Preliminary study on tubuloglomerular dysfunction and evidence of renal inflammation in patients with visceral leishmaniasis.

Visceral leishmaniasis (VL) is a re-emerging zoonosis of worldwide distribution. Monocyte chemotactic protein-1 (MCP-1) and malondialdehyde (MDA) are inflammation biomarkers that have never been investigated in VL. The aim of this study is to investigate the association between renal abnormalities and inflammation biomarkers in VL. This study is a preliminary prospective study with 16 VL adult patients evaluated before treatment compared with a group of 13 healthy volunteers and 5 VL patients evaluated after treatment. Urinary concentration and acidification tests were performed. MCP-1 and MDA were quantified in urine. Urinary concentration deficit was found in all VL patients before (100%) and four VL patients after (80%) treatment. Urinary acidification deficit was found in nine cases before (56.2%) and two cases after (40%) treatment. Urinary MCP-1 (374 ± 359 versus 42 ± 29 pg/mg creatinine, P = 0.002) as well as urinary MDA (5.4 ± 2.6 versus 2.0 ± 0.8 µmol/mL) showed significant differences between VL patients and controls. These data show that VL patients present urinary concentration and acidification deficit, which can persist even after specific treatment. Urinary MCP-1 and MDA are elevated in patients with VL, which suggests renal inflammation and incipient renal damage.

Comparative analysis of pediatric and adult visceral leishmaniasis in Brazil.

BACKGROUND: The aim of this study was to compare clinical manifestations, laboratory data, morbidity and mortality between adults and children with visceral leishmaniasis, with a focus on kidney function. METHODS: This was a retrospective cohort study with 432 patients with visceral leishmaniasis diagnosed at 1 center in the northeast of Brazil. Patients were divided into 2 groups according to age (>21 years and ≤ 21 years old). RESULTS: The time between onset of symptoms and beginning of treatment was longer in adults (89.5 versus 48.5 days, P < 0.001); signs and symptoms were similar in both groups. Failure of treatment with glucantime was more common in adults (17.6% versus 8.8%, P = 0.008). Acute kidney injury was observed in 160 patients (37.0%), and it was more severe in adults. Risk factors for acute kidney injury in adults were hypokalemia, leukopenia, chills and amphotericin B use. In children, secondary infections were found to increase the risk for acute kidney injury. Overall mortality was 8.8%, and it was significantly higher in adults (12.6% versus 4.1%, P = 0.002). CONCLUSIONS: The adult population had more severe laboratory abnormalities and a worse prognosis, possibly due to delay in diagnosis. Acute kidney injury is prevalent in both groups, and it is usually more severe in adults.

Acute kidney injury in children with visceral leishmaniasis.

BACKGROUND: There is no comprehensive study about renal function in children with visceral leishmaniasis (VL). The aim of this study was to investigate the incidence of acute kidney injury (AKI) in children with VL using pRIFLE classification and to determine the risk factors for AKI. METHODS: A retrospective cohort study was conducted with 146 patients younger than 14 years of age with VL diagnosis in one center located at the northeast of Brazil from December 2003 to 2010. AKI was evaluated by pediatric Risk, Injury, Failure, Loss, End-stage kidney disease (pRIFLE) criteria. RESULTS: The mean age was 5 ± 4.0 years (range, 5 months to 14 years), and 53.4% were males. AKI was observed in 67 patients (45.9%). The distribution according to the pRIFLE criteria was as follows: risk 45 (67.2%), injury 21 (31.3%), and failure 1 (1.5%). Patients in the AKI group were significantly younger (P < 0.001) and had jaundice (P = 0.028) and secondary infections (P = 0.001) more often than non-AKI patients. The AKI group had a significantly lower serum sodium (P = 0.03), potassium (P = 0.009), serum albumin (P = 0.001), and elevated serum globulins (P = 0.04), and a more prolonged prothrombin time (P = 0.001) at admission. Independent risk factors for AKI were: secondary infections (OR: 3.65, 95% CI: 1.426-9.358, P = 0.007), serum albumin decrement (OR: 1.672, 95% CI: 1.065-2.114, P = 0.019 per each 1 mg dL(-1) serum albumin decrement), and high serum globulin (OR: 1.35, 95% CI: 1.031-1.779, P = 0.029 per each 1 mg dL(-1) serum globulin increment). CONCLUSIONS: AKI is a frequent complication in children with VL. The risk factors for AKI were secondary infections, high serum globulin and low serum albumin.

