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Malarial Nephropathy - Causes, Symptoms, Diagnosis, and Treatment

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Malarial nephropathy is the deterioration of kidney function caused by a malarial infection.

Medically reviewed by

Dr. C. Elanchezhian

Published At June 23, 2022
Reviewed AtOctober 20, 2023

What Is Malaria?

Malaria is a parasitic infection caused when a female Anopheles mosquito with a malarial parasite bites a person. It acts as a vector to carry the parasite and spreads the disease. The mosquito becomes infected when the blood is drawn from an infected person containing the parasite. When that mosquito bites another person, the parasite is transferred to that person, leading to the infection's spread. Plasmodium is a single-celled parasite with four common species causing malaria.

They are:

  • Plasmodium falciparum.

  • Plasmodium malariae.

  • Plasmodium vivax.

  • Plasmodium ovale.

The most common species related to renal dysfunction or failure are P. falciparum and P. malariae. Falciparum malaria is a life-threatening disease and can cause liver and kidney failure, convulsions, and coma. The symptoms of the malarial infection appear after 7 to 30 days of the infection. Symptoms appear in cycles, including fever, chills, headache, nausea, and vomiting. The episode of the malarial infection starts with chills followed by high fever and sweating, which then returns to normal temperature.

What Is Nephropathy?

The kidneys are made up of small filtering units called the nephrons. The deterioration of the functions of the nephrons is called nephropathy. Acute kidney infection is caused by different Plasmodium species like falciparum and ovale. The kidney condition can worsen due to low hydration and fluid loss caused by vomiting, sweating, and dehydration. Chronic kidney disease is generally associated with malaria in patients suffering from repeated episodes of infection. Acute kidney infection is the most common complication of malaria and can occur in patients with a severe disease, P.falciparum.

How Does Malaria Cause Renal Failure?

Amongst all the Plasmodium species, P. falciparum causes the most severe form of malaria and is mainly responsible for acute kidney infections. The parasite in falciparum infection attacks the red blood cells (erythrocytes). These parasitized erythrocytes start the three mechanisms:

Hemodynamic:

Hemodynamic disturbances include parasitized erythrocytes, which adhere to adjacent healthy red blood cells, blood platelets, and the capillary endothelium. This results in intravascular knots and obstructs the microcirculation inside the kidneys.

Immunologic:

Immunological dysfunction happens when the parasite interacts with the body's innate immune system, and activation of B cells occurs, which causes the production of cytokines leading to immunosuppression. This mechanism produces antibodies leading to the formation of an immune complex, which is further related to injury to the glomerulus.

Metabolic Disturbances:

Metabolic disturbances include hemolysis of the red blood cells, causing anemia, jaundice, bleeding, and acute renal failure.

What Are the Symptoms of Malarial Nephropathy?

  • Proteinuria - It is the presence of protein in increased levels in the urine.

  • Microalbuminuria - A condition wherein the albumin level in the urine is in the range of 30 to 300 mg (less than 30 mg is considered the normal level).

  • Jaundice - Increase in the amount of bilirubin due to excessive destruction of red blood cells.

  • Anemia - Decrease in the hemoglobin concentration.

  • Hypoxia - Decrease in oxygen supply to the tissues.

  • Chills, Fever, and Sweating - These symptoms return to normal temperature.

  • Hyponatremia - Decrease in the sodium content in the blood.

  • Hyperkalemia - Increase in potassium content in the blood.

  • Oliguria or Anuria - Decrease in or complete cessation of urine.

  • Electrolyte Disturbance - Imbalance in electrolyte concentration of the blood.

  • Malarial Glomerulonephritis - P. falciparum infection leading to glomerulonephritis (disease that injures the glomeruli, the part of the kidney that filters blood) is uncommon. Children are more affected by this complication. The correct incidence of the malaria complication is unknown, but it is estimated to be around 18 percent.

