KP Parasitologi Blok 9 Ginjal dan Sal.

Kemih

Parasitic Infections in the

Kidney & Urinary Tract

Forman Erwin Siagian

Email:
forman.siagian@uki.ac.id
Dept. of Parasitology,
Faculty of Medicine-Universitas Kristen Indonesia
Jan, 18th 2021
In this lesson, you’ll learn about:
Epidemiology of Parasitic
Infections
Pathophysiology
and pathogenesis of of the
kidney and
Clinical signs and
symptoms of the
Urinary
Management of Tract
Characteristics of Parasitic Infection

(1) Different
stages of life cycle

(2) Tendency to
chronicity
parasitism

(3) Ability to evade

Host’s immune
response
Comparison of the Urinary Tract: Male vs. Female.
How parasite infect or affect organs...

Direct contact
• Common, e.g schistosoma

Ectopic
• very rare, e.g migrating worm or larvae

As consequences of derangement/ infection in

other part of the body; and or the host’s immune
response to infection
• More common e.g malaria

Underlying disease /condition that facilitates

parasite enter the body e.g ICU patients with
multiple catheter/invasive device
• Increasing number, e.g candidiasis biofilms
 Barsoum, 2013. AJKD

In terms of Urinary Tract...

• From 342 known parasites that
may cause disease in humans,
about 20 of these may lead to
kidney disorders

• However, the majority can cause

merely subclinical or mild and
self-limited disease that usually
passes unnoticed, particularly if
masked by more substantial
extrarenal manifestations.

• Only 4 (four) have attained

significant clinical or
epidemiologic Importance: (1)
schistosomiasis, (2) malaria, (3)
filariasis, and (4) leishmaniasis.
List of (some) parasitic infections in the urinary tract, esp.
Kidney
Malaria Toxoplasmosis

Schistosomiasis Trichinosis

Van Velthuysen and Florquin, 2000

Leishmaniasis

Barsoum, 2013
Opisthorchiasis

Trypanosomiasis Candidiasis

Hydatid disease Trichomoniasis

Filariasis Babesiosis
 Epidemiology of Malaria related Renal disease
• Vector: Anopheles spp
• In Southeast Asia, acute renal failure (ARF) is one of
the most common complications in adults with severe
falciparum malaria.
• The incidence ~15-48%  high fatality rate estimated
>70% in untreated patients .
• The availability of renal replacement therapy (RRT) and
appropriate antimalarial chemotherapy has been
shown to reduce case fatality rate as well as enhance
the recovery of renal function

Thanachartwet et al. Intl J Nephrol. 2013

Barsoum. 2000. J Am Soc Nephrol. Malarial Acute Renal Failure
Epidemiology clue from the last
two slide...?????
Pathophysiology of Kidney derangement
due to parasitic infection
• Glomerular lesions observed in parasitic infections
cover the whole range of lesions known. (parasite 
the great immitator)
• Most of these lesions are proliferative (?) and
therefore show an accumulation of cells in the
glomerular tuft, i.e., membranoproliferative (synonym
of mesangiocapillary) or mesangioproliferative type of
glomerulonephritis.
• Glomerular lesions with little or no proliferation, such
as in membranous glomerulopathy, focal segmental
glomerulosclerosis, and minimal-change disease, are
sometimes seen.(?)
Van Velthuysen and Florquin, 2000
 Clinical manifestations (in general)...
Proteo-hematuria to Nephritic Renal Rapidly progressive
Nephrotic syndrome syndrome insuficiency glomerulonephritis

