± 0.9; P < 0.01), elevated enzymes such as ALT (407 ± 151 versus 113 ± 6; P < 0.01) and AST (891 ± 475 versus 172 ± 11; P < 0.01), and prolonged PT (s) (13.9 ± 4.6 versus 12.3 ± 1.5; P < 0.01). Independent risk factors for AKI by multivariate analysis were male gender (OR: 43.6; 95% CI: 2.4-810), severe dengue classification (OR: 25.7; 95% CI: 2-333), and creatine kinase > 190 U/L (OR: 11.7; 95% CI: 1.1-122.4). The study results indicate a need to continue studying the association between AKI and mortality in dengue disease and the need for improved management of AKI with dengue.

Acute kidney injury in dengue among hospitalized children: A prospective view

Dengue viral infection (DVI) has emerged as one of the most common arthropod borne diseases and is more prevalent in the tropical countries. It has varied clinical spectrum ranging from undifferentiated fever to severe hemorrhagic fever and shock with multi-organ dysfunction. Acute kidney injury (AKI) is lesser known complication in DVI. Although studies report varying reports of AKI in DVI among children, exact incidence is not known as most of the studies are retrospective. Hospital-based observational study in 105 children with DVI requiring admission was studied for the occurrence of AKI along with clinical course and outcome. AKI Network (AKIN) criteria were used to define AKI. The IBM SPSS Statistics software version 21.0 was used for the statistical analysis. Of 105 children with dengue, six (5.71%) cases developed AKI. All six cases had urine output <0.5 mL/kg/h for ≥12 h. Out of six cases with AKI, four had raised serum creatinine (SCr) ≥0.3 mg/dL at admission. One child had normal SCr level at admission which got deranged over the next 12 h, one child had oliguria ( <0.5 mL/kg/h) for about 24 h though the renal function was not deranged. Out of six children with AKI, three (50%) in Stage III and three had AKI Stage II as per the AKIN criteria. Children with AKI (Group A) differed significantly from those without AKI (Group B) in having blood pressure <3^rd centile (P = 0.0023), tachycardia P = 0.008), hyponatremia and hypokalemia (P <0.001 and P = 0.029, respectively) and poor outcome 6% mortality in Group B compared to 66.67% in Group A) with P = 0.001. AKI is not a common complication of DVI but if develops it may lead to significant morbidity and mortality among pediatric age group.

A prospective 3 year study of clinical spectrum and outcome of dengue fever in ICU from a tertiary care hospital in North India

Background and Aims:

The incidence of specific complications and adverse outcomes in dengue patients needing admission to intensive care units (ICU) may be quite variable in different regions of India presumably because of different strains of dengue virus or due to re infection.

Methods:

Patients admitted with acute febrile illness (AFI) with either positive IgM antibody or NS1 antigen for dengue were enrolled. Data were collected for 3 years (2015-2017). A total of 313 patients with acute febrile illness were admitted in the study period (2252 total ICU admissions). A total of 137 (43.76%) cases were serologically proven as dengue fever.

Results:

Median age (IQR) of study population was 36.0 (26.0–52.0) years. Liver (65.7%) was the main organ involved followed by acute kidney Injury (AKI) (18.6%). Dengue Shock Syndrome (DSS) was found in 18.6% of cases. Fifty-two patients died and the crude mortality was 38.0%. On multivariate analysis APACHE Score <10, thrombocytopenia, hepatic dysfunction, AKI and dengue shock syndrome (DSS) were associated with the risk of mortality.

Conclusion:

This study in ICU patients showed high mortality in relatively younger patients. Liver (in the form of raised Bilirubin) was the most common organ dysfunction. The need to recognise early warning signs for ICU admission is highlighted.

Renal Involvement in Children with Dengue Fever: A Study in Tertiary Care Hospital of Bangladesh

Background and Objective: Dengue has emerged globally as the most relevant viral infection transmitted by a mosquito bite and represents a major threat to public health. Dengue-related renal manifestations such as proteinuria, hematuria, acute kidney injury (AKI), and rhabdomyolysis are not uncommon, and acute kidney injury (AKI) is a serious complication of dengue fever. There is relatively few data on the renal manifestations of dengue fever in children. Hence, this study was conducted to evaluate the incidence, characteristics, and clinical outcome of dengue fever with renal manifestations. Method. This prospective cross sectional study was conducted in Dr. M R Khan Children Hospital and Institute of Child Health, Dhaka, over a period of 1 year from January 2018 to December 2018. The study was approved by the ethical committee of the institute. A total number of 316 patients were admitted with the diagnosis of dengue fever either NS1 positive or antibody IgM positive or both IgM and IgG positive. Data were collected in a structured questionnaire form and were analyzed by SPSS version 20.0. The disease severity was classified according to the World Health Organization criteria. Renal manifestations were divided into AKI groups using pRIFLE criteria. Proteinuria was defined as urinary protein >1+ (30 mg/dL) by dipstick test. Hematuria was defined as red blood cell (RBC) >5/μL in a fresh uncentrifuged urine specimen. Result. Among 316 dengue patients, thirty-one patients (9.8%) had renal involvement. Most of the patients (54.83%) with renal manifestations were aged between 1 and 5 years. A total of 14 patients were found to have proteinuria (4.4%). Nephrotic-range proteinuria was seen in only one patient (0.3%). AKI was defined by pRIFLE criteria and was seen in 13 patients (4.1%); among AKI 6 (46.15%) had risk, three patients (23.07%) had injury and 4 (30.7%) had failure and needed peritoneal dialysis. Death occurred in 3 patients (9.6%) in dengue with AKI who had failure. The incidence of renal manifestations (proteinuria, hematuria, and AKI) is as high as 9.8% among patients with dengue, and those with AKI had significant morbidity and mortality. Conclusion. Renal involvement in children with dengue is not uncommon. Dengue associated with AKI had significant mortality and morbidity.

