Clinical Queries: Nephrology 5 (2016) 4041
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Clinical Queries: Nephrology
journal homepage: www.elsevier.com/locate/cqn
Letter to the Editor
Renal recovery after dengue induced acute
kidney injury (DAKI): A future perspective
Respected Editor,
Dengue viral infection (DVI) is manifested with variety of
clinical presentations including asymptomatic infection, undiffer-
entiated fever, dengue fever (DF), dengue hemorrhagic fever (DHF)
and life threatening dengue shock syndrome (DSS).1 In recent years
with the geographical spread of dengue illness and with more
involvement of adults, there have been increasing reports of DF
and DHF with unusual manifestations, termed as Expanded
Dengue Syndrome (EDS). These isolated organopathies include
hepatic, renal, cardiac, respiratory and neurological involvements
in dengue infection and could be explained as complication of
severe profound shock or associated with underlying host
conditions or coinfections.2 Several forms of renal involvement
have been identied in patients with dengue, including elevation
of the serum creatinine (SCr) level, acute kidney injury (AKI), acute
tubular necrosis (ATN), hemolytic uremic syndrome, proteinuria,
glomerulopathy and nephrotic syndrome.3
AKI is a signicant, albeit poorly studied and least appreciated
complication of DVI, besides of knowing the fact that even
transient increase in serum creatinine (SCr) is linked to increased
mortality.4 The data available are heterogeneous and mostly
originate from retrospective case series and case reports. The
reported frequency of dengue induced AKI (DAKI) exhibits wide
variation (0.8313.3%) in accordance to the particular population
being assessed, severity of dengue, criteria used for the diagnosis of
AKI and time of evaluation.5 Recently, we found highest proportion
of DAKI (14.2%) in a large retrospective cases series, regardless of
dengue severity.6 On the other hand, data on the kidney histology
in DAKI is limited and it might be due to contraindication of
performing a renal biopsy in patients with a hemorrhagic disease
such as DVI. Nevertheless, available data suggested presence of
DENV in one third of renal necropsies performed on DHF/DSS
patients.7 Several mechanisms have been proposed to account for
the etiopathogenesis of DAKI, including direct action by the virus,
hemodynamic instability, rhabdomyolysis, hemolysis and acute
glomerular injury. While none of the available evidence patently
favors any such mechanisms at the expense of the others, often two
or more mechanisms coexist simultaneously in the same patient.3
Initially it was accepted that patients who survive an episode of
AKI had a good renal outcome as assessed by a rapid return of
renal function towards baseline values in most patients and by the
reversible nature of AKI. However, Chawla and Kimmel reported
that patients who survive an episode of AKI are at risk of
developing CKD. Unfortunately existing data lack information of
renal recovery among DAKI patients.8 Laoprasopwattana et al.
reported that, among nine AKI survivors with dengue infection,
none had CKD and SCr levels returned to normal in median 32 days.
http://dx.doi.org/10.1016/j.cqn.2016.08.001
2211-9477/ 2016 Published by Elsevier, a division of RELX India, Pvt. Ltd.
However, this study is accompanied by several limitations,
primarily less sample size and inclusion of only children (age
<15 years) with severe forms of dengue infection (DHF/DSS).9
In a separate case series, we reported approximately half of the
dengue patients with AKI diagnosed by the Acute Kidney Injury
Network (AKIN) and RIFLE (Risk, injury, failure, loss of function,
end stage renal disease) criteria and more than 90% of patients
diagnosed by the conventional criterion (serum creatinine >2 mg/
dL) had renal insufciencies at discharge from the hospital.10 The
progression of underlying CKD or development of de novo CKD
may occur among these patients with poor renal outcomes at
discharge. Moreover, patients who fail to recover will have
signicantly shorter life span and succumb to a number of
morbidities.11 Furthermore, non-recovery of kidney function has
been reported among substantial proportion of patients experienc-
ing other tropical infections, i.e. leptospiral-AKI and malarial-
AKI.12,13 However there has been a dearth of investigation on renal
recovery among dengue patients with AKI. A growing body of
evidence has already suggested that the huge burden of CKD in
tropics and etiology remains unclear in 16% patients. In this
context, association of DAKI with progression and development of
CKD or acute kidney disease (AKD, partial renal recovery) is needed
to be evaluated. Additionally, impact of multiple AKI episodes after
DAKI also needs clinical focus. We strongly suggest large
prospective follow-up studies among dengue patients with AKI.
Conicts of interest
The authors have none to declare.
References
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 Letter to the Editor / Clinical Queries: Nephrology 5 (2016) 4041 41

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Tauqeer Hussain Mallhi*
Amer Hayat Khan *Corresponding author
Azmi Sarriff E-mail address: tauqeer.hussain.mallhi@hotmail.com (T.H. Mallhi).
Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences,
University Sains Malaysia, Penang 11800, Malaysia Received 18 August 2016