Severe Falciparum Malaria Complicated by Acute Kidney Injury Requiring Sequential Renal Replacement Therapy in an 8-Year-Old

An 8-year-old boy was referred with complaints of fever for 4 days, abdominal pain, vomiting, loose stools, hematuria, and decreased urine output. There was a history of similar illness in a sibling. At the referring hospital, the child had features of shock, for which he was started on injection Dopamine. Upon arrival at our centre, on examination, the child had periorbital edema and facial puffiness. He was hemodynamically stable, and hence, injection Dopamine was tapered and stopped. He had right hypochondrial tenderness with hepatomegaly and no splenomegaly. Initial investigation revealed severe anemia (Hb: 5.1 g/dL), thrombocytopenia (Platelets: 48,000/mm³), elevated AST/SGOT (88 U/L) and LDH (3693 U/L), suggesting ongoing hemolysis. The peripheral smear was positive for Falciparum malaria. Blood urea (193 mg/dL) and serum creatinine (2.8 mg/dL) were markedly elevated. Urine output was around 0.1-0.3 ml/kg/hr. Serial renal Parmenter monitoring is depicted in Table 1. Ultrasound KUB showed mild gallbladder wall edema, minimal ascites, and bilateral increased renal cortical echogenicity. The child was started on IV Artesunate. As a part of Artesunate-based combination therapy, the child also received a dose of sulphadoxine-Pyrimethamine and Primaquine. Due to persistent oliguria and worsening renal parameters, the child underwent peritoneal dialysis (PD). Despite 30 cycles of PD, renal parameters remained elevated, and the child was planned for hemodialysis (HD). Even after two HD sessions, serum creatinine remained elevated with persistent oliguria, and the child was taken for continuous renal replacement therapy (CRRT), consistent with stage III acute kidney injury likely secondary to tropical infection. Subsequently, two additional HD sessions were performed, following which the urine output gradually improved and renal parameters began to decline. The child showed significant clinical recovery with normalisation of urine output and improvement in renal function.