Impaired production of immune mediators in dengue virus type 2-infected mononuclear cells of adults with end stage renal disease

Chronic kidney disease is an epidemiologically identified risk factor for development of severe dengue in dengue-affected patients. However, available data on the immune pathogenesis in end stage renal disease (ESRD) patients affected by dengue is insufficient. We performed an in vitro study to evaluate the sequential immunological reactions and viral load in dengue virus type 2-infected mononuclear cells of patients with ESRD (n = 34) and in healthy controls (n = 30). The concentrations of interleukins (IL)-1 receptor antagonist (Ra), IL-2, IL-6, IL-8, IL-10, IL-12p40, granulocyte-macrophage colony-stimulating factor (GM-CSF), monocyte chemotactic protein-1 (MCP-1), macrophage inflammatory protein-1b (MIP-1b), vascular endothelial growth factor (VEGF), tumor necrosis factor (TNF)-α and viral load cycle threshold (Ct) were measured in the dengue virus type 2-infected mononuclear cells at 6 h, 24 h, 48 h, and 72 h post-infection. We found in the ESRD group significantly higher GM-CSF and IL-2 levels at 6 h post-infection. However, IL-8, IL-10, IL-12p40, TNF-α, MCP-1, and MIP-1b levels were found significantly lower than in the control group. At 24 h, 48 h, and 72 h post-infection, significantly lower levels of IL-1Ra, IL-6, IL-8, IL-10, IL-12p40, TNF-α, MCP-1, and MIP-1b were detected in ESRD group. Concentration of VEGF at 24 h and 48 h, and of GM-CSF at 48 h and 72 h were also found to be lower in ESRD group than in control group. Compared with controls, the viral load Ct values were significantly lower in ESRD group at 6 h and 24 h post-infection No significant difference in viral load Ct values between two groups was found at 48 h and 72 h post-infection. Our study discloses that the expression of immune mediators of dengue-infected mononuclear cells is impaired in ESRD patients.

Renal Injury in DENV-4 Fatal Cases: Viremia, Immune Response and Cytokine Profile

Dengue virus (DENV) infections may result in asymptomatic cases or evolve into a severe disease, which involves multiple organ failure. Renal involvement in dengue can be potentially related to an increased mortality. Aiming to better understand the role of DENV in renal injury observed in human fatal cases, post-mortem investigations were performed in four DENV-4 renal autopsies during dengue epidemics in Brazil. Tissues were submitted to histopathology, immunohistochemistry, viral quantification, and characterization of cytokines and inflammatory mediators. Probably due the high viral load, several lesions were observed in the renal tissue, such as diffuse mononuclear infiltration around the glomerulus in the cortical region and in the medullary vessels, hyalinosis arteriolar, lymphocytic infiltrate, increased capsular fibrosis, proximal convoluted tubule (PCT) damage, edema, PCT debris formation, and thickening of the basal vessel membrane. These changes were associated with DENV-4 infection, as confirmed by the presence of DENV-specific NS3 protein, indicative of viral replication. The exacerbated presence of mononuclear cells at several renal tissue sites culminated in the secretion of proinflammatory cytokines and chemokines. Moreover, it can be suggested that the renal tissue injury observed here may have been due to the combination of both high viral load and exacerbated host immune response.

Unusual clinical manifestations of dengue disease - Real or imagined?

The disease caused by each of the four serotypes of dengue virus (DENV) have plagued humans since last century. Symptoms of dengue virus (DENV) infection range from asymptomatic to dengue fever (DF) to severe dengue disease (SDD). One third of the world's population lives in regions with active urban DENV transmission, and thousands of serologically naïve travelers visit these areas annually, making a significant portion of the human population at risk of being infected. Even though lifelong immunity to the homotypic serotype is achieved after a primary DENV infection. Heterotypic DENV infections may be exacerbated by a pre-existing immune memory to the primary infection and can result in an increased probability of severe disease. Not only, age, comorbidities and presence of antibodies transferred passively from dengue-immune mother to infants are considered risk factors to dengue severe forms. Plasma leakage and multiple organ impairment are well documented in the literature, affecting liver, lung, brain, muscle, and kidney. However, unusual manifestation, severe or not, have been reported and may require medical attention. This review will summarize and discuss the increasing reports of unusual manifestations in the clinical course of dengue infection.

Clinical course of dengue fever and its impact on renal function in renal transplant recipients and patients with chronic kidney disease

AIM

Dengue fever is a mosquito-borne viral disease endemic in many tropical and sub-tropical countries. There are only limited data in the literature about dengue fever in renal transplant recipients and patients with chronic kidney disease. This study compares the clinical course of dengue fever and its impact on renal function in renal transplant recipients, patients with chronic kidney disease and patients with normal baseline renal function.

METHODS

An observational study was conducted from 1 May to 31 July 2017, at a tertiary care centre of South India. A major epidemic of dengue had occurred during the study period. Twelve renal transplant recipients, 22 patients with CKD and 58 patients with normal baseline renal function (control group) admitted with dengue fever were prospectively studied.

RESULTS

Nadir WBC count was lowest in renal transplant recipients (2575 ± 1187/mm³ ), [P < 0.001]. Renal transplant recipients took more time for normalization of platelet count (6 ± 4.5 days), [P < 0.001]. All 22 patients with CKD and 11 of 12 renal transplant recipients had worsening of renal function whereas only 17 of 58 patients in the control group had worsening [P < 0.001]. Sixteen patients with CKD, one renal transplant recipient and none among the control group required haemodialysis [P < 0.001]. Dialysis requiring patients had more haemoconcentration (52.5 ± 19.9% increase in haemoglobin), [P < 0.001]. Seven patients with CKD were dialysis dependent at the end of 2 weeks.