• ranging from isolated proteinuria or hematuria to nephrotic

syndrome (proteinuria of .3.5 g/day, hypoalbuminemia,
generalized edema, and hyperlipidemia), nephritic syndrome
(glomerular hematuria, recognized by erythrocyte casts in the
urine, and diminished glomerular filtration with some degree of
azotemia, oliguria, and hypertension), renal insufficiency, and
rapidly progressive glomerulonephritis (nephritic syndrome
with doubling of the creatinine level in serum within 3 months
as a sign of progressive renal failure).-
Van Velthuysen & Florquin, 2000
At the most basic level, remember that nephrotic syndrome involves
the loss of a lot of protein, whereas nephritic syndrome involves the
loss of a lot of blood
Pathogenesis of Malarial Glomerular Disease
• Only two of the malaria parasites, namely, P. malariae
(quartan malaria) and P. falciparum (falciparum malaria),
are clearly associated with renal disease, and this occurs
only in a small percentage of patients.
• Malarial nephritides are thought to result from the
combination of endothelial damage and immune-
complex deposition.
• The local release of inflammatory mediators and the
disturbance of the microvasculature by intravascular
hemolysis and coagulation may lead to glomerular
endothelium activation and damage
Van Velthuysen &Florquin. Glomerulopathy Associated with Parasitic Infections.
Clinmicrobiol Rev Jan. 2000, p. 55–66
Interaction of the hemodynamic and immunologic perturbation/derangement in
the pathogenesis of acute renal disease in falciparum malaria. ATN: acute
tubular necrosis, AIN: acute interstitial nephritis, PIGN: postinfectious
glomerulonephritis (includes exudative and necrotizing variants); MPGN:
mesangioproliferative glomerulonephritis
Mechanism of P. falciparum infection causing acute renal failure
Das, 2008. Renal failure in malaria.. J Vector Borne Dis
 ARF & Rhabdomyolysis
• Acute renal failure is a common complication in malaria
infection. This can be the result of multiple mechanisms [1]:
hypovolaemia, excessive haemolysis, disseminated
intravascular coagulation or impaired microcirculation due to
a high level of parasitized erythrocytes.
• Rhabdomyolysis is another uncommon way of inducing renal
failure in malaria infection. The diagnosis is based on high
serum level of muscular enzymes; Creatine Phosphokinase
(CPK) and clinical symptoms like myalgias.
• To our knowledge, only limited cases of rhabdomyolysis
complicated by acute renal failure during malaria infection
have been described
Reynaud et al. Rhabdomyolysis and acute renal failure in Plasmodium falciparum malaria.
Nephrol Dial Transplant (2005) 20: 847–855
• Ischaemic acute tubular necrosis is by far the most
common cause of acute renal failure in P. Falciparum
malaria (quartan malaria). It is the result of (1)
hypovolaemia, (2) peripheral pooling of blood and (3)
blockage of microcirculation by parasitized red cells and (4)
non-specific effects of infection. In this case, none of these
mechanisms may explain the renal failure
• This patient had a severe rhabdomyolysis that may be the
actual reason of this acute renal failure. Many mechanisms
may induce these muscle damages.
• In this case, rhabdomyolysis could not be explained by usual
causes (hyperthermia, crush syndrome, metabolic
abnormality, drugs or other infectious diseases). Thereafter,
the responsibility of P. falciparum as the physiopathological
mechanism of the rhabdomyolysis was supposed.
Sitprija V. Nephropathy in Falciparum malaria. 1988
 Filariasis
• 3 type of filariasis: (1) Lymphatic filariasis (can be
caused by three species: W. Bancrofti, B. Timori, B.
Malayi); (2) river blindness (caused by Onchocerca
volvulus); (3) loiasis (caused by Loa loa)

• Glomerular disease on filariasis patients are thought

to be related with immune complex mediated
response.

• Association of filariasis with renal disease often

difficut to established due to frequent co-
infection (Hepatitis B and malaria)

