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1. Acute Kidney Injury in Dengue Fever
Moderator: Dr. Waseem Ramzan Sir
Presented By : Dr.Mohd. Junaid Khan
Journal Of The Association Of Physicians Of India June 2022

2. Introduction
• Dengue fever is among the most cardinal arthropod-borne infection among humans. Around the
world, an estimated 2.5 billion individuals are at peril of infection.
• During the current decapod, DF has set off the second most widespread mosquito suffering
infection after malaria. The total cases of DF have gotten to around 50 million in total. The spread
of the virus in nonendemic regions with a high vector (Aedes aegypti and Ae. albopictus)
population.
• In India, the occurrence of dengue has expanded year after year. Every monsoon season
welcomes an outbreak of DF. New Delhi, from 1967 to 2003 has seen seven major outbreaks.

3. • A substantiate the case of dengue fever is a case that is confirmed by dealing with the given
laboratory standards, that is, dengue virus isolation from serum or affirmation of tetra fold or
greater change in reciprocal of IgG or IgM antibody numerations to other dengue dander in serum
samples paired with cerebrospinal fluid (CSF) using techniques like enzyme-linked
immunosorbent assay (ELISA).
• Acute kidney injury (AKI) is so far not a well-studied dengue complication. The renal
abnormalities, though not common, are AKI, proteinuria, glomerulonephritis, and hemolytic
uremic syndrome, which are considered complications of the disease.
• There are many timely epidemics of dengue infection and a limited database on the inclusion of
the renal system in dengue infection.
• This study was designed to evaluate the prevalence of AKI in Dengue Fever and find out the
predictors of the development of AKI in patients with Dengue Infection.

4. Methodology
• This study was done in the Department of General Medicine, Maharishi Markandeshwar Institute
of medical science and research, Mullana, Ambala.
• The study design was a hospital-based cross-sectional study.
• A total of 120 patients with clinical suspicion of dengue fever and confirmed on NS1/IgM fulfilling
the selection criteria were selected for the study.

5. Selection Criteria
Inclusion Criteria
• Patients with clinical suspicion of dengue fever confirmed on NS1/IgM.
Exclusion Criteria
• Known cases of diabetic nephropathy, and hypertensive nephropathy.
• Known case of chronic kidney disease.
• Infectious diseases like malaria and enteric fever.
• Known case of cirrhosis and liver dysfunction.
• History of treatment with NSAIDs.

6. • Patients were interviewed and demographic data like gender and age were noted. Patients were
also interviewed for a detailed clinical presentation, history of associated medical conditions like
chronic kidney disease, diabetic nephropathy, and hypertensive nephropathy.
• A thorough general physical examination was conducted to assess vital parameters, and clinical
signs followed by a systemic examination. All these findings were noted on a predesigned and
pretested performa.

7. • The Severity of Dengue Fever According to the criteria from the World Health Organization
(WHO), patients who have DF and hemorrhagic manifestations, low platelet count, and objective
evidence of leaky capillaries (20% elevation in hematocrit, lower serum albumin, and pleural or
other effusions) were classified as having DHF (WHO classification, DHF grades I/II).
• Acute Kidney Injury Based on the Acute Kidney Injury Network (AKIN) criteria, the patients were
evaluated for the diagnosis of AKI based on an increase in serum creatinine of 0.3 mg/dL or >50%
developing in <48 hours or urine output <0.5ml/kg/hr for more then 6 hours.
• Predictors of AKI The following predictors of AKI were evaluated.
• • Sex • Age • The severity of dengue fever • Other associated complications • Serositis •
Thrombocytopenia at admission • Blood urea at admission • Creatinine at admission • Laboratory
parameters • Imaging parameters.

8. Results
• This one-year hospital-based cross-sectional study was carried out in the Department of General
Medicine, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana,
Ambala.
• During the study period a total of 135 adults presented with dengue NS1/IgM tests. Of them, 120
were eligible and 15 were excluded.
• The general condition of the patients was assessed based on pallor, icterus, petechial
hemorrhage, and rashes.

9. • The hematuria and proteinuria were also observed with 34 patients showing the TLC count
<1000/cumm.
• Hepatic function is asses based on liver enzymes with ascites present in 36.7%. The majority of
patients (74.9%) show normal X-ray findings with pleural effusion in 14.2%, ARDS in 8.3%, and
ground glass appearance in 1.7% of the patients. Upon diagnosis of dengue without warning
signs, dengue with warning signs and severe dengue was observed in 87 (72.5%), 16 (13.3%), and
17 (14.2%), respectively .
• The diagnosis of AKI with dengue was observed in 27.5% with 83.3% of the patient
improved and discharged and mortality was noted in 16.7% of the patients.