CONCLUSION

Clinical features of dengue fever were different in renal transplant recipients and patients with CKD. Severe worsening of renal function was common in CKD patients. Worsening of renal function in renal transplant recipients was less severe and transient.

Clinical Indicators of Fatal Dengue in Two Endemic Areas of Colombia: A Hospital-Based Case-Control Study

According to the World Health Organization, 98% of fatal dengue cases can be prevented; however, endemic countries such as Colombia have recorded higher case fatality rates during recent epidemics. We aimed to identify the predictors of mortality that allow risk stratification and timely intervention in patients with dengue. We conducted a hospital-based, case-control (1:2) study in two endemic areas of Colombia (2009-2015). Fatal cases were defined as having either 1) positive serological test (IgM or NS1), 2) positive virological test (RT-PCR or viral isolation), or 3) autopsy findings compatible with death from dengue. Controls (matched by state and year) were hospitalized nonfatal patients and had a positive serological or virological dengue test. Exposure data were extracted from medical records by trained staff. We used conditional logistic regression (adjusting for age, gender, disease's duration, and health-care provider) in the context of multiple imputation to estimate exposure to case-control associations. We evaluated 110 cases and 217 controls (mean age: 35.0 versus 18.9; disease's duration pre-admission: 4.9 versus 5.0 days). In multivariable analysis, retro-ocular pain (odds ratios [OR] = 0.23), nausea (OR = 0.29), and diarrhea (OR = 0.19) were less prevalent among fatal than nonfatal cases, whereas increased age (OR = 2.46 per 10 years), respiratory distress (OR = 16.3), impaired consciousness (OR = 15.9), jaundice (OR = 32.2), and increased heart rate (OR = 2.01 per 10 beats per minute) increased the likelihood of death (AUC: 0.97, 95% confidence interval: 0.96, 0.99). These results provide evidence that features of severe dengue are associated with higher mortality, which strengthens the recommendations related to triaging patients in dengue-endemic areas.

Characteristics and associated factors of acute kidney injury among adult dengue patients: A retrospective single-center study

Severe dengue cases have been increasingly reported in Thailand, and the under-reporting of acute kidney injury (AKI) in cases of dengue viral infection has become an obstacle in obtaining an accurate description of the true nature and epidemiology of AKI. Because AKI may lead to patient morbidity and mortality, an early diagnosis is important in preventing its onset in dengue patients. This study aimed to determine the prevalence, clinical and laboratory characteristics, and associated factors of AKI among adult dengue patients. This retrospective study reviewed admission data from the medical records of adult dengue patients admitted to the Bangkok Hospital for Tropical Diseases between January 2012 and November 2017 and stratified these patients into AKI and non-AKI groups using the Kidney Disease Improving Global Outcomes criteria (KDIGO). A total of 1,484 patients were included in the study, with 71 categorized into the AKI group. The prevalence of AKI was 4.8%. In the AKI group, the predominant age range was 18–40 years (71.8%), with a female to male ratio of 1:2.7. These patients showed significantly (P < 0.05) higher proportions of altered consciousness, dyspnea, low mean arterial blood pressure, high-grade fever, major bleeding, severe thrombocytopenia, hypoalbuminemia, severe transaminitis, coagulopathy, metabolic acidosis, rhabdomyolysis, proteinuria, hematuria, and pyuria. Our study established that older age, male sex, diabetes mellitus, obesity, severe dengue, and coexisting bacterial infection were significant associated factors for AKI in dengue by multivariate analysis. A total of 10 (14.1%) patients with AKI received dialysis, among which 9 (12.7%) patients from the AKI group died. Our findings suggest that an awareness of AKI, its early diagnosis, and evaluation of clinical and laboratory characteristics of dengue patients will help clinicians to initiate appropriate therapy for dengue-associated AKI.

Prevalence of chronic comorbidities in dengue fever and West Nile virus: A systematic review and meta-analysis

Background

Flavivirus diseases such as dengue fever (DENV), West Nile virus (WNV), Zika and yellow fever represent a substantial global public health concern. Preexisting chronic conditions such as cardiovascular diseases, diabetes, obesity, and asthma were thought to predict risk of progression to severe infections.

Objective

We aimed to quantify the frequency of chronic comorbidities in flavivirus diseases to provide an estimate for their prevalence in severe and non-severe infections and examine whether chronic diseases contribute to the increased risk of severe viral expression.

Methods

We conducted a comprehensive search in PubMed, Ovid MEDLINE(R), Embase and Embase Classic and grey literature databases to identify studies reporting prevalence estimates of comorbidities in flavivirus diseases. Study quality was assessed with the risk of bias tool. Age-adjusted odds ratios (ORs) were estimated for severe infection in the presence of chronic comorbidities.

Results

We identified 65 studies as eligible for inclusion for DENV (47 studies) and WNV (18 studies). Obesity and overweight (i.e., BMI> 25 kg/m², prevalence: 24.5%, 95% CI: 18.6–31.6%), hypertension (17.1%, 13.3–21.8%) and diabetes (13.3%, 9.3–18.8%) were the most prevalent comorbidities in DENV. However, hypertension (45.0%, 39.1–51.0%), diabetes (24.7%, 20.2–29.8%) and heart diseases (25.6%, 19.5–32.7%) were the most prevalent in WNV. ORs of severe flavivirus diseases were about 2 to 4 in infected patients with comorbidities such as diabetes, hypertension and heart diseases. The small number of studies in JEV, YFV and Zika did not permit estimating the prevalence of comorbidities in these infections.

