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Chaiyabutr N, Noiprom J, Promruangreang K, Vasaruchapong T, Laoungbua P, Khow O, Chanhome L, Sitprija V. Acute phase reactions in Daboia siamensis venom and fraction-induced acute kidney injury: the role of oxidative stress and inflammatory pathways in in vivo rabbit and ex vivo rabbit kidney models. J Venom Anim Toxins Incl Trop Dis 2024; 30:e20230070. [PMID: 38808074 PMCID: PMC11131233 DOI: 10.1590/1678-9199-jvatitd-2023-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 03/25/2024] [Indexed: 05/30/2024] Open
Abstract
Background This study examines the direct nephrotoxic effects of Daboia siamensis venom (RVV) and venom fractions in in vivo and isolated perfused kidneys (IPK) to understand the role of inflammation pathways and susceptibility to oxidative stress in venom or fraction-induced acute renal failure. Methods We administered RVV and its venom fractions (PLA2, MP, LAAO, and PDE) to rabbits in vivo and in the IPK model. We measured oxidative stress biomarkers (SOD, CAT, GSH, and MDA) in kidney tissue, as well as inflammatory cytokines (TNF-α, IL-1β, IFN-γ, IL-4, IL-5, and IL-10), MDA and GSH levels in plasma and urine. We also calculated fractional excretion (FE) for pro-/anti-inflammatory cytokines and oxidative stress biomarkers, including the ratios of pro-/anti-inflammatory cytokines in urine after envenomation. Results In both kidney models, significant increases in MDA, SOD, CAT, and GSH levels were observed in kidney tissues, along with elevated concentrations of MDA and GSH in plasma and urine after injecting RVV and venom fractions. Moreover, RVV injections led to progressive increases in FEMDA and decreases in FEGSH. The concentrations of IL-4, IL-5, IL-10, IFN-γ, and TNF-α in plasma increased in vivo, as well as in the urine of the IPK model, but not for IL-1β in both plasma and urine after RVV administrations. Urinary fractional excretion of TNF-α, IL-1β, IFN-γ, IL-4, IL-5, and IL-10 tended to decrease in vivo but showed elevated levels in the IPK model. A single RVV injection in vivo disrupted the balance of urinary cytokines, significantly reducing either the TNF-α/IL-10 ratio or the IFN-γ/IL-10 ratio. Conclusion RVV induces renal tubular toxicity by increasing oxidative stress production and elevating inflammatory cytokines in urine. During the acute phase of acute kidney injury, the balance of urine cytokines shifts toward anti-inflammatory dominance within the first two hours post-RVV and venom fractions.
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Affiliation(s)
- Narongsak Chaiyabutr
- Queen Saovabha Memorial Institute, The Thai Red Cross Society,
Pathumwan, Bangkok, Thailand
| | - Jureeporn Noiprom
- Department of Research and Development, Queen Saovabha Memorial
Institute, The Thai Red Cross Society, Bangkok, Thailand
| | - Kanyanat Promruangreang
- Department of Research and Development, Queen Saovabha Memorial
Institute, The Thai Red Cross Society, Bangkok, Thailand
| | - Taksa Vasaruchapong
- Snake Farm, Queen Saovabha Memorial Institute, The Thai Red Cross
Society, Bangkok, Thailand
| | - Panithi Laoungbua
- Snake Farm, Queen Saovabha Memorial Institute, The Thai Red Cross
Society, Bangkok, Thailand
| | - Orawan Khow
- Department of Research and Development, Queen Saovabha Memorial
Institute, The Thai Red Cross Society, Bangkok, Thailand
| | - Lawan Chanhome
- Snake Farm, Queen Saovabha Memorial Institute, The Thai Red Cross
Society, Bangkok, Thailand
| | - Visith Sitprija
- Queen Saovabha Memorial Institute, The Thai Red Cross Society,
Pathumwan, Bangkok, Thailand
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Hora PS, Nogueira Junior JRDJ, Couto RD, Campos LMDCC, Soares TDJ, Casais-E-Silva LL, Souza SID. Renal functional and structural alterations induced by intramuscular injection of Bothrops leucurus venom. Toxicon 2023; 234:107265. [PMID: 37673342 DOI: 10.1016/j.toxicon.2023.107265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 07/03/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023]
Abstract
Acute kidney injury (AKI) is the main cause of death from Bothrops snakebite. Although many studies have investigated the nephrotoxicity induced by other Bothrops species, no study has assessed the renal alterations induced by intramuscular (i.m.) injection of Bothrops leucurus venom. In this study, we evaluated the nephrotoxicity induced by B. leucurus venom by analyzing renal function and histology. Wistar rats were submitted to i. m. injection of B. leucurus venom or saline and divided into two groups: Control group (C), rats submitted to i. m. injections of saline, and B. leucurus group (Bl), rats submitted to i. m. injections of B. leucurus venom (1 mg/kg). After venom or saline injection, serum and urine were collected to measure creatinine, albumin, sodium, and potassium levels. The glomerular filtration rate (GFR), urinary flow urinary, creatinine/serum creatinine ratio, and albuminuria-urinary creatinine ratio were determined. All rats were euthanized 72 h following the injections, and the kidneys were removed for histology and immunohistochemical studies. B. leucurus experimental envenoming was accompanied by an increase of 236% in serum creatine kinase activity in the Bl group. The weights of the right and left kidneys were, respectively, 26 and 22% higher in rats of the Bl group than in control rats. Regarding renal function, the Bl group showed a decrease of 37% in GFR compared to control group. The rats of the Bl group also presented increased cortical (8.20 ± 1.35) and medullar (6.17 ± 2.00) tubulointerstitial lesion area when compared to control group (0.02 ± 0.00) (1.20 ± 0.73), respectively. The number of macrophages was also higher in the renal cortex (6.66 ± 0.06) and medulla (1.22 ± 0.10) of rats from the Bl group when compared to control rats (1.04 ± 0.55), (0.65 ± 0.10), respectively. Our results indicate that B. leucurus venom promoted significant histological and functional renal alterations following intramuscular inoculation, which simulates the majority of snakebites observed in the clinical practice.