  • Nephrotic Syndrome Associated With Malaria - P. falciparum infection resulting in nephrotic syndrome (a kidney disorder characterized by the release of excessive protein in urine) is uncommon.

What Are the Risk Factors of Malarial Nephropathy?

Risk factors for high mortality include acute illness, advanced age, increased parasitemia, hyperkalemia, oliguria, hypotension, severe anemia, jaundice, and altered consciousness level. Patients with poor prognoses may suffer from multiple organ involvement, severe diarrhea, and respiratory distress.

How to Diagnose Malarial Nephropathy?

Signs and symptoms of malaria include fever, sweat, flu-like illness, chills, malaise, headache, muscle aches, tiredness, nausea, vomiting, and diarrhea may occur. Malaria may cause anemia (decrease in red blood cell count) and jaundice (yellowish discoloration of the skin and eyes) because of the loss of red blood cells. If untreated, the infection becomes severe and may cause kidney failure, coma, and death.

  • The precise way to diagnose malaria is through blood examination for the presence of the malarial parasites.

  • P. falciparum malaria-causing kidney injury can be diagnosed by urine analysis containing the kidney injury biomarkers, neutrophil gelatinase-associated lipocalin (NGAL), and kidney injury molecule-1 (KIM-1), which have the advantage of detecting AKI earlier than creatinine.

How to Treat Malarial Nephropathy?

Treatment of malarial nephropathy includes antimalarial drugs and measures that require correction of water and electrolyte disturbances, fluid replacement, and dialysis. The drug of choice for the treatment of malaria is Chloroquine. P. falciparum has resistance to Chloroquine.

Therefore, therapy should include:

  • Primaquine.

  • Quinine.

  • Benflumetol.

  • Mefloquine.

Primaquine is used in P. vivax and P. ovale to prevent relapse. Intravenous Quinine is widely used to treat cerebral and other serious complications of falciparum malariae. Antimalarial drug doses should be based on the patient's weight to provide good efficacy. For severe malaria treatment, intravenous or intramuscular antimalarial drugs are given.

The most effective drug in treating severe malaria is Artesunate, which is given for at least 24 hours. The solution of Artesunate is diluted in 5 ml of 5 percent dextrose and given intravenously or intramuscularly.

Dialysis should be considered in acute kidney injury treatment for more effectiveness. Antimalarial drugs are not filtered in hemofiltration dialysis, so dialysis does not interfere with the specific treatment of malaria. Further increase in the development of vaccines is required to prevent severe cases leading to renal failure. Malaria can be more severe in pregnant women than in women who are not. Malaria can increase the risk of pregnancy problems like prematurity and miscarriage.

Conclusion

Taking antimalarial drugs to kill the parasites as soon as diagnosed can prevent the illness. Prevent oneself from mosquito bites, especially at night, which can be done by using insect repellent and wearing long-sleeved clothing. A person who becomes ill with a fever, malaria, or flu-like illness during travel should seek medical care immediately. If one is traveling to a country where malaria transmission occurs, precautions should be taken against contracting malaria. Treatment of malaria-associated nephropathy should include antimalarial drugs and measures to control acute kidney injury. Malaria should be treated sooner as it causes severe damage to multiple organs.

Frequently Asked Questions

1.

Which Malarial Type Causes Nephrotic Syndrome?

The main reason behind malaria is a parasite called Plasmodium. There are several species of Plasmodium that are associated with renal disorders and it includes:
- Plasmodium falciparum
- Plasmodium vivax.
- Plasmodium malariae.
- Plasmodium ovale.
- Among them, Plasmodium falciparum is associated with the occurrence of nephrotic syndrome and other kidney and liver disorders.

2.

Does Malaria Affect the Liver and Kidneys?

The Plasmodium falciparum and Plasmodium malariae are the primary parasites involved in causing malaria. Studies show that these species are linked with liver and kidney dysfunction, which gradually progress to their failure.
- Liver abnormalities such as hepatic dysfunction and jaundice are mainly caused by malaria.
- Kidney abnormalities such as acute glomerulonephritis may progress to end-stage kidney failure. It occurs due to the damage of small blood vessels and filtrates in the kidney by malarial parasites.