Conclusion

Higher prevalence of chronic comorbidities was found in severe cases of flavivirus diseases compared to non-severe cases. Findings of the present study may guide public health practitioners and clinicians to evaluate infection severity based on the presence of comorbidity, a critical public health measure that may avert severe disease outcome given the current dearth of clear prevention practices for some flavivirus diseases.

Critical care for dengue in adult patients: an overview of current knowledge and future challenges

PURPOSE OF REVIEW

This review aims to update and summarize the current knowledge about clinical features, management, and risk factors of adult dengue patients requiring intensive care with consequently higher risk of mortality.

RECENT FINDINGS

Increasingly, there are more adult dengue patients who require intensive care. This may be due to a shift in epidemiology of dengue infection from mainly a pediatric disease toward adult disease. In addition, multiorgan dysfunction was observed to be a key risk factor for ICU admission and mortality. This may be due to older adults having preexisting comorbidities that potentially predispose to have multiple severe organ impairment. Interventions remain largely supportive but also require more evidence-based trials and treatment protocols.

SUMMARY

These findings highlight the common clinical manifestations of adult dengue patients and the challenges of clinical management in ICU. Risk factors for prediction of adult dengue patients who require ICU are available, but they lack validation and consistent study design for meta-analysis in future. Early recognition of these risk factors, with close monitoring and prompt clinical management, remains critical to reduce mortality.

Short-term renal outcomes following acute kidney injury among dengue patients: A follow-up analysis from large prospective cohort

BACKGROUND

Despite myriad improvements in the care of dengue patients, acute kidney injury (AKI) remained least appreciated intricacy of dengue infection. Exiting literature does not provide any information on renal outcomes among dengue patients surviving an episode of AKI.

METHODS

Dengue patients who developed AKI were followed up for post-discharge period of three months and renal recovery was assessed by using recovery criteria based on different thresholds of serum creatinine (SCr) and estimated glomerular filtration rates (eGFR).

RESULTS

Out of the 526 dengue participants, AKI was developed in 72 (13.7%) patients. Renal recovery was assessed among AKI survivors (n = 71). The use of less (±50% recovery to baseline) to more (±5% recovery to baseline) stringent definitions of renal recovery yielded recovery rates from 88.9% to 2.8% by SCr and 94.4% to 5.6% by eGFR, as renal function biomarkers. At the end of study, eight patients had AKI with AKIN-II (n = 7) and AKIN-III (n = 1). Approximately 50% patients (n = 36/71) with AKI had eGFR primitive to CKD stage 2, while 18.3% (n = 13/71) and 4.2% (n = 3/71) patients had eGFR corresponding to advanced stages of CKD (stage 3 & 4). Factors such as renal insufficiencies at hospital discharge, multiple organ involvements, advance age, female gender and diabetes mellitus were associated with poor renal outcomes.

CONCLUSIONS

We conclude that dengue patients with AKI portend unsatisfactory short-term renal outcomes and deserve a careful and longer follow-up, especially under nephrology care.

Differences in Mortality and Clinical Manifestations of Dengue Hemorrhagic Fever in Taiwan in Different Years: A Comparison for Cases in 2014 and 2015 Epidemics

People in southern Taiwan experienced two major dengue outbreaks in 2014 and 2015. The mortality and clinical features were very different between these 2 years. Dengue virus serotype 1 (DENV-1) caused epidemic outbreak in 2014 and DENV-2 was predominant in 2015. The characteristics of dengue hemorrhagic fever (DHF) cases in the 2 years was analyzed. We conducted a retrospective chart review to analyze the clinical and laboratory features of 206 adult patients with DHF in southern Taiwan in 2014 and 2015. The mortality rate of DHF cases in 2015 was higher than that of cases in 2014 (38.7% versus 12.4%, P < 0.0001). Compared with cases in 2014, DHF cases in 2015 had more complications, such as gastrointestinal bleeding (78.5% versus 61.9%, P = 0.01), severe hepatitis (30.1% versus 8%, P < 0.0001), and myocarditis (14% versus 0.9%, P < 0.0001). Among the mortality cases, diabetes, chronic renal failure, proton-pump inhibitors using, platelet transfusion, and Charlson comorbidity index score (Charlson score) were also higher in 2015. Multivariate analysis for the mortality cases revealed that the risk factors were Charlson score ≥ 5 (P = 0.02, odds ratio [OR] = 4.07, 95% confidence interval [CI] = 1.244-13.307), severe hepatitis (P < 0.0001, OR = 11.97, 95% CI = 3.831-37.396), and acute renal failure (P < 0.0001, OR = 98.76, 95% CI = 10.847-899.22). DHF cases in 2015 had higher mortality and more complications, such as gastrointestinal bleeding, severe hepatitis, and myocarditis, than in 2014 in southern Taiwan. In the 2-year DHF case series, Charlson score ≥ 5, severe hepatitis, and acute renal failure were independent significant variables for mortality.

Acute Renal Failure in Dengue Infection

INTRODUCTION

Acute Renal Failure (RF) is a rare but well recognized complication of Dengue Infection (DI). There has been paucity of published data regarding renal involvement in DI.

AIM

The aim of the present study was to elucidate different clinical presentations, disease outcomes of DI. To study the frequency, severity and predictors of RF in DI.