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Affiliation(s)
- Paloma Santos Hora
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista, Bahia, 45029094, Brazil
| | | | - Ricardo David Couto
- Faculdade de Farmácia, Universidade Federal da Bahia, Salvador, Bahia, 40170115, Brazil
| | | | - Telma de Jesus Soares
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista, Bahia, 45029094, Brazil
| | | | - Samira Itana de Souza
- Instituto de Ciências da Saúde, Universidade Federal da Bahia, Salvador, Bahia, 40231300, Brazil.
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Neves JCF, Ibiapina HNS, Magalhães-Gama F, Sachett JAG, Silva IM, Coelho KF, Alves EC, Tarragô AM, de Lima Ferreira LC, Malheiro A, Monteiro WM, Costa AG. CCL-2 and CXCL-8: Potential Prognostic Biomarkers of Acute Kidney Injury after a Bothrops atrox Snakebite. Mediators Inflamm 2022; 2022:8285084. [PMID: 36117588 PMCID: PMC9473908 DOI: 10.1155/2022/8285084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/10/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022] Open
Abstract
In the Brazilian Amazon, the snake Bothrops atrox is the primary cause of snakebites. B. atrox (BaV) venom can cause systemic pathophysiological changes such as acute kidney injury (AKI), which leads to the production of chemokines and cytokines in response to the envenomation. These soluble immunological molecules act by modulating the inflammatory response; however, the mechanisms associated with the development of AKI are still poorly understood. Here, we characterize the profile of these soluble immunological molecules as possible predictive biomarkers of the development of AKI. The study involved 34 patients who had been victims of snakebites by Bothrops sp. These were categorized into two groups according to the development of AKI (AKI(-)/AKI(+)), using healthy donors as the control (HD). Peripheral blood samples were collected at three-time points: before antivenom administration (T0) and at 24 and 48 hours after antivenom (T1 and T2, respectively). The soluble immunological molecules (CXCL-8, CCL-5, CXCL-9, CCL-2, CXCL-10, IL-6, TNF, IL-2, IL-10, IFN-γ, IL-4, and IL-17A) were quantified using cytometric bead array. Our results demonstrated an increase in CXCL-9, CXCL-10, IL-6, IL-2, IL-10, and IL-17A molecules in the groups of patients who suffered Bothrops snakebites (AKI(-) and AKI(+)) before antivenom administration, when compared to HD. In the AKI(+) group, levels of CXCL-8 and CCL-2 molecules were elevated on admission and progressively decreased during the clinical evolution of patients after antivenom administration. In addition, in the signature analysis, these were produced exclusively by the group AKI(+) at T0. Thus, these chemokines may be related to the initiation and extension of AKI after envenomation by Bothrops and present themselves as two potential biomarkers of AKI at T0.
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Affiliation(s)
- Juliana Costa Ferreira Neves
- Post-graduate Program in Tropical Medicine, Amazonas State University (UEA), Manaus, AM, Brazil
- Carlos Borborema Clinical Research Institute, Tropical Medicine Foundation Doctor Heitor Vieira Dourado (FMT-HVD), Manaus, AM, Brazil
| | - Hiochelson Najibe Santos Ibiapina
- Post-graduate Program in Tropical Medicine, Amazonas State University (UEA), Manaus, AM, Brazil
- Carlos Borborema Clinical Research Institute, Tropical Medicine Foundation Doctor Heitor Vieira Dourado (FMT-HVD), Manaus, AM, Brazil
| | - Fábio Magalhães-Gama
- Post-Graduate Program in Basic and Applied Immunology, Federal University of Amazonas (UFAM), Manaus, AM, Brazil
- Post-Graduate Program in Health Sciences, René Rachou Institute, Oswaldo Cruz Foundation (FIOCRUZ-Minas), Minas Gerais, Belo Horizonte, Brazil
- Directorate of Teaching and Research, Hematology and Hemotherapy Foundation of Amazonas (HEMOAM), Manaus, AM, Brazil
| | - Jacqueline Almeida Gonçalves Sachett
- Post-graduate Program in Tropical Medicine, Amazonas State University (UEA), Manaus, AM, Brazil
- Carlos Borborema Clinical Research Institute, Tropical Medicine Foundation Doctor Heitor Vieira Dourado (FMT-HVD), Manaus, AM, Brazil
- Department of Education and Research, Alfredo da Matta Foundation (FUAM), Manaus, AM, Brazil
| | - Iran Mendonça Silva
- Carlos Borborema Clinical Research Institute, Tropical Medicine Foundation Doctor Heitor Vieira Dourado (FMT-HVD), Manaus, AM, Brazil
| | - Kerolaine Fonseca Coelho
- Post-graduate Program in Tropical Medicine, Amazonas State University (UEA), Manaus, AM, Brazil
- Carlos Borborema Clinical Research Institute, Tropical Medicine Foundation Doctor Heitor Vieira Dourado (FMT-HVD), Manaus, AM, Brazil