3.

Can Anti-Malarial Drugs Affect the Kidney?

Malaria is a parasitic infection and anti-malarial drugs like Chloroquine were found effective in treating it. However, several studies show that the prolonged use of Chloroquine in treating malaria affects the kidney severely. It results in acute kidney failure. In addition, it also causes liver toxicity and other neurological disorders. Therefore Chloroquine is now replaced with Artesunate for treating malaria.

4.

What Are the Causes of Nephropathy?

The primary cause of nephropathy is the increased blood glucose level (diabetes) and blood pressure (hypertension). This results in damage to blood vessels and filtrates of the kidneys leading to nephropathy. The other cause and risk factors include:
- High cholesterol.
- Smoking.
- Genetic disorders.
- Certain drugs.

5.

What Causes Nephrotic Syndrome?

The small group of blood vessels in the kidney that filter blood and waste products are damaged in nephrotic syndrome. The disease is caused by the following factors and conditions:
- Infectious diseases like malaria, hepatitis, etc.
- Medications like anti-inflammatory drugs.
- Diabetic kidney disease.
- Minimal change disease.
- Amyloidosis.

6.

Does Malaria Cause Hypoglycemia?

The falciparum malaria is associated with causing hypoglycemia in the affected individual. The plasmodium falciparum is involved in the following:
- Increased use of blood glucose.
- Decreased synthesis of glucose.
This results in lowered blood glucose levels, that is hypoglycemia (severe complication).

7.

Can UTI Occur Due to Malaria?

UTI or urinary tract infection is a bacterial infection of the urinary tract caused mainly by Escherichia coli. However, much research proves that UTIs may occur due to malaria. In addition, the prevalence of UTI in children (3 months to 12 years) affected by malaria is found to be 13.3 %. Even though UTIs most commonly occur due to bacterial infections, it is important to differentiate them from malarial consequences, as the complications are high. Therefore it is important to diagnose the cause of UTI for proper management. The occurrence of UTIs in malarial endemic areas can be suspected of co-existence of malaria with UTI.

8.

Is Malaria Detected by Urine Test?

The main investigations used in diagnosing malaria are blood examination and urinalysis. Even though blood examination is more specific and sensitive in detecting malaria, the urine examination aid in detecting the kidney injury due to Plasmodium falciparum. It detects the following kidney injury biomarkers in urine:
- Neutrophil gelatinase-associated lipocalin (NGAL).
- Kidney injury molecule-1 (KIM-1).

9.

Can Malaria Cause Proteinuria?

Malaria is an infectious disease and is caused by parasitic species like Plasmodium falciparum, P. vivax, P. ovale, and P. malariae. Amon them the Plasmodium falciparum is the commonest species associated with causing a severe form of malaria. The species also affects the kidney leading to a condition called acute glomerulonephritis. Along with this, the release of protein in urine is referred to as proteinuria occurs due to the damage of filtrates in the kidney and may also occur in 20 to 50 % of the cases.

10.

What Is the Color of Urine in Malaria?

The normal urine appears light straw. In addition, the change in the normal color of urine is a sign of several underlying conditions. In malaria, the kidneys and liver are severely damaged leading to several signs and symptoms. The urine output is greatly decreased due to the damage to kidney filters and blood vessels. The released urine also appears dark in color, which is a significant sign of malaria.

11.

Is Nephropathy Serious?

Nephropathy is a life-threatening and serious disease. It usually arises as a result of end-stage kidney disease. The risk factors include diabetes, hypertension, smoking, high cholesterol, etc. In addition, it greatly affects life due to the following complications:
Increased potassium in the blood.
- Anemia.
- Fluid retention.
- Cardiovascular disease.
- Kidney failure (requires transplantation for survival).
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Dr. C. Elanchezhian
Dr. C. Elanchezhian

General Medicine

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