MATERIALS AND METHODS

Patients diagnosed either as Dengue Fever (DF) or Dengue Haemorrhagic Fever/Dengue Shock Syndrome (DHF/DSS) respectively were enrolled for this study. The diagnostic criteria for DI were febrile illness associated with one of the following: 1) detection of dengue-specific IgM capture antibody or Non-Structural Protein1 (NS1) antigen; or 2) a four-fold or greater increase of dengue-specific IgG capture antibody by ELISA and haemoagglutination inhibition assay. Patients were diagnosed as having Acute RF, if serum creatinine was >1.2 mg/dl or who showed improvement by 50% in serum creatinine from the initial value. It is an observational study of medical charts, data of age, gender, and medical history of any underlying diseases in association with the severity of DI of each patient recorded. All of the laboratory results were collected. Parameters that influenced the clinical presentations and outcomes for development of classical DF or DHF/DSS in patients with or without RF were analysed and compared. Descriptive and inferential statistical analysis was carried. The Statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1, Med Calc 9.0.1, Systat 12.0 and R environment ver.2.11.1 were used.

RESULTS

Most common symptoms were fever followed by headache and pain in abdomen. Among the patients with RF, all patients had recovery. The patients with DHF/DSS were more susceptible to develop renal failure compared to DF group. There were statistically significant higher frequencies of renal failure, haemoconcentration, thrombocytopenia, low serum cholesterol. Patients in the RF group also had significantly higher percentages of shock, haemoconcentration, thrombocytopenia, raised AST and low serum cholesterol compared to non-RF group. There were no mortality and none of them had to receive renal replacement therapy during hospitalization.

CONCLUSION

Patients with DHF/DSS were more susceptible to develop renal failure compared to DF group. Patients in the RF group had higher percentages of shock, haemoconcentration, thrombocytopenia, raised AST and low serum cholesterol.

Tropical Diseases Nephropathy - An Underemphasized Comorbidity

The tropical areas are a home to a number of diseases because of the hot & humid climate, and lack of health care facilities. Tropical Nephropathies are a major health problem and a matter of great concern. The main causes of kidney injury in tropics are due to bacterial, viral or parasitic infections like malaria, dengue, leptospirosis, scrub typhus, acute gastroenteritis, tuberculosis, leprosy and toxic envenomations like snake bite. Renal injury associated with tropical infections has a wide spectrum of presentations ranging from acute kidney injury to chronic kidney disease. Renal involvement in infectious diseases by one or other mechanism is a definite cause of increased morbidity and mortality. Proper understanding of these diseases, early diagnosis, patient education and improved health care facilities will lead to a better outcome and improved survival. This article reviews the various tropical infections causing kidney injury including pathophysiology and line of management.

Current management of severe dengue infection

INTRODUCTION

Traditionally a disease mainly affecting the pediatric population, dengue burden has increased significantly in recent decades and adults with severe disease may become more common. There is currently no effective anti-viral agent available for the treatment of dengue and supportive care is the mainstay of management. Areas covered: We present a review of current literature on dengue severity classification systems and the management of severe dengue in adults. In particular, emphasis was placed on organ impairment in dengue and management of elderly individuals with multiple medical problems. Expert commentary: There is an urgent need to search for an effective anti-viral agent to treat infected individuals. The commercial availability of a dengue vaccine in older children has provided optimism in reducing the disease burden but long term efficacy and safety are unknown. The results from phase III trials of two new candidate vaccines are eagerly awaited.

Defining acute kidney injury in dengue viral infection by conventional and novel classification systems (AKIN and RIFLE): a comparative analysis

BACKGROUND

Several criteria have been used to stratify acute kidney injury (AKI) in dengue infection and have resulted in variations in its incidence as well as clinic-laboratory characteristics. The current study was aimed to compare three commonly used criteria of AKI among patients with dengue.

METHODS

667 patients with dengue were defined and staged according to the conventional definition (CD), the Acute Kidney Injury Network (AKIN) and the Risk, Injury, Failure, Loss of function, End stage renal disease (RIFLE) criteria. Appropriate statistical methods were used to compare these three criteria.

RESULTS

The incidence of AKI during dengue infection was 14.2% by AKIN criteria, 12.6% by RIFLE criteria and 4.2% by CD. AKIN and RIFLE criteria were comparable while AKIN-I identified 11 more patients with AKI than RIFLE-R (76.8% vs. 73.8%, p=0.023). CD was found to be less sensitive than AKIN and RIFLE due to stratification of only severe AKI cases with serum creatinine ≥176.8 µmol/L. Overall mortality was 1.2% and severe stages of AKI were associated with increased mortality (p<0.001). AKIN criteria identified seven risk factors, RIFLE identified six and CD identified three risk factors. Old age, severe dengue and the use of nephrotoxic drugs were found to be independent predictors identified by all criteria while hypertension was only identified by AKIN.

CONCLUSIONS

The incidence of AKI in dengue infection, the risk factors for its development and clinico-laboratory characteristics vary significantly according to the diagnostic criteria used. In our analysis, AKIN and RIFLE were comparable to each other and superior to CD with regard to early diagnosis and sensitivity.

Relevance of Non-communicable Comorbidities for the Development of the Severe Forms of Dengue: A Systematic Literature Review

Patients with dengue fever and comorbidities seem to be at higher risk of developing complications and/or severe dengue compared to healthier individuals. This study systematically reviews the evidence related to comorbidities and dengue. A systematic literature review was performed in five databases (EMBASE, PUBMED, Global Health, SciELO, Cochrane) and grey literature for full-text articles since its inceptions until October 10, 2015. A total of 230 articles were retrieved. Sixteen studies were analysed after applying all inclusion and exclusion criteria. Seven case control studies and nine retrospective cohort studies showed that comorbidities may contribute to severe dengue, especially 1) cardiovascular disease, 2) stroke, 3) diabetes, 4) respiratory disease and 5) renal disease, as well as old age. However, due to heterogeneity in studies, the real estimate effect of comorbidities as modifiers of dengue severity could not be established. Further research in regions with high prevalence of dengue infection would contribute to a better understanding of the relevance of comorbidities in severe dengue, especially with a standardised protocol, for outcomes, specific comorbidities, study design—best using prospective designs—and sample sizes.

