Clinical picture, nephrotic syndrome in P. malariae

Chronic infection with P. malariae may, via immunological mechanisms (chronic immune complex glomerulonephritis) cause a nephrotic syndrome, characterised by oedema and proteinuria (> 3.5 gram per 24 hours). There is often significant hyperlipidaemia, and lipid bodies are sometimes found in the urine (which appear in polarisation microscopy like bunches of grapes with a Maltese cross pattern). If a kidney biopsy is carried out, it should be borne in mind that severe bleeding will occur in 1% of cases. The treatment of nephrotic syndrome is difficult. A curative malaria treatment is of course indicated, but will not produce any improvement of the kidney problems. Salt restriction and diuretics are indicated (both thiazide and loop diuretics). Albumin IV and treatment with an ACE-inhibitor [angiotensin-converting enzyme-inhibitor] such as enalapril (Renitec®) is only possible in better settings. In significant hypercholesterolaemia simvastatin is beneficial but expensive (Zocor®, a HMG-CoA reductase inhibitor). Patients with advanced nephrotic syndrome lose coagulation inhibitors through the urine (protein S, C, antithrombin III) and are therefore at increased risk of thrombosis, chiefly in the vena renalis. Steroids and immunosuppressives are of little benefit in this disorder. An important challenge is to distinguish the entity from minimal change glomerulonephritis (electron microscopy needed to confirm "minimal change").

Category: Medicine Notes