RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS (in Block Letters) / Dr. SAI SEKHAR P, S/o P.D. NAIDU,D/NO. 57-24-77, URVASI, KANCHARAPALEM,
VISAKHAPATNAM 530008, ANDHRAPRADESH.
2 / NAME OF THE INSTITUTION / J.J.M. MEDICAL COLLEGE, DAVANGERE – 577 004,
KARNATAKA.
3 / COURSE OF STUDY AND SUBJECT / POSTGRADUATE DEGREE M.D. GENERAL MEDICINE
4 / DATE OF ADMISSION TO COURSE / 18-05-2012
5 / TITLE OF THE TOPIC / “RENAL AND HEPATIC DERANGEMENTS IN MALARIA WITH CLINICAL OUTCOME”
6 / BRIEF RESUME OF THE INTENDED WORK
6.1 Need for the Study:
Malaria is the most important parasitic disease of man. The human disease is a protozoan infection of red blood cells transmitted by the bite of a blood feeding female anopheline mosquito. The word malaria comes from the Italian, and literally means "Bad Air."1
It is estimated that about 243 million clinical cases occur each year and specific mortality rate for malaria was 17 per lakh population worldwide each year.2 At present 109 countries are considered as endemic to malaria. Plasmodium falciparum is known for its dreaded complication of renal dysfunction. An upsurge in the incidence of acute renal failure in malaria has been reported in India and varies from 13 percent to 17.8 percent.3
Significant hepatic derangements were observed in both P.Falciparum and P.Vivax, more pronounced in P.Falciparum infection, in late phases of illness. Liver function test should be performed in early course of malaria to prevent complications and to reduce mortality2. Hence this study is undertaken to correlate renal parameters and hepatic parameters with clinical outcome.
6.2 Review Of Literature:
Malaria in man caused mainly by four distinct species.
· Plasmodium vivax,
· Plasmodium falciparum,
· Plasmodium ovale,
· Plasmodium malariae.
CLINICAL FEATURES: Malaria has a variety of presentations, fever with chills and rigor being the most common to many other symptoms.
CLINICAL MANIFESTATIONS OF SEVERE MALARIA:
The definitions of severe falciparum malaria includes.4
1. Renal failure
2. Cerebral malaria
3. Severe anemia
4. Pulmonary edema.
5. Hypoglycemia
6. Circulatory collapse or shock
7. Spontaneous bleeding from gums, nose, gastrointestinal tract or substantial laboratory evidence of DIC.
8. Repeated generalized convulsions.
9. Metabolic acidosis.
10. Macroscopic hematuria.
11. Jaundice (more than 3 mg%)
12. Hyperparasitemia.
Renal involvement in malaria:
Varies from asymptomatic glomerulonephritis, acute renal failure and nephrotic syndrome.5 Two basic mechanisms are known in the pathogenesis of renal failure in plasmodium falciparum malaria:
1. Specific effects of parasitised erythrocytes with haemorrheologic changes.
2. Nonspecific inflammatory and associated factors like hypovolaemia, intravascular haemolysis, intravascular coagulation, catecholamine effect, endotoxaemia and jaundice.
Hepatic involvement in malaria:
Hepatic involvement is a common accompaniment of acute falciparum malaria and hepatic dysfunction ranges from a mild elevation of liver enzymes to the range of acute hepatitis. Presence of hepatitis in patients with P.falciparum indicates a more severe illness with a higher incidence of complications, multiorgan failure and caries a bad prognosis.6 Hepatic dysfunction contributes to hypoglycemia, lactic acidosis and impaired drug metabolism. Basic mechanisms are known in the pathogenesis of hepatic dysfunction in plasmodium falciparum malaria:
1. Hemolysis.
2. Hepatocytic injury
3. Cholestasis.
- A study done in 2008 on P.vivax induced nephropathy with total no. of 398 cases out of which 75 patients suffered from P.vivax induced nephropathy with GFR <80ml/min.7
- A study done in 2008 on acute renal failure in P. falciparum malaria found out that it is associated with significant mortality and morbidity. 789 patients analyzed above the age of 14yrs, out of these 12% of the patients had elevated creatinine levels( >3mg/dl ), Jaundice present in 19%cases.8
- A study done in 2006 found that among 237 patients admitted with acute renal failure, among them 46% cases are due to falciparum alone with 78% requiring dialysis.9
- Study done in Attavar found that out of 80 patients, 35 percent suffered from jaundice and 32.5 percent suffered from abnormal kidney functions.10
- A study done in Pune, India showed that 2.5% of patients with falciparum malaria suffered from jaundice.
6.3 Objectives of the Study:
1. To determine the abnormalities of renal parameters in malarial patients.
2. To correlate the renal and clinical profile with the severity and outcome.
3. To determine any alteration in hepatic function and to find out extent of hepatic involvement..
4. To compare the hepatic biochemical derangements induced by P. falciparum and P. vivax, to find out the extent of hepatic involvement.
