Malaria-Related Kidney Failure Case Report Form
Report essential details of a malaria-related kidney failure case. Please complete all fields accurately.
Patient Age (in years)
*
Patient Gender
*
Male
Female
Other
Prefer not to say
Date of Case Presentation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Malaria Diagnosis
*
Plasmodium falciparum
Plasmodium vivax
Mixed infection
Other
Kidney Failure Diagnosis
*
Acute kidney injury (AKI)
Chronic kidney disease (CKD)
Other
Key Laboratory Findings
*
Summary of Treatment Provided
*
Outcome of the Case
*
Recovered
Ongoing treatment
Deceased
Unknown
Reporting Institution or Facility (do not include personal names)
*
Additional Notes (optional)
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