| | - Eliane Campos Alves
- Post-graduate Program in Tropical Medicine, Amazonas State University (UEA), Manaus, AM, Brazil
- Carlos Borborema Clinical Research Institute, Tropical Medicine Foundation Doctor Heitor Vieira Dourado (FMT-HVD), Manaus, AM, Brazil
| | - Andréa Monteiro Tarragô
- Post-Graduate Program in Basic and Applied Immunology, Federal University of Amazonas (UFAM), Manaus, AM, Brazil
- Directorate of Teaching and Research, Hematology and Hemotherapy Foundation of Amazonas (HEMOAM), Manaus, AM, Brazil
- Post-Graduate Program in Sciences Applied to Hematology, UEA, Manaus, AM, Brazil
| | - Luiz Carlos de Lima Ferreira
- Post-graduate Program in Tropical Medicine, Amazonas State University (UEA), Manaus, AM, Brazil
- Carlos Borborema Clinical Research Institute, Tropical Medicine Foundation Doctor Heitor Vieira Dourado (FMT-HVD), Manaus, AM, Brazil
| | - Adriana Malheiro
- Post-graduate Program in Tropical Medicine, Amazonas State University (UEA), Manaus, AM, Brazil
- Post-Graduate Program in Basic and Applied Immunology, Federal University of Amazonas (UFAM), Manaus, AM, Brazil
- Directorate of Teaching and Research, Hematology and Hemotherapy Foundation of Amazonas (HEMOAM), Manaus, AM, Brazil
- Post-Graduate Program in Sciences Applied to Hematology, UEA, Manaus, AM, Brazil
| | - Wuelton Marcelo Monteiro
- Post-graduate Program in Tropical Medicine, Amazonas State University (UEA), Manaus, AM, Brazil
- Carlos Borborema Clinical Research Institute, Tropical Medicine Foundation Doctor Heitor Vieira Dourado (FMT-HVD), Manaus, AM, Brazil
| | - Allyson Guimarães Costa
- Post-graduate Program in Tropical Medicine, Amazonas State University (UEA), Manaus, AM, Brazil
- Carlos Borborema Clinical Research Institute, Tropical Medicine Foundation Doctor Heitor Vieira Dourado (FMT-HVD), Manaus, AM, Brazil
- Post-Graduate Program in Basic and Applied Immunology, Federal University of Amazonas (UFAM), Manaus, AM, Brazil
- Post-Graduate Program in Health Sciences, René Rachou Institute, Oswaldo Cruz Foundation (FIOCRUZ-Minas), Minas Gerais, Belo Horizonte, Brazil
- Directorate of Teaching and Research, Hematology and Hemotherapy Foundation of Amazonas (HEMOAM), Manaus, AM, Brazil
- Post-Graduate Program in Sciences Applied to Hematology, UEA, Manaus, AM, Brazil
- Nursing School of Manaus, UFAM, Manaus, AM, Brazil
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Silva DPD, Ferreira SDS, Torres-Rêgo M, Furtado AA, Yamashita FDO, Diniz EADS, Vieira DS, Ururahy MAG, Silva-Júnior AAD, Luna KPDO, Fernandes-Pedrosa MDF. Antiophidic potential of chlorogenic acid and rosmarinic acid against Bothrops leucurus snake venom. Biomed Pharmacother 2022; 148:112766. [PMID: 35247716 DOI: 10.1016/j.biopha.2022.112766] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/21/2022] [Accepted: 02/27/2022] [Indexed: 12/22/2022] Open
Abstract
Bothrops leucurus is responsible for most cases of snakebite in Northeast Brazil; however, this species is not included in the pool of venoms used in antivenom production in Brazil. The serotherapy has logistical and effectiveness limitations, which stimulates the search for therapeutic alternatives. Chlorogenic acid and rosmarinic acid present several biological activities, but their antiophidic potential has been poorly explored. Thus, the aim of this approach was to evaluate the potential inhibitory effects of these compounds on B. leucurus venom. Initially, the enzymatic inhibition of toxins was evaluated in vitro. Then, anti-hemorrhagic, anti-myotoxic, and anti-edematogenic assays were performed in vivo, as well analysis of several biochemical markers and hemostatic parameters. In addition, the interaction of inhibitors with SVMP and PLA2 was investigated by docking analysis. Results revealed that compounds inhibited in vitro the enzymatic activities and venom-induced edema, with a decrease in both myeloperoxidase and interleukin quantification. The inhibitors also attenuated the hemorrhagic and myotoxic actions and mitigated changes in serum biochemical and hemostatic markers, as well as decreased lipid peroxidation in liver and kidney tissues. Docking analysis revealed attractive interactions of both inhibitors with the zinc-binding site of SVMP and, in the case of PLA2, chlorogenic acid showed a similar inhibition mechanism to that described for rosmarinic acid. The results evidenced the antiophidic potential of both compounds, which showed higher efficiency than antivenom serum. Thus, both inhibitors are promising candidates for future adjuvants to be used to complement antivenom serotherapy.