7. / MATERIALS AND METHODS
7.1 Source of Data:
Minimum of 100 patients, both male and female with malaria presenting to the OPD or getting admitted in Bapuji Hospital and Chigateri Government Hospital attached to J.J.M. Medical College will be included in this study.
7.2 Method of collection of Data (including sampling procedures if any):
Minimum of 100 patients, with malaria presenting to the OPD or patients getting admitted in Bapuji Hospital and Chigateri Government Hospital will be studied using random sampling methods over a period of one and half years. Patient will be studied with the following investigations.
Investigations:
a) Peripheral blood smear /rapid spot test for malarial parasite.
b) Complete haemogram.
c) Blood urea and serum creatinine.
d) Serum sodium and serum potassium.
e) Random Blood Sugar.
f) Urine for Protein, Sugar, White blood cells and red blood cells.
g) Liver function tests which includes prothrombin time, total protein, albumin, total bilirubin, direct and indirect bilirubin, aspartate aminotransferase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP).
Inclusion criteria:
1. Patients of age greater than 16 years and both sexes.
2. Patients positive for malarial parasites either by thick and thin smear or by Rapid spot malarial test.
Exclusion criteria:
Patients in whom renal and hepatic dysfunction might already be present were excluded from the study.
1. Known hypertensive.
2. Known diabetics.
3. Patients with known renal disease.
4. Patients with urinary tract infections.
5. Patients with chronic liver diseases, alcoholics.
6. Patients who are on anti tubercular treatment.
Study design:
A Cross sectional clinical study consisting of 100 new cases of malaria is undertaken to study the renal and hepatic derangements.
7.3 Does the Study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly:
Yes
a) Peripheral blood smear /rapid spot test for malarial parasite
b) Complete haemogram
c) Blood urea and serum creatinine.
d) Serum sodium and serum potassium.
e) Random Blood Sugar.
f) Urine for Protein, Sugar, White blood cells and red blood cells.
g) Liver function tests which includes in prothrombin time, total protein, albumin, total bilirubin, direct and indirect bilirubin, aspartate aminotransferase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP).
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes
8. / LIST OF REFERENCES :
1. White NJ; Malaria. Mansons tropical diseases edited by Gordon Cook 21st edition. Pg 1217-1291.
2. Malaria; Text book of preventive and social medicine edited by K.Park 21st edition. Pg 231-244.
3. Sharma AK Arora M, Gupta R. Malarial acute renal failure in Rajastan J Asso phys India 1998, 1001-1002.
4. HC Agarwal, Sarit Chatla. Malaria. API text book of general medicine. Edited by YP Munjal. 9th edition. Pg 1177-1179.
5. Nand N, Aggarwal HK, Sharma M, Singh M, Systemic manifestations of malaria. J.Ind Acad clin Med 2001(2); 189-194.
6. Singh R, Kaur M, Arora D. A prospective study of hepatic involment in plasmodium falciparum malaria. Journal of clinical and diagnostic research, 2010 April; (4): 2190-2197.
7. Chung BH et al. Predictors of Plasmodium vivax malaria induced nephropathy in young Korean men. Department of internal medicine, The Armed forces Yagju City, Gyeonnggi Province, republic of Korea. Nephrology clin pract 2008; Epub 2008 October 27. 110 (3); c 172-7.
8. Mishra SK, Mahanta KC, Mohanty S at Ispart general hospital – malaria associated with acute renal failure experience from Rourkala- Indian medical association 2008 October 106(10), 640-2,654.
9. Junejo Abdul Mannan, Hasan Ali, Manohar Lal,Department of nephrology and internal medicine, Jinnah Postgraduate medical college, Karachi-Acute Renal failure in malaria-J Ayub Med coll Abott Abad 2006;18(4).
10. Preetem N Wasnik, TP Manohar, NR Humaney, HR Salkar. Study of clinical profile of Falciparum malaria in a Tertiary Referfral centre in Central India, Department of medicine, NKP salve institute of medical sciences, Nagpur. Japivol60. October, 2012.
11. Anand AC, Puri P Jaundice in malaria. J Gastroenterol Hepatol. 2005 Sep;20(9):1322-32.
9. / SIGNATURE OF THE CANDIDATE
10. / REMARKS OF THE GUIDE / It is a good study for Indian scenario as malaria and its renal and hepatic complications are more common in our country.
11. / NAME & DESIGNATION OF
(In Block Letters) 11.1 Guide / Dr. S GURUSHANTHAPPA. MD DNB
PROFESSOR,
J.J.M MEDICAL COLLEGE,
DAVANGERE-577004.
11.2 SIGNATURE
11.3 CO-GUIDE (if any)
11.4 SIGNATURE
11.5 HEAD OF THE DEPARTMENT / Dr. S.N. VISHWAKUMAR MD
PROFESSOR AND
HEAD OF THE DEPT OF GENERAL MEDICINE,
J.J.M.MEDICAL COLLEGE,
DAVANGERE-577004
11.6 SIGNATURE
12. /