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Acute kidney injury in the tropics: What are the challenges?
Vivekanand Jha
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Tropical zones where all twelve months have mean temperatures > 18 °C (64.4 °F).
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Temperate Tropical
SpringDry season
Cool
Summer Hot
Autumn Wet Season
Winter
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Water: Implications for kidney disease
• Waterborne diseases account for > 2.2 m deaths and >82 m DALYs
• Waterborne infections cause kidney injury: – Direct : diarrheal diseases, salmonellosis,
shigellosis, cholera, – Vector borne: malaria, dengue, – Leptospirosis, schistosomiasis
• Indirect effect of diarrheal diseases on other causes of kidney injury
The United Nations World Water Development Report
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Jha, V. & Parameswaran, S. (2013) Nat. Rev. Nephrol.
“Tropical Underdevelopment” © 2001 by Jeffrey D. Sachs,used by permission of The Wiley Agency LLC
Global GDP per capita by latitude
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Relevance to (kidney) health
• High prevalence of– Vector-transmitted infections– Water-borne illnesses– Recurrent dehydration
• Encounter with venomous animals/insects• Consumption of potentially toxic plants/herbs
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Geographic, biodiversity climate & socio-economic variables are linked with richness of infectious
diseases
Morand et al. PLoS ONE 9(2): e90032
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AKI in Tropical Countries
Grossly under-reported. Pattern and prevalence of community acquired ARF
significantly different from the developed world. The pattern may differ between various tropical
countries and even in different regions of the same country.
The average age lower compared to advanced countries (mean age 34 yrs in India).
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AKI in the Tropics
• High incidence of AKI requiring RRT in rural areas with scarce healthcare resources*
• Patient population much younger• Most have isolated renal involvement at onset• Little/no background CKD• Renal support would lead to (?) substantial
recovery
*Jha V, Semin Nephrol 2008
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Distribution of CA-AKI in the tropics
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Most Common Causes of AKI
Katz et al., 2000
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Plant Areas from where reported Active molecule Renal manifestation
Other manifestations
Aloe capensis(cape aloe)
Zimbabwe, S Africa
Aloins, aloinosides Acute renal failure Gastrointestinal fluid loss, dehydration
Catha edulis(khat leaf)
East AfricaArab peninsula
S-cathioneEphedrine
Acute tubular necrosis
Hepatotoxicity
Colchicum autumnale(meadow saffron)
Turkey Colchicine Acute tubular necrosis
Hemorrhagic gastroenteritis, muscle paralysis, respiratory failure
Dioscorea quartiniana (yam)
Africa, Asia Discorine, dioscine Acute tubular necrosis
Convulsions, symptoms related to inadequate processing
Glycerrhiza glabrata (Liquorice)
Japan Glycerrhizic acid Acute tubular necrosis
Rhabdomyolysis, hypokalemia
Larrea tridentate (chapparal)
Chile, South Africa Nordihydroguiaretic acid, s-quinone
Renal cysts Hepatic failure
Securidacea longepedunculata (violet tree, wild wisteria)
Congo Methylsalicylate, securinine, saponins
Acute tubular necrosis
Vomiting, diarrhoea Root, bark used as intravaginal poison
Semacarpum anacardium (marking nut)
India Phenols Acute tubular necrosis
Fever, dysuria, hematuria
Uncaria tomentosa (cat’s claw, una de gato)
Peru Oxindole alkaloids, pentacyclic triterpenes
Acute interstitial nephritis
Other plants : Euphorbia metabelensis, Crotalaria labminifolia, Artemisia absinthium and Mentha pulegium
Plant nephrotoxins in the tropics
Jha V, Oxford Textbook of Medicine 6th Ed
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Management• Presentation often delayed• Uncertain etiology• Multisystem involvement• Limited availability of dialysis• Acute peritoneal dialysis mainstay of
treatment in remote areas
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Challenges
Jha V Clin Nephrol 2015
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Economic impact of ESRD treatment
Ramachandran and Jha, PLOS One 2013
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Changing disease epidemiology
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ID outbreaks and loss of biodiversity
Morand et al. PLoS ONE 9(2): e90032
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Worldwide annual maximum temperature changes
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Tropical infections, AKI and CKD
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icddr,bDhaka, Bangladesh
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Research agenda• Tropical AKI registry to document disease pattern
and variations• Long-term impact of tropical AKI• Financial impact of AKI on patient families and
society• Development and testing of models of service
delivery, aimed at – early identification, – prevention and – early intervention in the community
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Conclusions• Tropical AKI irrevocably linked to tropical ecosystem and
culture• AKI incidence and pattern reflects unfinished public
health agenda• Presentation and outcome depend on treatment
availability• More information and awareness needed in the
community• Climate change to have a major impact, danger of
slipping on gains • Research needs to focus on this “neglected disease”
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