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Affiliation(s)
- Diana Pontes da Silva
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
| | - Sarah de Sousa Ferreira
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
| | - Manoela Torres-Rêgo
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil; Chemistry Institute, Federal University of Rio Grande do Norte, Avenue Senador Salgado Filho, 3000, Lagoa Nova, Natal 59072-970, Brazil.
| | - Allanny Alves Furtado
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
| | - Fabiana de Oliveira Yamashita
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
| | - Eduardo Augusto da Silva Diniz
- Chemistry Institute, Federal University of Rio Grande do Norte, Avenue Senador Salgado Filho, 3000, Lagoa Nova, Natal 59072-970, Brazil.
| | - Davi Serradella Vieira
- Chemistry Institute, Federal University of Rio Grande do Norte, Avenue Senador Salgado Filho, 3000, Lagoa Nova, Natal 59072-970, Brazil.
| | - Marcela Abbott Galvão Ururahy
- Biochemistry Laboratory, Department of Clinical Analysis and Toxicological, College of Pharmacy, Federal University of Rio Grande do Norte, Rua General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
| | - Arnóbio Antônio da Silva-Júnior
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
| | - Karla Patrícia de Oliveira Luna
- Center of Biological and Health Sciences, State University of Paraíba, Avenue Baraúnas, S/N, Bodocongó, Campina Grande 58429-500, Brazil.
| | - Matheus de Freitas Fernandes-Pedrosa
- Laboratory of Technology and Pharmaceutical Biotechnology (Tecbiofar), College of Pharmacy, Federal University of Rio Grande do Norte, Avenue General Gustavo Cordeiro de Farias, S/N, Petrópolis, Natal 59012-570, Brazil.
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Sanhajariya S, Duffull SB, Isbister GK. Population pharmacokinetics of Pseudechis porphyriacus (red-bellied black snake) venom in snakebite patients. Clin Toxicol (Phila) 2021; 59:956-962. [PMID: 33832399 DOI: 10.1080/15563650.2021.1896731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Understanding the time course of venom exposure in snakebite patients is important for the optimisation of treatment including antivenom dose and timing. We aimed to investigate the pharmacokinetics of red-bellied black snake (RBBS; Pseudechis porphyriacus) venom in envenomed patients. METHODS Timed venom concentration data were obtained from patients with RBBS envenomation recruited to the Australian Snakebite Project (ASP), including demographics and antivenom treatment. Venom concentrations were measured using an enzyme immunoassay. Data were modelled using NONMEM version 7.3. Uncertainty in venom "dose" was accounted for by arbitrarily fixing the average amount to 1 mg and incorporating between-subject variability on relative bioavailability. A scale parameter for venom clearance was implemented to account for the rapid venom clearance following antivenom dosing. A sensitivity analysis was performed to determine the magnitude of venom clearance amplification. RESULTS There were 457 venom concentrations in 114 patients (median age 41, 2-90 y; 80 male). Antivenom was administered to 54 patients a median of 4.2 h post-bite (0.67 to 32 h). A one-compartment model with first-order absorption and elimination provided the best description of the data. The estimated clearance and volume of distribution were 5.21 L/h and 39.9 L, respectively. The calculated elimination half-life of P. porphyriacus venom from the final pharmacokinetic model was 5.35 ± 0.36 h. The variability in the relative dose of injected venom was 140%. Antivenom administration increased venom clearance by 40-fold. Ten patients showed evidence of a double peak in the absorption profile. CONCLUSION The information on the exposure time of venom in the body following envenomation will help improve treatment and the timing of antivenom.
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Affiliation(s)
- Suchaya Sanhajariya
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia.,Otago Pharmacometrics Group, School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Stephen B Duffull
- Otago Pharmacometrics Group, School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
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Albuquerque PLMM, Paiva JHHGL, Martins AMC, Meneses GC, da Silva GB, Buckley N, Daher EDF. Clinical assessment and pathophysiology of Bothrops venom-related acute kidney injury: a scoping review. J Venom Anim Toxins Incl Trop Dis 2020; 26:e20190076. [PMID: 32704246 PMCID: PMC7359628 DOI: 10.1590/1678-9199-jvatitd-2019-0076] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/10/2020] [Indexed: 12/14/2022] Open
Abstract
Bothrops are one of the most common medically important snakes found in Latin America. Its venom is predominantly hemotoxic and proteolytic, which means that local lesion (edema and redness) and hemorrhagic symptoms are recurrent in envenoming by this snake. Although hemorrhage is usually the major cause of death, snakebite-related acute kidney injury is another potentially fatal clinical complication that may lead to chronic kidney disease. The present review highlights the main studies on Bothrops venom-related acute kidney injury, including observational, cross-sectional, case-control and cohort human studies available up to December 2019. The following descriptors were used according to Medical Subject Headings (MeSH): on Medline/Pubmed and Google Scholar "acute kidney injury" or "kidney disease" and "Bothrops"; on Lilacs and SciELO "kidney disease" or "acute kidney injury" and "Bothrops". Newcastle-Ottawa quality assessment scale was used to appraise the quality of the cross-sectional and cohort studies included. The selection of more severe patients who looked for health care units and tertiary centers is a risk of bias. Due to the methodological heterogeneity of the studies, a critical analysis of the results was performed based on the hypothesis that the design of the included studies influences the incidence of acute kidney injury. Fifteen human studies (total participants 4624) were included according to stablished criteria. The coagulation abnormalities (hemorrhagic symptoms, abnormal fibrinogen and activated partial thromboplastin time) were associated with acute kidney injury in the most recent studies reported. The findings observed in this review provide up-to-date evidence about the acute kidney injury pathogenesis following Bothrops syndrome. Studies pointed out that coagulation abnormalities comprise the major pathway for acute kidney injury development. This review may improve patient management by primary healthcare providers, allowing earlier diagnosis and treatment of Bothrops venom-related acute kidney injury.
