Tropical Acute Kidney Injury

The growth of viruses has increased in tropical areas as a result of inadequate sanitation and overcrowding; they are primarily spread by excess vectors. India is the afflicted nation.

Aetiology

Diarrhea caused by infection (bacterial, viral, and parasitic). Skin diseases, such as chikungunya, dengue, leptospirosis, and malaria. Obstetric AKI (septic abortions, postpartum hemorrhage).  Venomation caused by arthropods and snakes.

Techniques such as putting a rod into the uterus are employed when MTP is not performed medically in order to remove the fetus and, in the event that the rod becomes infected with germs, to remove it.
The outcome is septic abortions.

1.   Snake Bite

All snake bites do not harm humans; Only snakes from the Elapidae and Viperidae families affect the kidneys; Haematotoxic and myotoxic toxins should result in DIC. Rhabdomyolysis-causing myotoxicity • Haemolysis

Local and Systemic Manifestation

Acute Kidney Injury 

The condition typically begins within a few hours and is catabolic and oliguric. It causes acute tubular necrosis and is characterized by a two-week duration. An example of this type of condition is rhabdomyolysis. The threshold for dialysis should be extremely low. If the patient's potassium levels do not improve after receiving medical treatment, dialysis may be considered. Should oliguria continue.

Acute tubular necrosis- recovery within two weeks. Acute cortical necrosis if not recovered. Necrosis will occur in a portion of the cortex due to the massive amount of glomerular debris. As a result, the patient will have chronic renal disease.

Laboratory Investigations

• Disseminated Intravascular coagulation (DIC: Anemia)
• Thrombocytopenia
• Rhabdomyolysis
• Elevated 
• CPK levels
• Potassium levels
• Phosphorus levels
• Haemoconcentration (Third spacing)
• Patients will generally be recovered but sometimes it can progress to CKD

Pathology of Snake Bite

The kidney displays many petechial hemorrhages. The involvement of the small blood vessels will cause hemolysis within the blood vessel.
Creation of clots in the microcirculation. Consequently, petechial bleeding happens.

Microscopy

• Acute tubular injury
• Variable degree of the interstitial edema
• Mesangiolysis
• Thrombotic microangiopathy (TMA)

Electron Microscopy

Because snake venom directly affects the proximal tubules, changes mostly take place there. Organelle degeneration in the proximal tubule
Consequently, intracellular cytoplasmic entities are seen.

Other Mechanisms

 The tubular toxicity will be directly caused by the enzymes and toxins secreted by the snake. Shock; Acute cortical necrosis;  Systemic thrombotic microangiopathy (TMA); Disseminated intravascular coagulation.

Management

Pentavalent anti-snake venom is its antivenom; it triggers allergic reactions on its own.  Third spacing: Treating opportunistic infections; • Appropriate volume replacement

2. Bee Sting

A single bee stung can result in anaphylaxis and allergy; a multiple bee sting can cause rhabdomyolysis, intravascular hemolysis, cardiac (shock), hepatic, and pulmonary (acute tubular necrosis).

3. Malaria

It is commonly seen in India

• It has five species

• Plasmodium falciparum
• Plasmodium vivax
• Plasmodium ovale
• Plasmodium malaria
• Plasmodium knowlesi

• Plasmodium falciparum: 60% of Acute kidney injury
  • It infects all ages of RBC
  • This load will cause the acute tubular injury 
• Vivax, ovale, and knowlesi will infect the young erythrocytes 
• Plasmodium malariae: Infects old erythrocytes 

Pathogenesis

• Infect RBCs have
  • Knobs
  • Rosettes
  • Sequestration
  • Less pliable
• These knobs and parasitized erythrocytes will adhere to the endothelium
• Hence it causes endothelial damage

Other Mechanism

Proinflammatory cytokine release induces a characteristic resembling sepsis. It thus raises the vascular permeability. In addition, the kidneys are insulted by hypoxia and ischemia. Considering that microcirculation is impacted. There will also be rabdomyolysis.

It also produces TMA and cortical necrosis. Immune complex-mediated glomerulonephritis; tumors: it causes ATN; hemoglobin cast; myoglobin cast; and hemoglobin cast.

Clinical Features

• Constitutional features (Fever, malaise, fatigue)
• Urinalysis
  • Proteinuria (Tubular: <1gm)
  • RBC
  • WBC
  • Granular cast
  • Oliguria 
• Haemoglobinuria
• Rhabdomyolysis (Causes myoglobinuria)
• Electrolyte Imbalance: Hyponatremia

Treatment

Combination treatment with alesunate. Renal failure: treatment with renal replacement. Death rate from malaria with AKI: 10–50%.

4. Leptospirosis 

Most common zoonosis. Disease vectors: Wild and domestic mammals. It includes- Rodents (Most common: Rat fever), Dogs, Pigs.

Leptospira is excreted by vectors through urine, which enters through mucosal membranes or torn skin and causes infection. Increases during heavy rainfall or flooding.

Pathogenesis 

Leptospira interrogans is the species that causes it, and leptospiral endotoxins damage tubulointerstitial cells.
• Endotoxins:
• GLP; lipopolysaccharides
These patients will develop non-oliguric AKI because lipoproteins affect tubular Na-K-ATPase and result in hypokalemia and urine concentrating abnormalities.

Clinical Features

Multiple organ failure syndrome is linked to Weil's illness; AKI is widespread but severe in the condition. AKI: Associated with hypokalemia and non-oliguric. Late: Development of tubular function problems and chronic kidney disease (CKD). Later: Renal involvement may occur following recovery.  Treatment: Penicillin

5. Hemorrhagic Fevers-  Dengue

It is an acute febrile sickness that encompasses yellow fever and dengue.  The creature responsible: Aedes Aegypti .Dengue fever, dengue hemorrhagic fever, dengue shock syndrome, and undifferentiated fever are the four serotypes of dengue flavivirus that fall under this spectrum.

Clinical features

 Shows signs of the constitutional symptoms (fatigue, fever, and body aches);  Shows signs of shock and hemorrhage; Involves the kidneys;
 Hemolytic uremic syndrome; glycomeronephritis; proteinuria; abnormal electrolyte levels AKI affects 1-30% of dengue patients. Rhabdomyolysis, shock, and hemolysis

6.Yellow Fever

Causative organism: Flavivirus.  Aedes aegypti is the carrier;  Spectrum; Asymptomatic to Fever;  Hemorrhagic fever;  AKI;  Death.
Severe disease develops 4–5 days following the onset of clinical symptoms;  Incubation period: 1 week;  It advances further to renal failure.

High-Yielding Points

Acute tubular necrosis, acute cortical necrosis, immune complex glomerulonephritis, malaria, and snake bites are among the conditions that can result from TMA

Mesangiolysis. Edema interstitial.

Hope you found this blog helpful for your NEET SS Nephrology Preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.