Dengue fever is a viral disease, transmitted by Aedes mosquitoes. Although for most cases of dengue fever the illness is self-limiting or asymptomatic, severe dengue can occur. Severe dengue is now classified by 1) plasma leakage, and/or 2) severe haemorrhage and/or 3) organ failure. Complications and deaths occur in this group of cases with severe dengue. Patients with dengue fever and comorbidities seem to be at higher risk of developing complications and/or severe dengue compared to healthier individuals. This study systematically reviews the evidence related to comorbidities and the severe forms of dengue fever. Sixteen studies were analysed after applying all inclusion and exclusion criteria. Seven case control studies and nine retrospective cohort studies assessed comorbidities and development of severe forms of dengue. The results showed that comorbidities are relevant to severe dengue, especially 1) cardiovascular disease, 2) stroke, 3) diabetes, 4) respiratory disease and 5) renal disease, as well as old age. The study of comorbidities in dengue fever is fundamental for improved patient outcome by differential case management of patients, reducing the burden of the disease. Further research in regions with high prevalence of dengue infection would contribute to a better understanding of the relevance of comorbidities with severe forms of dengue fever. An agreed protocol for such studies is urgently needed.

Dengue hemorrhagic fever and the kidney

Dengue virus infection (DVI)/dengue hemorrhagic fever (DHF) is a common febrile illness with a variety of severities. The mortality rate is high in dengue shock syndrome (DSS), caused by circulatory failure due to plasma leakage resulting in multi-organ failure. However, acute kidney injury (AKI) is rarely reported. In areas of endemic DVI, the prevalence of AKI due to DVI has been reported to be as high as 6.0 % in children with AKI, and 0.9 % in children with DVI who were admitted to a hospital. The mechanism of AKI in DVI is not clear. It may result from (a) direct injury as in other infectious diseases, (b) an indirect mechanism such as via the immune system, since DHF is an immunological disease, or (c) hypotensive DSS, leading in turn to reduced renal blood supply and renal failure. The mortality rates of DF/DHF, DSS and DHF/DSS-related AKI are <1 %, 12-44 %, and >60 %, respectively. Kidney involvement is not actually that rare, but is under-recognized and often only reported when microscopic hematuria, proteinuria, electrolyte imbalance, or even AKI is found. The prevalence of proteinuria and hematuria has been reported as high as 70-80 % in DVI. A correct diagnosis depends on basic investigations of kidney function such as urinalysis, serum creatinine and electrolytes. Although DVI-related renal involvement is treated supportively, it is still important to make an early diagnosis to prevent AKI and its complications, and if AKI does occur, dialysis may be required. Fortunately, in patients who recover, kidney function usually completely recovers as well.

Dengue-associated acute kidney injury

Dengue is presently the most relevant viral infection transmitted by a mosquito bite that represents a major threat to public health worldwide. Acute kidney injury (AKI) is a serious and potentially lethal complication of this disease, and the actual incidence is unknown. In this review, we will assess the most relevant epidemiological and clinical data regarding dengue and the available evidence on the frequency, etiopathogenesis, outcomes and treatment of dengue-associated AKI.

Incidence, Characteristics and Risk Factors of Acute Kidney Injury among Dengue Patients: A Retrospective Analysis

BACKGROUND

Dengue induced acute kidney injury (AKI) imposes heavy burden of illness in terms of morbidity and mortality. A retrospective study was conducted to investigate incidence, characteristics, risk factors and clinical outcomes of AKI among dengue patients.

METHODOLOGY

A total 667 dengue patients (2008-2013) were retrospectively evaluated and were stratified into AKI and non-AKI groups by using AKIN criteria. Two groups were compared by using appropriate statistical methods.

RESULTS

There were 95 patients (14.2%) who had AKI, with AKIN-I, AKIN-II and AKIN-III in 76.8%, 16.8% and 6.4% patients, respectively. Significant differences (P<0.05) in demographics and clinico-laboratory characteristics were observed between patients with and without AKI. Presence of dengue hemorrhagic fever [OR (95% CI): 8.0 (3.64–17.59), P<0.001],rhabdomyolysis [OR (95% CI): 7.9 (3.04–20.49)], multiple organ dysfunction OR (95% CI):17.9 (9.14–35.12), P<0.001], diabetes mellitus [OR (95% CI): 4.7 (1.12–19.86), P = 0.034], late hospitalization [OR (95% CI): 2.1 (1.12–19.86), P = 0.033] and use of nephrotoxic drugs [OR(95% CI): 2.9 (1.12–19.86), P = 0.006] were associated with AKI. Longer hospital stay (>3days) was also observed among AKI patients (OR = 1.3, P = 0.044) [corrected].Additionally, 48.4% AKI patients had renal insufficiencies at discharge that were signicantly associated with severe dengue, secondary infection and diabetes mellitus. Overall mortality was 1.2% and all fatal cases had AKI.

CONCLUSIONS

The incidence of AKI is high at 14.2% among dengue patients, and those with AKI portended significant morbidity, mortality, longer hospital stay and poor renal outcomes. Our findings suggest that AKI in dengue is likely to increase healthcare burden that underscores the need of clinicians' alertness to this highly morbid and potentially fatal complication for optimal prevention and management.