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Affiliation(s)
- Polianna Lemos Moura Moreira Albuquerque
- University of Fortaleza (Unifor), Fortaleza, Ceará, Brazil
- Toxicological Information and Assistance Center, Instituto Doutor Jose Frota Hospital, Fortaleza, Ceará, Brazil
| | | | - Alice Maria Costa Martins
- Graduate Program in Pharmaceutical Sciences, Federal University of Ceará (UFC), Fortaleza, Ceará, Brazil
| | | | - Geraldo Bezerra da Silva
- Public Health and Medical Sciences Graduate Programs, School of Medicine, University of Fortaleza, Fortaleza, Ceará, Brazil
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The Influence of the Different Disposition Characteristics of Snake Toxins on the Pharmacokinetics of Snake Venom. Toxins (Basel) 2020; 12:toxins12030188. [PMID: 32188075 PMCID: PMC7150903 DOI: 10.3390/toxins12030188] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/12/2020] [Accepted: 03/14/2020] [Indexed: 12/04/2022] Open
Abstract
Snake venom is comprised of a combination of different proteins and peptides with a wide range of molecular weights and different disposition processes inherent to each compound. This causes venom to have a complex exposure profile. Our study investigates 1) how each molecular weight fraction (toxin) of venom contributes to the overall time course of the snake venom, and 2) the ability to determine toxin profiles based on the profile of the overall venom only. We undertook an in silico simulation and modelling study. Sixteen variations of venom, comprising of two to nine toxins with different molecular weights were investigated. The pharmacokinetic parameters (i.e., clearance, CL, and volume of distribution, V) of each toxin were generated based on a log-linear relationship with molecular weight. The concentration–time data of each toxin were simulated for 100 virtual patients using MATLAB and the total concentration–time data of each toxin were modelled using NONMEM. We found that the data of sixteen mixtures were best described by either two- or three-compartment models, despite the venom being made up of more than three different toxins. This suggests that it is generally not possible to determine individual toxin profiles based on measurements of total venom concentrations only.
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8
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Júnior FAN, Jorge ARC, Marinho AD, Silveira JADM, Alves NTQ, Costa PHS, E Silva PLB, Chaves-Filho AJM, Lima DB, Sampaio TL, Morais GBD, Evangelista JSAM, Martins AMC, Júnior RSF, Macedo DS, Jorge RJB, Monteiro HSA. Bothrops alternatus Snake Venom Induces Cytokine Expression and Oxidative Stress on Renal Function. Curr Top Med Chem 2019; 19:2058-2068. [PMID: 31400266 DOI: 10.2174/1568026619666190809100319] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/21/2019] [Accepted: 06/05/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Envenomation caused by Bothrops alternatus is common in Southern Brazil. Acute Kidney Injury occurs after Bothrops snakebite and more information is necessaryrequired to understand its mechanism. OBJECTIVE The objective was to evaluate the effect of Bothrops alternatus venom (BaV) on renal cells and rat isolated kidney function. METHODS Wistar rats (n = 6, weighing 260-320 g) were perfused with a Krebs-Henseleit solution containing 6 g 100 mL-1 of bovine serum albumin. After 30 minutes, the kidneys were perfused with BaV to a final concentration of 1 and 3 μgmL-1; and subsequently were evaluated for Perfusion Pressure (PP), Renal Vascular Resistance (RVR), Urinary Flow (UF), Glomerular Filtration Rate (GFR), and percentage of electrolyte tubular transport. Renal histological analysis, cytokine release, oxidative stress and cytotoxicity in renal proximal tubular cells were assessed. RESULTS BaV reduced PP, RVR, GFR, UF, total and proximal sodium transport (%TNa+), and chloride (%TCl-) in the isolated kidney perfusion model. Histological analysis of perfused kidneys disclosed the presence of proteinaceous material in the glomeruli and renal tubules, vacuolar tubular epithelial cell degeneration, Bowman's capsule degeneration, swelling of glomerular epithelial cells, glomerular atrophy and degeneration, and the presence of intratubular protein. Cytokine release (TNF-α, IL-1β, IL-10) and oxidative stress were increased in the kidneys. The viability of LLC-MK2 cells (IC50: 221.3 μg/mL) was decreased by BaV and necrosis was involved in cell death. CONCLUSION These findings indicate that BaV modifies functional parameters in an isolated perfused kidney model and has cytotoxic effects on renal lineage cells.
