How is serum creatinine (a measure of kidney function) managed in patients with dengue?

Serum Creatinine Monitoring and Management in Dengue

Regular monitoring of serum creatinine is essential in dengue patients to detect and manage acute kidney injury early, with measurements recommended at diagnosis and every 24-48 hours during hospitalization, particularly during the critical phase.

Pathophysiology of Renal Involvement in Dengue

Dengue can affect kidney function through several mechanisms:

• Direct viral invasion of renal tissue
• Immune-mediated injury
• Rhabdomyolysis
• Hemodynamic changes due to capillary leak and shock
• Hypoperfusion from dehydration

Screening and Monitoring Protocol

Initial Assessment

• Measure serum creatinine at presentation for all dengue patients
• Calculate baseline estimated glomerular filtration rate (eGFR)
• Perform urinalysis to check for proteinuria, hematuria, or myoglobinuria

Ongoing Monitoring

• Monitor serum creatinine every 24-48 hours during hospitalization 1
• Increase frequency to daily measurements in:
  • Severe dengue
  • Dengue shock syndrome
  • Patients with pre-existing kidney disease
  • Patients with initial abnormal creatinine values
  • Patients receiving nephrotoxic medications

Risk Stratification

Patients at higher risk for AKI in dengue include those with:

• Pre-existing chronic kidney disease
• Diabetes mellitus
• Advanced age
• Severe dengue with shock
• Significant hemoconcentration (>52% increase in hemoglobin) 2

Management of Creatinine Abnormalities

Stage-Based Management (Modified KDIGO Classification)

1. Stage 1 AKI (Increase in serum creatinine by ≥0.3 mg/dL within 48h or 1.5-1.9× baseline):

   • Withdraw nephrotoxic drugs and diuretics
   • Careful fluid management with close monitoring
   • Daily creatinine measurements

2. Stage 2-3 AKI (Increase in serum creatinine 2-3× baseline or >3× baseline):

   • Volume expansion with albumin (1g/kg) for 48 hours 3
   • More intensive monitoring
   • Consider vasoconstrictors if hepatorenal syndrome criteria are met

3. Severe AKI with indications for RRT:

   • Refractory hyperkalemia
   • Severe metabolic acidosis
   • Volume overload unresponsive to diuretics
   • Uremic symptoms 1

Fluid Management

• Judicious fluid resuscitation guided by clinical parameters
• Use crystalloids and/or colloids for fluid resuscitation 3
• Consider colloid solutions in children with severe Dengue shock syndrome 3
• Avoid excessive fluid administration to prevent pulmonary edema 1
• Monitor for signs of fluid overload

Special Considerations

Patients with Pre-existing CKD

• Higher risk of AKI requiring dialysis (72.7% vs 29.3% in normal baseline function) 2
• May require more frequent creatinine monitoring (every 12-24 hours)
• Lower threshold for nephrology consultation

Transplant Recipients

• May have delayed platelet recovery 2
• Usually experience transient worsening of renal function
• Require careful adjustment of immunosuppressive medications

Follow-up After Recovery

• Evaluate kidney function 3 months after dengue episode 1
• Screen for development of chronic kidney disease
• Adjust medications as kidney function recovers

Common Pitfalls to Avoid

1. Relying solely on serum creatinine: Creatinine may underestimate kidney dysfunction due to decreased muscle mass or altered production in severe illness

2. Delayed recognition of AKI: Even small increases in creatinine (>0.3 mg/dL) are associated with increased mortality

3. Excessive fluid administration: Can lead to pulmonary edema, especially during recovery phase

4. Failure to recognize nephrotic-range proteinuria: Though uncommon, can occur in severe dengue 4

5. Missing coinfections: Consider other endemic infections (malaria, leptospirosis) that may worsen kidney injury 5

By implementing this systematic approach to monitoring and managing serum creatinine in dengue patients, clinicians can detect kidney complications early and intervene appropriately to improve outcomes.