Renal Complications in Severe Malaria

Acute kidney injury (AKI) is a rare but serious complication of malaria. Its occurrence is rapidly life-threatening. The aim of this study is to shed light on the mechanism of AKI and the particularities of its clinical presentation and management.

We report three cases of patients admitted to the medical intensive care unit at the Ibn Rochd University Hospital in Casablanca with malaria complicated by acute renal failure, who had travelled to sub-Saharan Africa and neglected chemoprophylaxis. AKI was defined according to the Kidney Disease Improving Global Outcomes (KDIGO) classification criteria.

The patients were three men, aged 34, 35 and 48 respectively, with no notable medical history. The clinical presentation was severe haemoglobinuric malaria associated with AKI in all three patients. The onset of AKI was 2, 3 and 5 days respectively after the beginning of the malaria attack. Oligoanuria was present in all three patients, and the AKI was severe, requiring haemodialysis in all cases. Anemia, thrombocytopenia, hepatic cytolysis and hyperbilirubinemia were present, and thick blood cell count was positive. All three patients were treated with artesunate. Renal biopsy was deferred because of thrombocytopenia in one patient and profound anaemia in the second. In the third patient, biopsy revealed acute tubular necrosis with typical lesions of pinkish, granular or string-shaped cylinders, suggesting either myoglobin or haemoglobin cylinders. The outcome was fatal in all cases.

AKI in malaria can be either functional or organic, related to acute tubular necrosis (ATN). ATN remains the principal renal manifestation caused by P. falciparum and may be the dominant clinical presentation of a severe malaria attack. Its prognosis depends on early diagnosis and management, but remains severe, with a high mortality rate despite extrarenal replacement therapy. On the basis of this study, renal function tests should be performed routinely in patients with severe malaria.