Visceral leishmaniasis in children: a cohort of 120 patients in a metropolitan city of Brazil.

There are few studies regarding the clinical presentation of visceral leishmaniasis (VL) in children. The aim of this study was to investigate the clinical manifestations, major complications and causes of death in children with VL. A retrospective study was performed with pediatric patients (< or = 14 years old) with a diagnosis of VL in Fortaleza, state of Ceara, in Northeast Brazil. A total of 120 patients were included. The mean age was 5 +/- 3.9 years, and 53.4% were male. The main clinical manifestations at admission were: fever (94.2%), splenomegaly (94.2%), hepatomegaly (82.5%), anorexia (55%), malaise (47.5%), cough (41.6%), abdominal pain (27.5%), vomiting (25.5%), and diarrhea (16.6%). Acute kidney injury was found in 25% of the patients. The main complication during hospital stay was pulmonary infection, found in 27.5% (n = 33), leading to sepsis in 3 cases. Glucantime was the drug of choice in 90% (n = 108) of the cases, amphotericin B in 7.5% (n = 9) and AmBisome in 2.5% (n = 3). Death occurred in 4 cases (3.3%) due to sepsis (3 cases) and hemorrhagic complications (1 case). Visceral leishmaniasis is a frequent infection among children in our region. The main complications were pulmonary infection and acute kidney injury related to antiparasitic therapy, along with sepsis and hemorrhage.

Renal dysfunction in leprosy: a historical cohort of 923 patients in Brazil.

We investigated the factors associated with renal dysfunction in leprosy patients from Brazil. We report on a historical cohort of leprosy patients followed in two hospitals in Fortaleza City in northeastern Brazil. The factors associated with renal dysfunction were investigated. A total of 923 patients were included, with a mean age of 41.5 ± 19.1 years, and 53.3% were male. Renal dysfunction was found in 35 cases (3.8%). Proteinuria was found in 4.8% of cases, haematuria in 6.8% and leukocyturia in 10.4%. Factors associated with renal dysfunction by multivariate analysis were: reaction episode (odds ratio [OR] = 3.9, P = 0.03), multibacillary classification (OR = 3.5, P = 0.02) and advanced age (OR = 1.04, P = 0.01). Four patients (0.4%) died. Leprosy is associated with renal dysfunction, especially in older patients and those presenting with reaction episode and multibacillary classification.

Renal function improvement with pentavalent antimonial agents in patients with visceral leishmaniasis.

BACKGROUND: The aim of this study is to investigate tubular and glomerular function after visceral leishmaniasis (VL) treatment with pentavalent antimonials. METHODS: This is a prospective study including 14 patients with VL diagnosis treated with pentavalent antimonials. Urine acidification and concentration tests were performed. Estimated glomerular filtration rate (eGFR), fractional excretion of sodium (FE(Na)) and potassium (FE(K)) and free water clearance (C(H2O)) were measured to assess glomerular and tubular function. RESULTS: The VL group had a significantly lower FE(K), serum sodium and plasma osmolality (P(osm)). No significant differences were found regarding proteinuria, eGFR, FE(Na) or C(H2O). Patients in the VL group had lower urinary osmolality (U(osm)) before DDAVP use when compared to the control group, as well as a lower U/P(osm). The urinary pH before and after CaCl(2) load was higher in the VL group. CONCLUSION: This study shows evidence of reversal of some tubular dysfunction in VL, but other dysfunctions may persist, especially urinary acidification capacity.

Risk factors for acute kidney injury in visceral leishmaniasis (Kala-Azar).

The aim of this study was to investigate the factors associated with acute kidney injury (AKI) in patients with visceral leishmaniasis (VL). The study patients had a diagnosis of VL and were admitted to a tertiary hospital. A multivariate analysis was performed to analyze the risk factors for AKI. A total of 224 patients were included. The mean age was 36 +/- 15 years. AKI was observed in 33.9% of cases. Risk factors associated with AKI were male gender (odds ratio [OR] = 2.2; P = 0.03), advanced age (OR = 1.05; P < 0.001), and jaundice (OR = 2.9; P = 0.002). There was an association between amphotericin B use and AKI (OR = 18.4; P < 0.0001), whereas glucantime use was associated with lower incidence of AKI compared with amphotericin B use (OR = 0.05; P < 0.0001). Mortality was 13.3%, and it was higher in AKI patients (30.2%). Therefore, factors associated with AKI were male gender, advanced age, and jaundice. Amphotericin B was an important cause of AKI in VL.