Beware Of Frequent Kidney Diseases After Floods

In the past few days, the extremely heavy rainfall in Beijing, Tianjin, and Hebei has attracted public attention. Some areas in Beijing, Hebei, Shanxi, and other places have experienced heavy or extremely heavy rain. According to the latest regional warning situation of the Meteorological Department, as of 10:00 on August 1, the Mentougou District of Beijing is still in the orange rainstorm warning state, and other districts have been downgraded to the yellow rainstorm warning 1. In addition, the rainfall has caused 11 deaths and 27 people lost contact2.

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The so-called "after a major disaster, there must be a major epidemic". After floods, typhoons, hurricanes and other natural disasters, diarrhea, acute respiratory infectious diseases, malaria, leptospirosis, and other diseases frequently occurred, which brought 2 injuries to the people in the disaster area 3. Among these 2 injuries, many diseases can lead to kidney disease. Doctors, patients, and even the general population should pay attention to prevent and treat these diseases correctly. These diseases can be divided into acute kidney injury (AKI) and chronic kidney disease (CKD) due to flooding.

AKI

There are two main types of flood-related AKI, AKI caused by diarrhea and AKI caused by leptospira infection.

1 diarrhea

Renal ischemia is the leading cause of AKI in developing countries. Diarrhea, infectious disease, abortion complicated by infection, dyes, and the use of herbal remedies can all lead to renal ischemia. Diarrhea is not only related to the long-term poor living environment and drinking water sanitation but also related to an unclean diet after natural disasters3-4. According to statistics, people in most areas affected by floods, hurricanes, and tsunamis suffered from large-scale diarrhea3.

The response to this type of AKI should be prevention first, supplemented by treatment. People in disaster areas should eat clean food, such as eating packaged food, and drink bottled water, which can avoid diarrhea. Do not eat food that has deteriorated or been soaked in floods; do not eat livestock, poultry, and animal products after drowning (disease); food should be cooked thoroughly, raw and cooked should be separated, tableware should be cleaned and disinfected before use; leftovers should not be eaten Do not buy or eat unlicensed food; large gatherings should be avoided during floods and receding water. After diarrhea, blood volume should also be replenished in time, such as by drinking light salt water, etc. 4.

If unfortunately develop AKI or AKI high-risk patients, according to the KDIGO AKI guidelines, in the absence of hemorrhagic shock, it is recommended to use isotonic crystalloids instead of colloids (albumin/starch) as a volume expansion method for AKI high-risk or AKI patients ( 2B) 5.

2 Leptospira

Leptospirosis is a zoonotic disease caused by bacterial infection with the bacterium Leptospira. According to statistics, compared with cold and temperate regions, subtropical regions such as Thailand, India, and southern my country are more prone to leptospirosis after floods and typhoons4. Although the main disaster area of this flood is in the north, due to the high temperature in summer, the possibility of a Leptospira outbreak cannot be completely ruled out.

The clinical presentation of leptospirosis varies from mild, nonspecific symptoms such as flu-like symptoms (fever, myalgia, and headache); to severe symptoms with end-stage organ damage (eg, acute kidney injury, acute liver failure, bleeding sexual diathesis); acute hemoptysis due to pulmonary hemorrhage; acute disturbance of consciousness due to aseptic meningoencephalitis; and acute heart failure due to acute or subacute myocarditis6-7.

Three indicators of suspected leptospirosis infection include:

① acute febrile illness; 

② jaundice; 

③ AKI. 

The presence of severe myalgias, bleeding diathesis, and marked jaundice at presentation predicts severe leptospirosis7.

Renal involvement in leptospirosis ranges from asymptomatic urinary abnormalities to severe AKI requiring maintenance dialysis. The typical pathological manifestations of the kidney are renal tubular injury and interstitial nephritis, including renal tubular epithelial cell shedding or necrosis, lumen expansion, accompanied by hyaline casts and cell debris, interstitial edema, and lymphocytes, monocytes, and plasma nephritis. Cells and other inflammatory cell infiltration. Common laboratory findings are hypokalemia and renal sodium depletion. The incidence of AKI due to leptospirosis ranges from 10% to 88%, usually nonoliguric, and hypokalemia accounts for 45% to 50% of AKI cases. Thus, the combination of hyponatremia, hypokalemia, and clinical cues of non oliguric AKI (or polyuria) is a unique feature of leptospirosis nephropathy6-7.