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Affiliation(s)
- F A Nogueira Júnior
- Department of Physiology and Pharmacology, Faculdade de Medicina, Universidade Federal do Ceará, 60430-270, Fortaleza, Ceará, Brazil
| | - A R Coelho Jorge
- Department of Physiology and Pharmacology, Faculdade de Medicina, Universidade Federal do Ceará, 60430-270, Fortaleza, Ceará, Brazil
| | - A D Marinho
- Department of Physiology and Pharmacology, Faculdade de Medicina, Universidade Federal do Ceará, 60430-270, Fortaleza, Ceará, Brazil
| | - J A de Moraes Silveira
- Department of Physiology and Pharmacology, Faculdade de Medicina, Universidade Federal do Ceará, 60430-270, Fortaleza, Ceará, Brazil
| | - N T Queiroz Alves
- Department of Physiology and Pharmacology, Faculdade de Medicina, Universidade Federal do Ceará, 60430-270, Fortaleza, Ceará, Brazil
| | - P H Sá Costa
- Department of Physiology and Pharmacology, Faculdade de Medicina, Universidade Federal do Ceará, 60430-270, Fortaleza, Ceará, Brazil
| | - P L Braga E Silva
- Department of Physiology and Pharmacology, Faculdade de Medicina, Universidade Federal do Ceará, 60430-270, Fortaleza, Ceará, Brazil
| | - A J Maia Chaves-Filho
- Department of Physiology and Pharmacology, Faculdade de Medicina, Universidade Federal do Ceará, 60430-270, Fortaleza, Ceará, Brazil
| | - D B Lima
- Department of Clinical and Toxicological Analyses, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - T L Sampaio
- Department of Clinical and Toxicological Analyses, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - G B de Morais
- Faculdade de Medicina Veterinária. Universidade Estadual do Ceará, Fortaleza, Ceará, Brazil
| | | | - A M Costa Martins
- Department of Clinical and Toxicological Analyses, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - R S Ferreira Júnior
- Centro de Estudos de Venenos e Animais Peçonhentos - CEVAP, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - D S Macedo
- Department of Physiology and Pharmacology, Faculdade de Medicina, Universidade Federal do Ceará, 60430-270, Fortaleza, Ceará, Brazil
| | - R J Bezerra Jorge
- Department of Physiology and Pharmacology, Faculdade de Medicina, Universidade Federal do Ceará, 60430-270, Fortaleza, Ceará, Brazil
| | - H S Azul Monteiro
- Department of Physiology and Pharmacology, Faculdade de Medicina, Universidade Federal do Ceará, 60430-270, Fortaleza, Ceará, Brazil
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9
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Machado M, Wilson TM, Ribeiro de Sousa DE, Lopes Câmara AC, Furlan FH, Silva Almeida E Macêdo JT, Pupin RC, Amaral de Lemos RA, Armién AG, Barros SS, Riet-Correa F, Botelho de Castro M. Fatal lancehead pit viper (Bothrops spp.) envenomation in horses. Toxicon 2019; 170:41-50. [PMID: 31499078 DOI: 10.1016/j.toxicon.2019.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/16/2019] [Accepted: 09/01/2019] [Indexed: 11/26/2022]
Abstract
Snake bite envenomations in farm animals are generally overestimated as the cause of mortality in rural areas in Latin America. However, most cases are based only on anecdotal information and assumptions, and lack diagnostic evidence. There are few proven reports of envenomation and death in horses caused by snakebites from members of the Bothrops genus (lancehead pit vipers). This study presents epidemiological and clinical-pathological findings of fatal bothropic envenomation in horses from Central Western Brazil in order to contribute to the correct diagnosis of this condition. A survey of the records of equine necropsies from the Veterinary Pathology Laboratories of the University of Brasilia, Federal University of Mato Grosso and Federal University of Mato Grosso do Sul, from January 2010 to February 2018, was performed. Five fatal cases of bothropic snakebite were identified in 755 necropsies of horses, corresponding to 0.66% of these cases, ranging annually from 0.33% to 0.89%. The main necropsy findings were marked swelling and diffuse subcutaneous hemorrhage, and identification of the fang marks in 2 out of five horses. Hemorrhage in most organs and tissues was the pathological hallmark of systemic envenomation. Myonecrosis, dermonecrosis, and moderate to severe kidney degeneration and necrosis were also observed. Fatal Bothrops snakebites in horses have a low occurrence in Central Western Brazil and most cases occur in the rainy season. The diagnosis of this condition may be substantiated by clinical signs and pathological findings. Local hemorrhage and necrosis, systemic hemorrhagic disorders and injuries related to acute kidney injury are the predominant clinical signs. These findings should be considered in the diagnosis and therapeutic management of these envenomations.
