KDIGO stage 3 acute kidney injury in children with severe Plasmodium falciparum malaria including blackwater fever: a case series from a resource-limited setting in Southwest Ethiopia.

backgroundAcute kidney injury (AKI) is a frequent complication of severe Plasmodium falciparum malaria in children, and blackwater fever (BWF) can precipitate severe renal injury. Evidence on management when renal replacement therapy (RRT) is unavailable remains limited.

methodsWe describe four pediatric patients with confirmed P. falciparum malaria and KDIGO stage 3 AKI managed at Mizan-Tepi University Teaching Hospital (MTUTH), Southwest Ethiopia, between November and December 2025. Two cases met the operational definition of BWF, while two had severe malaria-associated AKI without documented hemoglobinuria. All met standard indications for RRT, which was not available. Management included intravenous artesunate, careful fluid titration, electrolyte correction, blood transfusion when indicated, and avoidance of nephrotoxic agents.

resultsPeak serum creatinine ranged from 10.77 to 17.23 mg/dL. Two of four patients (50%) achieved complete clinical and renal recovery. One patient had partial recovery, the remaining patient died after presenting with anuria, pulmonary edema, and multi-organ failure. In the two BWF cases, renal recovery was preceded by a prolonged oliguric phase followed by polyuric recovery and a biphasic potassium pattern from hyperkalemia to hypokalemia. One surviving patient was discharged with residual renal dysfunction and persistent proteinuria.

conclusionsIn this small case series from a resource-limited setting without dialysis, conservative management of severe malaria-associated KDIGO stage 3 AKI was associated with renal recovery in three of four children. These findings are hypothesis-generating and highlight the need for dialysis access, closer electrolyte monitoring, and prospective studies of phase-specific renal recovery in malaria-associated AKI.