Van Velthuysen & Florquin, 2000

 schistosomiasis
• Association with renal glomerular disease
revealed in 1970’s though it was one of
the oldest and most widely spread
helminth infection world wide
• 2 species known responsible as causes:
Schistosoma haematobium and S. Mansoni
• Infection occur through contact with
water containing the infective free-
swimming cercaria
 Schistosoma Glomerulopathy
• The pathophysiology of glomerular lesion in schistosomiasis
has some common characteristics with the lesion that occur
in other parasitic diseases, especially malaria.
• The glomerular lesion in schistosomiasis has combination of
direct invasion (S. Haematobium) and immunological nature
(S. Mansoni). Antigens from the parasite seem to be related to
glomerulopathy and have been found in the sera of humans
and animals infected by the S. mansoni.
• Antibodies directed against the parasite have also been found
in humans and animals with schistosomiasis, which seem to be
related to the development of glomerular injury.
• Among the isolated circulating antigens, those from the
digestive tract of the adult parasite are the most involved in
the pathogenesis of glomerulopathy
da Silva Junior et al. Schistosomiasis associated kidney disease.Asian Pac J Trop Dis 2013; 3(1): 79-84
 direct invasion + immune response..?
da Silva Junior et al. Schistosomiasis associated kidney disease.Asian Pac J Trop Dis 2013; 3(1): 79-84
the initial glomerular injury in human schistosomiasis is a mesangio-
proliferative glomerulonephritis mediated chiefly by worm (gut)
antigens, which have been detected as circulating antigen/s in infected
patients as well as in experimental animals. Specific antibodies of all major
immunoglobulin classes have also been detected in the sera of both humans
and experimental animals. Therefore, a glomerular inflammatory injury
which occurs as a consequence of glomerular immune-complex
deposition was suggested as the more probable mechanism of the
glomerulopathies detected in mansonian schistosomiasis.
 Leishmaniasis (~kala-azar)
• due to Leishmania donovani  visceral
leishmaniasis (other form of leishmaniasis,
cutaneous leishmaniasis NOT related with renal
disease
• Transmitted by the bites of sand flies of the
genera Phlebotomus and Luzomyia.
• 60% patients of kala-azar  mild-proteinuria
with benign change in the urinary sediment
(microscopic hematuria and leukocyturia)
• Pathological picture glomerulonephritis
 Hydatid Cyst of Urinary Tract
• Echinococcosis is an infection caused by the larval stage of a
tapeworm called Echinococcus.
• There are 3 species of Echinococcus that cause hydatid disease.
Echinococcus granulosus is the most common type, whereas E.
multilocularis and E. oligartus account for a small number of
cases.
• Dog is the definitive host of Echinococcus granulosus, Sheep is
the usual intermediate host, but humans are accidental
intermediate hosts.
• humans as an accidental intermediate hosts, got the infection
by ingested. In the human duodenum, the parasitic embryo
penetrates the mucosa, allowing access to the blood stream,
and enters the liver (most commonly) and the lungs.
Shostari et al. Urol J (Tehran) 2007; 4:41-5
 Hydatid Cyst of Urinary Tract....
• Clinical manifestations result from blood-borne invasion of the
liver (50% to 70%) and the lungs (20% to 30%). Most infected
individuals are asymptomatic and it might take 5 to 20 years for
a cyst to grow to its symptomatic size (3 cm to 15 cm).

Shostari et al. Urol J (Tehran) 2007; 4:41-5

 Hydatid Cyst of Urinary Tract
• The kidneys are the most commonly affected organs in the
urogenital tract (2% to 4%), although hydatid cyst of the
prostate, the seminal vesicles, and the testes have also been
reported. Echinococcal larvae may reach the kidney through the
blood stream or lymph nodes, and by direct invasion.
• Renal hydatidosis is a rare entity and the main challenge is
preoperative diagnosis. Radiological and serologic studies,
although indicative, cannot confirm the diagnosis, and only
pathologic examination after surgical removal can confirm
echinococcal infection

Shostari et al. Urol J (Tehran) 2007; 4:41-5

What do you think about this..?

www.uspharmacist.com
 Specialized population:
Severely ill (ICU patients) and
HIV infected patients
Biofilms & morphological plasticity: Candida spp
• Uropathogens use different mechanisms for survival in
response to stresses in the bladder (such as starvation
and immune responses).
• By forming biofilms and undergoing morphological
changes, uropathogens can persist and cause recurrent
infections
• Candida spp Candidiasis biofilms associated infection
(4th BSI and 3rd UTI) in the urinary catheter (incl.
Pacemakers, artificial heart valves, voice prostheses, CNS
shunt)
• Specialized populations, e.g ICU patients
Flores-Mireles et al. Nat Rev Microbiol. 2015
HIV and schistosomiasis co-infection in African children - thelancet.com
How to make a correct diagnose?
Brief anamnesis

Careful physical examination

Laboratory, Radiology or
other supporting
examination
 Parasitology Laboratory
Examination
• Correct diagnosis made by findings of
parasite in clinical specimen, in case of
suspected parasitic UTI means that at
least urine sample(s) were sent to our
lab to be examined
 Management...
• Species-specific (e.g Malaria anti-malaria,
Schistosomiasis & Filariasis anthelminthic)
• Made a correct diagnosis before starting to
prescribe medication
• By doing a comprehensive anamnesis, physical
examination and supporting examination (e.g
laboratory, radiographic, immunology, pathology)
• In case of suspected parasite infection, in order
to make a correct diagnosis finding the
parasite in clinical sample is obligatory/
mandatory!
 conclusion
Urinary Tract Disorders in Parasitic Infections
could be the results of :

The parasite The Host immune

(directly) response (indirectly)

Combo of no. 1 & no. 2

Thank you for your attention....
Any Questions..?