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Affiliation(s)
- Mizael Machado
- Veterinary Pathology Laboratory, Veterinary Teaching Hospital, Via L4 Norte, sn/, Universidade de Brasília (UnB), Campus Universitário Darcy Ribeiro, 70636-200, Brasília, Distrito Federal, Brazil
| | - Tais Meziara Wilson
- Veterinary Pathology Laboratory, Veterinary Teaching Hospital, Via L4 Norte, sn/, Universidade de Brasília (UnB), Campus Universitário Darcy Ribeiro, 70636-200, Brasília, Distrito Federal, Brazil
| | - Davi Emanuel Ribeiro de Sousa
- Veterinary Pathology Laboratory, Veterinary Teaching Hospital, Via L4 Norte, sn/, Universidade de Brasília (UnB), Campus Universitário Darcy Ribeiro, 70636-200, Brasília, Distrito Federal, Brazil
| | - Antônio Carlos Lopes Câmara
- Large Animal Veterinary Teaching Hospital, Universidade de Brasília (UnB), SIT PqEAT, Granja do Torto, 70297-400, Brasília, Distrito Federal, Brazil
| | - Fernando Henrique Furlan
- Veterinary Pathology Laboratory, Veterinary Teaching Hospital Universidade Federal de Mato Grosso (UFMT), Av. Fernando Corrêa da Costa 2367, Boa Esperança, 78060-900, Cuiabá, Mato Grosso, Brazil
| | - Juliana Targino Silva Almeida E Macêdo
- Veterinary Pathology Laboratory, Veterinary Teaching Hospital, Via L4 Norte, sn/, Universidade de Brasília (UnB), Campus Universitário Darcy Ribeiro, 70636-200, Brasília, Distrito Federal, Brazil
| | - Rayane Chitolina Pupin
- College of Veterinary Medicine and Animal Science, Universidade Federal de Mato Grosso do Sul (UFMS), Av. Senador Filinto Müller 2443, 79074-460, Campo Grande, Mato Grosso do Sul, Brazil
| | - Ricardo Antônio Amaral de Lemos
- College of Veterinary Medicine and Animal Science, Universidade Federal de Mato Grosso do Sul (UFMS), Av. Senador Filinto Müller 2443, 79074-460, Campo Grande, Mato Grosso do Sul, Brazil
| | - Anibal G Armién
- Ultrastructural Pathology Unit, Veterinary Diagnostic Laboratory, University of Minnesota, 1333 Gortner Ave, MN 55108, St. Paul, MN, USA
| | - Severo Sales Barros
- Department of Pathology, Veterinary Faculty, Federal University of Pelotas, Campus Capão do Leão, 96010-900, Pelotas, Rio Grande do Sul, Brazil
| | - Franklin Riet-Correa
- Instituto Nacional de Investigación Agropecuaria (INIA), Estación Experimental INIA La Estanzuela, Ruta 50 Km 11, Colonia del Sacramento, Colonia, Uruguay
| | - Márcio Botelho de Castro
- Veterinary Pathology Laboratory, Veterinary Teaching Hospital, Via L4 Norte, sn/, Universidade de Brasília (UnB), Campus Universitário Darcy Ribeiro, 70636-200, Brasília, Distrito Federal, Brazil.
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10
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Costa KCT, de Sousa BB, Dias EHV, Pereira DFDC, Matias MS, Oliveira WJ, Mundim AV, Mamede CCN, Izidoro LFM, Costa JDO, de Oliveira F. Systemic alterations induced by phospholipase A 2 , BmooTX-I, isolated from Bothrops moojeni snake venom. Int J Exp Pathol 2018; 99:226-235. [PMID: 30456925 DOI: 10.1111/iep.12290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 02/21/2018] [Accepted: 08/13/2018] [Indexed: 01/09/2023] Open
Abstract
Ophidic accidents are among the problems of public health in Brazil. The components from bothropic venom are responsible for many systemic clinical complications resulting from envenomation. The present work aimed to analyse the systemic changes induced in mice after intraperitoneal administration of BmooTX-I, a myotoxic acidic phospholipase A2 isolated from Bothrops moojeni venom. Urinalysis was performed and the following plasma biochemical markers were documented: urea, creatinine and uric acid (renal function); glucose and amylase (pancreatic function); alanine aminotransferase, alkaline phosphatase and gamma-GT (intra- and extrahepatic function); creatine kinase and enzymatic lactate (muscle function). Our results showed that after the intraperitoneal injection of BmooTX-I the urine of these animals showed glycosuria, proteinuria, haematuria, bacteriuria, bilirubinuria, polyuria and nitrite. The plasma biochemical analysis showed alterations in levels of urea, creatinine and uric acid. Amylase concentration was not altered significantly, but the plasma glucose increased significantly compared to controls. The plasma levels of alanine aminotransferase and alkaline phosphatase decreased and increased, respectively, in these same animals. On the other hand, the plasma γGT concentration did not undergo significant modification compared to the control group. The plasma concentration of CK increased, while the enzymatic lactate concentration decreased after the injection of the BmooTX-I. Therefore, in mice BmooTX-I is capable of causing systemic alterations which manifest as renal, muscular, hepatic and pancreatic impairment.
