Peadiatrics, The University Of Yaounde I
June, 2013


Malaria is a public health problem accounting for two million deaths each year with half of these victims being children under five years of age. In Cameroon malaria constitutes the first cause of mortality accounting for 30-35% in the general population and 40% in children less than five years of age. Kidney involvement constitutes a poor prognostic factor in malaria. Malaria is a major cause of acute kidney injury (AKI) in Africa. The cost of malaria increases exponentially with kidney involvement especially if dialysis is needed. In India, 57% of patients with malarial AKI need dialysis with greater proportion of non-recovery of renal function compared with other causes of AKI. In a recent hospital-based study in Cameroon, malaria was responsible for 66% of AKI in children. Considering the high endemicity of malaria in Cameroon, and the associated mortality with renal involvement, we sought to determine the prevalence and outcome of renal abnormalities during malaria.
Our main objective was to compare the prevalence and evolution of renal abnormalities in children with malaria to those seen in other febrile illnesses; and determine factors associated with persistence of renal abnormalities at one month

We carried out a descriptive and analytic prospective study involving children less than sixteen years of age, whose parents or guardians gave their assent from September 2012 to February 2013. Our cases were children with a positive thick blood smear for malaria, while children with other febrile illnesses who had a negative thick blood smear for malaria were used as controls. A total of 209 children were recruited, from two district hospitals in Cameroon. Relevant clinical and paraclinical data was obtained from the patient’s file. For each participant blood and urine samples were taken on admission, at one week and at one month, for serum creatinine levels and dipstick urinalysis. Urinary proteins were evaluated semi-quantitatively ( 2+;] 100-500mg/dl], 3+;] 500- 2000mg/dl], 4+ ;> 2000mg/dl). AKI was defined by serum creatinine levels with respect to age ( • ≤ 5years: >0.4mg/dl •] 5-10] years: > 0.7mg/dl • >10 years :> 1mg/dl). Data was analysed using SPSS version 18.0 software. Group comparison amongst was analysed with Student’s T test for two groups and one way analysis of variance (ANOVA) for more than two groups. Chi square test and Pearson Test were used when appropriate. A P-value <0.05 was considered statistically significant. Ethical clearance was obtained from ethical committee of the Faculty of Medicine and Biomedical Sciences of the University of Yaoundé I.

A total of 200 children were enrolled in the study. One hundred with malaria (simple malaria = 46; severe malaria = 54) and 100 with other febrile illnesses (skin infection, sore throat, ear infection, respiratory tract infection, gastro-intestinal tract infection). The group with malaria was comparable to the other febrile illness group in terms of age, birth weight and temperature (P-values; 0.65, 0.66 and 0.83 respectively), parasite load was significantly greater in the severe malaria group than in the simple malaria group (P-value; 0.03). The mean age of the participants was 6.5± 3.9 years (range= 1-15 years), with a sex ratio of 1. A total of 32 (16%) children had low birth weight. At baseline; the mean serum creatinine was comparable amongst the groups (P-value; 0.145). The prevalence of AKI was significantly higher in the malaria group compared to the control group (15.5% vs. 5%, P-value; 0.003). Within the malaria group the proportion of AKI was significantly higher in severe malaria compared to the simple malaria group (19 vs. 12, P-value; 0.04). At baseline, a significantly greater number of participants in the malaria group had proteinuria (19 vs. 16 P-value; 0.01).
At one month, the mean serum creatinine was significantly higher in the malaria group (0.91 ± 0.08mg/dl vs. 0.88 ± 0.12mg/dl, P-value; 0.01) and AKI persisted in 4 children all in the severe malaria group. Of 6 (3.9%) children with normal baseline serum creatinine levels who developed AKI from black water fever at 1 week, 3 still had persistent AKI at one month. At one month only one child in the severe malaria group still had proteinuria. Hemodialysis was needed in one case. Low birth weight and presence of dehydration at baseline were factors associated with persistence of AKI at one month while baseline heamaturia was associated with persistent proteinuria at one month. In the control

Renal abnormalities consisting of; raised serum creatinine, proteinuria and hematuria, are more prevalent during malaria compared to other febrile illnesses. Theses abnormalities increase with the severity of malaria. The prevalence of AKI is higher during malaria compared to other febrile illnesses. At one month renal abnormalities persist in the severe malaria group compared to none in the other febrile illnesses. Severity of malaria is associated to the persistence of renal abnormalities. These results suggest that renal function needs to be monitored over one month in children with severe malaria.

Keywords: Children, Malaria, Proteinuria, Acute kidney injury.