Clinical features of and risk factors for rhabdomyolysis among adult patients with dengue virus infection

Among 1,076 dengue patients, 9 patients with rhabdomyolysis and 1,067 patients without rhabdomyolysis (controls) were retrospectively analyzed. Of nine patients with rhabdomyolysis, the most commonly reported symptom other than fever was myalgia; dengue hemorrhagic fever (DHF) was found in seven cases, and acute kidney injury was found in six cases. Furthermore, one (11.1%) patient died. The median duration from hospital admission to rhabdomyolysis diagnosis was 3 days. Patients with rhabdomyolysis had higher age, proportion of men, prevalence of hypertension, frequency of myalgia, and incidences of DHF, pleural effusion, and acute kidney injury than controls. Multivariate analysis showed that hypertension (odds ratio [OR] = 14.270), myalgia (OR = 20.377), and acute kidney injury (OR = 65.547) were independent risk factors for rhabdomyolysis. Comparison of cytokine/chemokine concentrations in 101 DHF patients, including those with (N = 4) and without (N = 97) rhabdomyolysis, showed that interleukin-6 and tumor necrosis factor-α levels were significantly increased in the former.

Biopsy proven acute tubular necrosis due to rhabdomyolysis in a dengue fever patient: a case report and review of literature

Renal histology results are very scarce in dengue-associated rhabdomyolysis patients developing acute kidney injury (AKI). We report a case of dengue fever-induced AKI associated to rhabdomyolysis with a renal biopsy showing acute tubular necrosis (ATN) and renal deposition of myoglobin. A 28-year-old patient who presented dengue fever (DF) complicated by severe AKI and rhabdomyolysis is described. The patient required hemodialysis for three weeks. A renal biopsy revealed ATN with positive staining for myoglobin in the renal tubuli. The patient was discharged with recovered renal function. In conclusion, this case report described a biopsy proven ATN associated to DF-induced rhabdomyolysis, in which renal deposition of myoglobin was demonstrated. We suggest that serum creatine phosphokinase should be monitored in DF patients to allow for an early diagnosis of rhabdomyolysis and the institution of renal protective measures.

The pathology of severe dengue in multiple organs of human fatal cases: histopathology, ultrastructure and virus replication

Dengue is a public health problem, with several gaps in understanding its pathogenesis. Studies based on human fatal cases are extremely important and may clarify some of these gaps. In this work, we analyzed lesions in different organs of four dengue fatal cases, occurred in Brazil. Tissues were prepared for visualization in optical and electron microscopy, with damages quantification. As expected, we observed in all studied organ lesions characteristic of severe dengue, such as hemorrhage and edema, although other injuries were also detected. Cases presented necrotic areas in the liver and diffuse macro and microsteatosis, which were more accentuated in case 1, who also had obesity. The lung was the most affected organ, with hyaline membrane formation associated with mononuclear infiltrates in patients with pre-existing diseases such as diabetes and obesity (cases 1 and 2, respectively). These cases had also extensive acute tubular necrosis in the kidney. Infection induced destruction of cardiac fibers in most cases, with absence of nucleus and loss of striations, suggesting myocarditis. Spleens revealed significant destruction of the germinal centers and atrophy of lymphoid follicles, which may be associated to decrease of T cell number. Circulatory disturbs were reinforced by the presence of megakaryocytes in alveolar spaces, thrombus formation in glomerular capillaries and loss of endothelium in several tissues. Besides histopathological and ultrastructural observations, virus replication were investigated by detection of dengue antigens, especially the non-structural 3 protein (NS3), and confirmed by the presence of virus RNA negative strand (in situ hybridization), with second staining for identification of some cells. Results showed that dengue had broader tropism comparing to what was described before in literature, replicating in hepatocytes, type II pneumocytes and cardiac fibers, as well as in resident and circulating monocytes/macrophages and endothelial cells.

Challenges in dengue fever in the elderly: atypical presentation and risk of severe dengue and hospital-acquired infection [corrected]

BACKGROUND/METHODS

To better understand dengue fever in the elderly, we compared clinical features, World Health Organization (WHO) dengue classification and outcomes between adult (<60) and elderly (≥60) dengue patients. We explored the impact of co-morbidity and hospital-acquired infection (HAI) on clinical outcomes in the elderly. All patients managed at the Communicable Disease Centre, Singapore, between 2005 and 2008 with positive dengue polymerase chain reaction (PCR) or who fulfilled WHO 1997 or 2009 probable dengue criteria with positive dengue IgM were included.

RESULTS

Of the 6989 cases, 295 (4.4%) were elderly. PCR was positive in 29%. The elderly suffered more severe disease with more dengue haemorrhagic fever (DHF) (29.2% vs. 21.4%) and severe dengue (SD) (20.3% vs. 14.6%) (p<0.05). Classic dengue symptoms were more common in the adult group. The elderly were less likely to fulfill WHO 1997 (93.6% vs. 96.4%) (p = 0.014), but not WHO 2009 probable dengue (75.3% vs. 71.5%). Time to dengue diagnosis was similar. There was no significant difference in the frequency of warning signs between the two groups, but the elderly were more likely to have hepatomegaly (p = 0.006) and malaise/lethargy (p = 0.033) while the adults had significantly more mucosal bleeding (p<0.001). Intensive care admission occurred in 15 and death in three, with no age difference. Notably, the elderly stayed in hospital longer (median 5 vs. 4 days), and suffered more pneumonia (3.8% vs. 0.7%) and urinary infection (1.9% vs. 0.3%) (p = 0.003). Predictors of excess length of stay were age (adjusted odds ratio [aOR] 2.01, 95% confidence interval [CI] 1.37-2.88), critical illness (aOR 5.13, 95%CI 2.59-9.75), HAI (aOR 12.06, 95%CI 7.39-19.9), Charlson score (aOR 6.9, 95%CI 2.02-22.56) and severe dengue (DHF/dengue shock syndrome/SD) (aOR 2.24, 95%CI 1.83-2.74).