The main methods for the diagnosis of leptospirosis are microscopy, immunostaining, biological culture, and DNA amplification. Indirect hemagglutination test, enzyme-linked immunosorbent assay, and leptospirosis IgM test paper are its indirect identification methods6-7.

The treatment of leptospirosis is mainly divided into cause treatment (such as antibiotics) and symptomatic treatment. Of note, leptospirosis may also require renal replacement therapy (RRT), starting with severe metabolic acidosis, fluid overload, and uremia6-7.

CKD

After the flood, the water body in the disaster area was polluted, and human and animal corpses and feces were soaked in the water body. People in disaster areas will inevitably come into contact with or even soak in water bodies for a long time when fleeing or avoiding disasters. However, this may cause schistosome parasitism of enteric and genitourinary origin8.

The common species of schistosomiasis in my country is intestinal-derived schistosomiasis, and the species is Schistosoma japonicum. The main symptoms are abdominal pain, diarrhea, and blood in the stool. These symptoms may also cause AKI. Although schistosomiasis of the urogenital system is rare, it is not uncommon. The common species is Schistosoma haematobium. This type of schistosome directly attacks the patient's kidneys, making the patient progress to CKD. Its typical symptom is hematuria. In advanced cases, kidney damage and fibrosis of the bladder and ureters are sometimes diagnosed. Bladder cancer is another possible complication at an advanced stage. Women infected with genitourinary schistosomiasis may present with genital lesions, vaginal bleeding, dyspareunia, and vulvar nodules. Men with genitourinary schistosomiasis may develop lesions in the seminal vesicles, prostate, and other organs. The disease can also have other long-term irreversible consequences, including infertility8.

For kidney disease associated with schistosome infection, the latest recommendations of the KDIGO guidelines are as follows9:

Appropriate testing for endemic coinfections (Salmonella, HBV, HCV, HIV) is warranted in patients with schistosomiasis, and targeted therapy may alter the severity of underlying glomerulonephritis or sequelae of schistosomiasis. Kidney biopsy should be performed in patients with suspected schistosomiasis glomerulonephritis in the presence of viral co-infection (HCV, HBV, HIV). Patients with glomerulonephritis associated with schistosomiasis infection should be treated with antiparasitic drugs in sufficient doses and for a sufficient course of treatment to eradicate the parasitic infection.

When a disaster strikes, in addition to actively saving lives, we should also pay attention to avoid secondary disasters, prevent and treat epidemics, and overcome difficulties together. We hope that the people in the disaster-stricken areas will get out of the shadow of the disaster as soon as possible and start a beautiful and healthy new life.

REFERENCE:

1. Guo Songqiao. Mentougou District of Beijing is still under an orange rainstorm warning. Meteorological experts explain the reasons for extreme precipitation. Financial Associated Press. August 1, 2023. Link: https://finance.sina.com.cn/jjxw/2023- 08-01/doc-imzeskqe0335188.shtml

2. Ren Shan. This round of heavy rainfall in Beijing has killed 11 people, 2 of whom died in the line of duty during rescue and disaster relief. Beijing Daily. August 1, 2023. Link: https://news.bjd.com. cn/2023/08/01/90022902.shtml

3. Kouadio I K , Aljunid S , Kamigaki T , et al. Infectious diseases following natural disasters: prevention and control measures[J]. Expert Review of Anti-infective Therapy, 2012, 10(1):95-104.

4. Li PK, Burdmann EA, Mehta RL; World Kidney Day Steering Committee 2013. Acute kidney injury: global health alert. Kidney Int. 2013 Mar;83(3):372-6.

5. KDIGO. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International. March 2012. Vol2 supplement 1.

6. Chancharoenthana, W.; Leelahavanichkul, A.; Schultz, M.J.; Dondorp, A.M. Going Micro in Leptospirosis Kidney Disease. Cells 2022, 11, 698.

7. Sun Shiren. Kidney Injury Related to Natural Focal Diseases[J]. PLA Medical Journal, 2019,44(7):568-573.

8. World Health Organization. Schistosomiasis. Official website: https://www.who.int/zh/news-room/fact-sheets/detail/schistosomiasis

9. Kidney Disease: Improving Global Outcomes (KDIGO) Glomerular Diseases Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int. 2021 Oct;100(4S):S1-S276.