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Thrombotic microangiopathy and acute kidney injury following vivax malaria

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Abstract

Background

Infection with Plasmodium vivax, a common human parasite, is occasionally recognized to cause severe organ dysfunction similar to P. falciparum infection. Acute kidney injury (AKI) in malaria is attributed to acute tubular necrosis; thrombotic microangiopathy is not described.

Methods

This observational study includes patients referred to a tertiary care center in North India during June to September 2011 with severe AKI, anemia, and thrombocytopenia following vivax malaria. Renal biopsies were processed by light, immunofluorescence, and electron microscopy.

Results

Nine patients (including 5 children) had persistent AKI with thrombocytopenia and variable anemia following the diagnosis of malaria. Based on peripheral smear, eight patients were diagnosed with vivax malaria and had received antimalarial therapy prior to referral; a laboratory diagnosis of P. vivax infection was made for one patient at this center. Renal histology in all cases showed features of thrombotic microangiopathy, including fibrin thrombi, subendothelial widening, and mesangiolysis, along with variable tubulointerstitial nephritis and acute tubular or cortical necrosis. Ultrastructural examination confirmed endothelial injury and subendothelial widening. All patients required hemodialysis, and six were dialysis dependent at four weeks. Delayed presentation to the hospital (P = 0.019), hemolysis on peripheral smear (P = 0.083), and prolonged oligoanuria (P = 0.036) were associated with dialysis dependence.

Conclusion

The association of anemia, thrombocytopenia, and renal histological evidence of thrombotic microangiopathy with vivax malaria is novel, and suggests the presence of severe endothelial injury. Further studies are necessary to confirm the association and examine the factors associated with its occurrence.

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Acknowledgments

The renal histology slides were also reviewed by Sanjeev Sethi, M.D., Ph.D., Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA.

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Authors and Affiliations

  1. Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, 3053, Teaching Block, New Delhi, India

    Aditi Sinha, Abdus Sami Bhat, Ashima Gulati, Pankaj Hari & Arvind Bagga

  2. Department of Pathology, All India Institute of Medical Sciences, New Delhi, India

    Geetika Singh & Amit Kumar Dinda

  3. Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India

    Sarita Mohapatra & J. C. Samantaray

  4. Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India

    Sanjay Kumar Agarwal

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  1. Aditi Sinha
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  2. Geetika Singh
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  4. Sarita Mohapatra
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  5. Ashima Gulati
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  10. Arvind Bagga
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Correspondence to Arvind Bagga.

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Sinha, A., Singh, G., Bhat, A.S. et al. Thrombotic microangiopathy and acute kidney injury following vivax malaria. Clin Exp Nephrol 17, 66–72 (2013). https://doi.org/10.1007/s10157-012-0656-9

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  • DOI: https://doi.org/10.1007/s10157-012-0656-9

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