What is the treatment for dengue fever in a patient with chronic kidney disease (CKD) and uncontrolled diabetes mellitus (DM)?

Treatment of Dengue Fever in Patients with Chronic Kidney Disease and Uncontrolled Diabetes

The treatment of dengue fever in patients with chronic kidney disease (CKD) and uncontrolled diabetes requires careful fluid management, close monitoring of renal function, and optimization of glycemic control with SGLT2 inhibitors or GLP-1 receptor agonists if eGFR ≥20 mL/min/1.73m².

Initial Assessment and Risk Stratification

Patients with CKD and diabetes who develop dengue fever are at significantly higher risk of complications:

• Pre-existing renal disease increases the risk of severe dengue by 4.5 times 1
• Patients with CKD experience more severe worsening of renal function during dengue infection 2
• Mortality rates are substantially higher in dengue patients with renal failure (28.6% vs 1.2% in those without renal failure) 3

Immediate Laboratory Evaluation:

• Complete blood count with platelet monitoring
• Serum creatinine and eGFR using race-free CKD-EPI equation
• Electrolytes (sodium, potassium, chloride, bicarbonate)
• Liver function tests
• Blood glucose monitoring
• Urinary albumin-to-creatinine ratio

Fluid Management

Fluid management is the cornerstone of dengue treatment but must be modified for CKD patients:

• Use cautious fluid resuscitation - avoid fluid overload which can worsen renal function and precipitate pulmonary edema
• Monitor for signs of fluid overload (peripheral edema, pulmonary congestion)
• In severe cases, consider central venous pressure monitoring
• Isotonic crystalloids (0.9% normal saline) are preferred initially
• Calculate fluid requirements based on ideal body weight and adjust for degree of renal impairment

Renal Function Monitoring

• Monitor serum creatinine and electrolytes every 12-24 hours
• Track urine output hourly in severe cases
• Be prepared for renal replacement therapy if acute kidney injury develops
• Patients with CKD are more likely to require hemodialysis during dengue infection 2

Glycemic Management

Glycemic control is critical but challenging during dengue infection:

• For patients with eGFR ≥20 mL/min/1.73m², continue or initiate SGLT2 inhibitors which provide both renal and cardiovascular protection 4
• For patients with severely reduced eGFR (<20 mL/min/1.73m²), insulin therapy with frequent blood glucose monitoring is recommended
• Target HbA1c range of 7-8% is appropriate for most CKD patients 4
• Consider continuous glucose monitoring for precise management during acute illness 4
• Avoid hypoglycemia which is more common in CKD patients due to:
  • Impaired renal gluconeogenesis
  • Altered insulin clearance
  • Impaired counterregulatory hormone responses 4

Medication Management

Antihypertensive Medications:

• Continue ACE inhibitors or ARBs if patient is hemodynamically stable
• Do not discontinue for mild to moderate increases in serum creatinine (≤30%) 4
• Temporarily hold if severe hypotension or significant AKI develops

Diabetes Medications:

• For eGFR ≥20 mL/min/1.73m²: SGLT2 inhibitors are recommended to reduce CKD progression 4
• For all CKD stages: GLP-1 receptor agonists can be considered for cardiovascular risk reduction 4
• Adjust insulin dosing based on frequent glucose monitoring
• Temporarily discontinue metformin if significant dehydration or AKI develops

Nutritional Support

• Aim for dietary protein intake of 0.8 g/kg body weight per day for non-dialysis CKD patients 4
• For patients on dialysis, consider 1.0-1.2 g/kg/day to prevent protein-energy wasting 4
• Ensure adequate caloric intake while managing blood glucose
• Monitor and replace electrolytes as needed

Indications for Nephrology Referral

• Continuously decreasing eGFR or increasing albuminuria
• eGFR <30 mL/min/1.73m² 4
• Need for renal replacement therapy
• Uncertainty about etiology of worsening kidney function

Special Considerations

• Patients with diabetes and CKD have higher risk of dengue hemorrhagic fever/dengue shock syndrome 3
• The severity of GFR impairment correlates with higher percentages of DHF/DSS and mortality 3
• Warning signs may be less apparent in patients with renal failure, requiring more vigilant monitoring 3
• Haemoconcentration is associated with higher risk of requiring dialysis 2

Follow-up After Recovery

• Reassess renal function 2-4 weeks after recovery
• Adjust medications based on post-recovery renal function
• Resume comprehensive diabetes and CKD management
• Monitor for residual renal impairment, as some CKD patients may become dialysis-dependent even after recovery from dengue 2

By following this approach, clinicians can optimize outcomes for this high-risk patient population with dengue fever complicated by CKD and uncontrolled diabetes.