10. • When AKI is associated with sex the applied statistics show that amongst the total 33
AKI–associated patients nine were females and 24 were males. Similarly, the AKI is
associated with age showing a majority of age groups lie between 31 and 50 years old
(48%), dengue severity where the majority stands with dengue with no warning signs (16,
48.5%) and other complications [ARDS, Coronary Artery Disease (CAD), MODS, and
sepsis).
• The creatinine and urea values were also observed as the marker of deteriorating renal
functions. Patients with numbers were having creatinine on the higher sides with >1.2
stands with 25 (75.8%). whereas for urea the major numbers stand at 72.7% constituting
the values range at 18–49 mg/dL.
• Platelets values were also measured in our study and 14 patients were found to have
platelets in the range between 20 and 49 × 1000/ cumm and nine patients had platelets
less than 20 thousand per cumm.

11. • Creatinine
• 2.36 ± 1.96mg/dl
• 0.86 ± 0.50mg/

13. Discussion
• The incidence of dengue is equal in males and females. However, in the present study
males (69, 57.5%) were more than females (51, 42.5%) with a male to female ratio of
1.35:1. These findings were comparable with a study conducted by Sharma et al.who
reported a male to female ratio of 3:1.
• In our study, all the patients presented with fever (100%). The second common clinical
presentation was myalgia (62.5%) followed by nausea (47.5%), headache (45.8%), and
vomiting (43.3%). The other uncommon clinical manifestations were abdominal pain
(42.5%), joint pains (25%), retro orbital pain (19.2%), cough/cold (10%), malena (9.2%),
altered mental status (8.3%), and bleeding gums (8.3%). However, very few patients (six
patients) presented with rash (6.7%), loose stool (6.7%), oliguria (4.2%), epistaxis (2.5%),
and hemoptysis (1.7%). Compared to other studies findings were similar but oliguria was
seen in our study.
• The most common clinical sign was pallor (15.8%) followed by icterus (12.5%) and
petechial hemorrhage over the body (7.5%).

14. • Imaging - In the present study pleural effusion, ARDS and ground glass appearance were the
findings seen on chest X-rays in 14.2%, 8.3%, and 1.7% of the patients, respectively. On the other
hand, Kumar A et al., in their retrospective study reported that, ARDS (4.72%) and pleural
effusion (4.29%).
• Ultrasound Abdomen - In this study, ascites (36.7%) and thickened gall bladder (39.2%) were the
common findings noted on ultrasound abdomen followed by hepatomegaly (25.8%) and
splenomegaly (19.2%). On the other hand, Narayanan M. et al.,78 showed hepatomegaly in 60%
and a study in Delhi by Tripathi BK et al. in 23% of the cases
• Laboratory Parameters -Urine Analysis In the present study, urine analysis revealed 21.7% of the
patient had 1+ proteinuria while haematuria was evident in 20.8% of the patients. No other
previous studies have mentioned urine studies in patients with dengue fever.

15. • At admission platelet count of <20,000 was noted in 14.1% of the patients and 33% of the
patients had a platelet count between 20,001 and 49,999/cumm which means nearly half
of the patients (47.1%) had low platelet count. The platelet count ranged between 4000
and 319,000/cumm.
• Acute Kidney Injury- In this study serum, creatinine levels were estimated at the time of
admission and serial measurement were obtained on a day-to-day basis in select cases. The
creatinine levels at admission ranged between 0.1 to as high as 9.69 mg/dL but the mean serum
creatinine levels were 1.27 ± 1.29 mg/dL and median levels were 0.87 mg/dL suggestive of
normal kidney function.

16. • However, based on AKIN criteria, 33 out of 120 patients developed AKI. Hence the prevalence of
AKI in dengue fever was 27.5%. Looking at the raised serum creatinine level at admission, it may
be hypothesized that, every one out of three patients with dengue fever is likely to present with
raised serum creatinine as a consequence of dengue and accordingly are at high risk of
developing AKI.
• This acute nephropathy could be related to prerenal ARF consequent to third space loss of fluid.
The spectrum of renal disorders is least studied in dengue infection varies from mild
glomerulonephritis and urinary sedimentations to severe AKI. It is a complication of DVI which has
not been studied much. Though the prevalence of AKI observed in the present study (27.5%) was
this, it was high compared to the studies by Lee et al.
• This wide variation observed in the prevalence rate of AKI can be explained by the varied sample
size, different study designs, and different criteria used to address the definition of AKI.

17. Conclusion
• Based on the findings of this study it may be concluded that there is a high prevalence of AKI
(27.5%) in patients presenting with dengue fever in the study area hence it cannot be neglected.
• The significant predictors of AKI in patients with DF are male gender, advanced age, hypotension,
high serum creatinine, and blood urea levels at the time of admission and lower platelet count at
admission., evidence of polyserositis, and other complications.
• Laboratory parameters including raised total count, and abnormal liver function tests at
admission are also associated with the risk of developing AKI in patients with DF.
• Persons with dengue fever with warning signs and severe dengue had more evidence of AKI
compared to dengue fever. The person who developed AKI had more mortality.

18. Take Home Message
• Patients with male gender, advanced age, hypotension, high serum creatinine, and blood urea
levels at the time of admission and lower platelet count at admission., evidence of polyserositis
along with raised total count, and abnormal liver function tests at admission are associated with
the risk of developing AKI in patients with DF.

19. THANK YOU