CONCLUSION

Elderly dengue patients present atypically and are at higher risk of DHF, SD and HAI. Aside from dengue severity, age, co-morbidity and HAI were associated with longer hospital stay.

Deaths due to dengue fever at a tertiary care hospital in Lahore, Pakistan

OBJECTIVE

We conducted this study to review deaths due to dengue fever (DF) during a large outbreak of DF in Lahore, Pakistan.

METHODS

We reviewed deaths due to DF at Jinnah Hospital Lahore between August and November 2011. Clinical and laboratory data were abstracted. The 2011 World Health Organization Regional Office for South-East Asia (WHO SEARO) guidelines were used to classify the disease.

RESULTS

Out of 128,634 probable DF patients who visited the outpatient department, 2313 patients were hospitalized; 1699 (73.3%) were male. RT-PCR was positive in 92 of 114 hospitalized patients (DENV-2 in 91 patients and DENV-3 in 1 patient). Sixty dengue-related deaths were reported; 41 (68.3%) were male. The mean age (± standard deviation) was 44 (± 20.5) y. The diagnosis at the time of presentation was DF in 5 (8.3%), dengue haemorrhagic fever without shock in 16 (26.6%), dengue shock syndrome in 20 (33%), and expanded dengue syndrome in 19 (31.7%) patients. Expanded dengue syndrome included encephalopathy in 12 (20%) patients, intracerebral bleed in 3 (5%), multiorgan failure in 3 (5%), and Guillain-Barré syndrome in 1 (1.6%). Twenty-nine (48.3%) patients had at least 1 comorbidity.

CONCLUSION

Dengue shock syndrome and expanded dengue syndrome were the most common causes of death.

Risk factors of mortality among dengue patients admitted to a tertiary care setting in Kerala, India

Dengue is one of the most serious and rapidly emerging tropical mosquito-borne diseases. The state of Kerala in India is hyperendemic for the disease and is one of the leading states in the reporting of deaths due to dengue. As primary prevention of dengue has had limited success, the prevention of mortality through the identification of risk factors and efficient patient management is of utmost importance. Hence, a record-based case control study was conducted in the Medical College Hospital in Thiruvananthapuram to identify the risk factors of mortality in patients admitted with dengue. Dengue patients over 40years of age were 9.3 times (95% CI; 1.9-44.4) more likely to die compared with younger patients. The clinical features associated with mortality from dengue were altered sensorium (odds ratio (OR) - 156, 95% CI; 12.575-1935.197), abnormal reflexes (OR - 8.5, 95% CI; 1.833-39.421) and edema (OR - 13.22, 95% CI; 2.651-65.951). Mortality was also higher in those patients with co-morbidities such as diabetes mellitus (OR - 26, 95% CI; 2.47-273.674) and hypertension (OR - 44, 95% CI; 6.23-315.499). The independent predictors of mortality were altered sensorium and hypertension. Dengue fever patients with these clinical features and those who are elderly should be more rigorously monitored and promptly referred from lower settings when required to reduce mortality.

Risk factors for fatality among confirmed adult dengue inpatients in Singapore: a matched case-control study

Objectives

To identify demographic, clinical and laboratory risk factors for death due to dengue fever in adult patients in Singapore.

Methods

Multi-center retrospective study of hospitalized adult patients with confirmed dengue fever in Singapore between 1 January 2004 and 31 December 2008. Non-fatal controls were selected by matching age and year of infection with fatal cases. World Health Organization 1997, 2009 criteria were applied to define dengue hemorrhagic fever (DHF), warning signs and severe dengue. Statistical significance was assessed by conditional logistic regression modeling.

Results

Significantly more fatal cases than matched controls had pre-existing co-morbid conditions, and presented with abdominal pain/tenderness. Median pulse rates were significantly higher while myalgia was significantly less frequent in cases. . Fatal cases also had higher leucocyte counts, platelet counts, serum sodium, potassium, urea, creatine and bilirubin levels on admission compared to controls. There was no statistical significant difference between the prevalence of DHF and hematocrit level among cases and controls. Multivariate analysis showed myalgia and leucocyte count at presentation were independent predictors of fatality (adjusted odds ratios 0.09 and 2.94 respectively). None of the controls was admitted to intensive care unit (ICU) or given blood transfusion, while 71.4% and 28.6% of fatal cases received ICU admission and blood transfusion.

Conclusions

Absence of myalgia and leucocytosis on admission were independently associated with fatality in our matched case-control study. Fatalities were also commonly associated with co-morbidities and clinicians should be alarmed if dengue patients fulfilled severe dengue case definition on admission.

Presence of Viral Genome in Urine and Development of Hematuria and Pathological Changes in Kidneys in Common Marmoset (Callithrix jacchus) after Inoculation with Dengue Virus

Common marmosets (Callithrix jacchus) developed high levels of viremia, clinical signs including fever, weight loss, a decrease in activity and hematuria upon inoculation with dengue virus (DENV). Presence of DENV genome in urine samples and pathological changes in kidneys were examined in the present study. Levels of DENV genome were determined in 228 urine samples from 20 primary DENV-inoculated marmosets and in 56 urine samples from four secondary DENV-inoculated marmosets. DENV genome was detected in 75% (15/20) of marmosets after primary DENV infection. No DENV genome was detected in urine samples from the marmosets with secondary infection with homologous DENV (0%, 0/4). Two marmosets demonstrated hematuria. Pathological analysis of the kidneys demonstrated non-suppressive interstitial nephritis with renal tubular regeneration. DENV antigen-positive cells were detected in kidneys. In human dengue virus infections, some patients present renal symptoms. The results indicate that marmosets recapitulate some aspects of the involvement of kidneys in human DENV infection, and suggest that marmosets are potentially useful for the studies of the pathogenesis of DENV infection, including kidneys.