Abstract
BackgroundMalarial acute renal failure (MARF) is a component of the severe malaria syndrome, and complicates 1–5% of malaria infections. This form of renal failure has not been well characterized by histopathology.Case presentationA 44 year-old male presented to the emergency department with a 5-day history of fever and malaise after returning from Nigeria. A blood film was positive for Plasmodium falciparum. His creatinine was 616 µmol/L coming from a normal baseline of 89 µmol/L. He had a urine protein:creatinine ratio of 346 mg/mmol (4.4 g/L). He required dialysis. A renal biopsy showed acute interstitial nephritis with podocyte foot-process effacement. He was treated with artesunate and his renal function improved. At 1 year follow-up his creatinine had plateaued at 120 µmol/L with persistent low-grade proteinuria.ConclusionAcute interstitial nephritis and podocyte foot-process effacement might be under-recognized lesions in MARF. Studying the mechanisms of MARF could give insight into the immunopathology of severe malaria.
Highlights
Malarial acute renal failure (MARF) is a component of the severe malaria syndrome, and complicates 1–5% of malaria infections
Two important renal lesions were identified in this patient with MARF; the presence of eosinophilic Acute interstitial nephritis (AIN) explains the acute drop in glomerular filtration rate, and fusion of the podocyte foot-processes (“minimal change disease”, Minimal change disease (MCD)) explains the heavy proteinuria
More recently Ogbadoyi et al [10] reported from Nigeria that about 70% of malaria patients had proteinuria, typically without an associated rise in creatinine, but again without any renal biopsy to explain the source of proteinuria
Summary
The conclusion that this case of AIN was caused by P. falciparum infection is supported firstly by the biological precedent in animal models, secondly, because the natural history of the illness and all clinical features are best explained by the malaria infection and, thirdly, because NSAID induced nephropathy does not fit with the patient’s drug history, histology or outcome. Describing the underlying renal pathology found in MARF is important as it can inform treatment strategies and improve our understanding of immunopathology in severe malaria. Authors’ contributions PJG wrote the first draft of the manuscript. PJG, JOR, TMcH, HT, LG and DR interpreted patient data regarding the diagnosis and contributed to the manuscript. TMcH analysed and interpreted the renal biopsy. All authors read and approved the final manuscript. Author details 1 Department of Nephrology, University College Hospital, Galway, Republic of Ireland. Department of Pathology, University College Hospital, Galway, Republic of Ireland. Department of Infectious Disease, University College Hospital, Galway, Republic of Ireland. Ethics approval and consent to participate Informed, signed consent was obtained from the patient to publish details about the case anonymously. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations
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