What is treatment of acute renal failure in malaria?

The treatment of ARF includes guidelines initiation of appropriate antimalarials, at the earliest, and maintenance of fluid and electrolytes: Recording of intake and output chart, prevention of fluid overload, and secondary infection including pneumonia. Appropriate treatment of acquired infection with antibiotics. To prevent fluid overload a central venous pressure (CVP) line can be established.

Fluid challenge: 1. If any patient is dehydrated, he should be given a fluid challenge of upto 20 ml/kg of 0.9% saline infused over 60 minutes. In order to prevent fluid overload, auscultation of lungs and jugular venous pressure (JVP) measurements (and if possible, CVP measurements) should be performed after every 200 ml of fluid. The CVP should always be kept between 0 and +5. If there is no urine output after fluid replacement, an intravenous diuretic challenge may be given.

2. Diuretic challenge: The loop diuretic (furosemide or bumetanide) 40 mg is given initially and then in incremental dose of 100, 200 and 400 mg at half–hourly intervals. If there is still no urine flow, dopamine 2.5–5 mg/kg/min may be tried. Antimalarials
1. Quinine, chloroquine and artemisinin are the mainstay of therapy. Even in the presence of pregnancy and acute renal failure (ARF), quinine should not be withheld for fear of toxicity. Quinine should be given in a dose of 10 mg/kg 8 hourly during the first 48 hours of treatment. However, when it needs to be given beyond this period, the dose should be reduced to two–thirds or one-half. The dose should not be reduced in the initial 48 hours.

2. Cardiotoxicity of quinine must be of concern in malaria patients with ARF after 3 days of quinine therapy, and ECG monitoring during quinine infusion is recommended in all severe malaria patients with persistent ARF. If there is any arrhythmia, the infusion should be discontinued.

Dialysis: Dialysis has improved the survival of the cases when instituted early in the course. Clearance of urea and other molecular waste products is much faster with hemodialysis as compared to peritoneal dialysis. However, peritoneal dialysis has certain advantages such as: Peritoneal dialysis does not need a special set up, it can be started immediately, it may prove to be life saving. Thus, in the absence of facilities for hemodialysis whenever indicated, peritoneal dialysis should be started as early as possible.
Other associated conditions requiring attention:

Hypervolemia
Hyperkalemia
Metabolic acidosis
Anemia
Infection