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Affiliation(s)
- Kellen Cristina Torres Costa
- Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil.,Instituto de Genética e Bioquímica, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil
| | - Bruna Barbosa de Sousa
- Instituto de Genética e Bioquímica, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil.,Instituto Nacional de Ciência e Tecnologia em Nano-Biofarmacêutica (N-Biofar), Belo Horizonte, MG, Brazil
| | | | | | - Mariana Santos Matias
- Instituto de Genética e Bioquímica, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil
| | - Wilson Júnior Oliveira
- Faculdade de Medicina Veterinária, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil
| | - Antônio Vicente Mundim
- Faculdade de Medicina Veterinária, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil
| | - Carla Cristine Neves Mamede
- Instituto Nacional de Ciência e Tecnologia em Nano-Biofarmacêutica (N-Biofar), Belo Horizonte, MG, Brazil.,Instituto de Ciências Agrárias, Universidade Federal de Uberlândia, Monte Carmelo, MG, Brazil
| | | | - Júnia de Oliveira Costa
- Instituto Federal de Educação, Ciência e Tecnologia do Triângulo Mineiro, Campus Ituiutaba, Ituiutaba, MG, Brazil
| | - Fábio de Oliveira
- Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil.,Instituto Nacional de Ciência e Tecnologia em Nano-Biofarmacêutica (N-Biofar), Belo Horizonte, MG, Brazil
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11
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Pharmacokinetics of Snake Venom. Toxins (Basel) 2018; 10:toxins10020073. [PMID: 29414889 PMCID: PMC5848174 DOI: 10.3390/toxins10020073] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 01/31/2018] [Accepted: 02/03/2018] [Indexed: 12/01/2022] Open
Abstract
Understanding snake venom pharmacokinetics is essential for developing risk assessment strategies and determining the optimal dose and timing of antivenom required to bind all venom in snakebite patients. This review aims to explore the current knowledge of snake venom pharmacokinetics in animals and humans. Literature searches were conducted using EMBASE (1974–present) and Medline (1946–present). For animals, 12 out of 520 initially identified studies met the inclusion criteria. In general, the disposition of snake venom was described by a two-compartment model consisting of a rapid distribution phase and a slow elimination phase, with half-lives of 5 to 48 min and 0.8 to 28 h, respectively, following rapid intravenous injection of the venoms or toxins. When the venoms or toxins were administered intramuscularly or subcutaneously, an initial absorption phase and slow elimination phase were observed. The bioavailability of venoms or toxins ranged from 4 to 81.5% following intramuscular administration and 60% following subcutaneous administration. The volume of distribution and the clearance varied between snake species. For humans, 24 out of 666 initially identified publications contained sufficient information and timed venom concentrations in the absence of antivenom therapy for data extraction. The data were extracted and modelled in NONMEM. A one-compartment model provided the best fit, with an elimination half-life of 9.71 ± 1.29 h. It is intended that the quantitative information provided in this review will provide a useful basis for future studies that address the pharmacokinetics of snakebite in humans.
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12
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Kuniyoshi AK, Kodama RT, Moraes LHF, Duzzi B, Iwai LK, Lima IF, Cajado-Carvalho D, Portaro FV. In vitro cleavage of bioactive peptides by peptidases from Bothrops jararaca venom and its neutralization by bothropic antivenom produced by Butantan Institute: Major contribution of serine peptidases. Toxicon 2017; 137:114-119. [DOI: 10.1016/j.toxicon.2017.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/19/2017] [Accepted: 07/20/2017] [Indexed: 11/24/2022]
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13
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Means R, Cabrera J, Moreno X, Amini R. Remote South American Snakebite with Extensive Myonecrosis. Clin Pract Cases Emerg Med 2017; 1:47-49. [PMID: 29849429 PMCID: PMC5965440 DOI: 10.5811/cpcem.2016.11.31220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 11/19/2016] [Accepted: 11/28/2016] [Indexed: 11/11/2022] Open
Abstract
This report describes a patient envenomated by a Bothrops atrox, common fer-de-lance viper, in the remote rainforest of eastern Ecuador and without access to definitive care for seven days. Antivenom was not administered; by the time of presentation to a hospital, he had suffered myonecrosis of his lower leg, which was treated with debridement and eventual skin graft. The ramifications of this long evacuation demonstrate the need for more accessible health services and educational outreach.
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Affiliation(s)
- Russel Means
- University of Arizona, Department of Emergency Medicine, Tucson, Arizona
| | | | - Xavier Moreno
- Macas General Hospital, Department of Emergency Medicine, Macas, Ecuador
| | - Richard Amini
- University of Arizona, Department of Emergency Medicine, Tucson, Arizona
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14
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Burdmann EA, Jha V. Acute kidney injury due to tropical infectious diseases and animal venoms: a tale of 2 continents. Kidney Int 2017; 91:1033-1046. [PMID: 28088326 DOI: 10.1016/j.kint.2016.09.051] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 09/10/2016] [Accepted: 09/28/2016] [Indexed: 12/20/2022]
Abstract
South and Southeast Asia and Latin American together comprise 46 countries and are home to approximately 40% of the world population. The sociopolitical and economic heterogeneity, tropical climate, and malady transitions characteristic of the region strongly influence disease behavior and health care delivery. Acute kidney injury epidemiology mirrors these inequalities. In addition to hospital-acquired acute kidney injury in tertiary care centers, these countries face a large preventable burden of community-acquired acute kidney injury secondary to tropical infectious diseases or animal venoms, affecting previously healthy young individuals. This article reviews the epidemiology, clinical picture, prevention, risk factors, and pathophysiology of acute kidney injury associated with tropical diseases (malaria, dengue, leptospirosis, scrub typhus, and yellow fever) and animal venom (snakes, bees, caterpillars, spiders, and scorpions) in tropical regions of Asia and Latin America, and discusses the potential future challenges due to emerging issues.
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Affiliation(s)
- Emmanuel A Burdmann
- LIM 12, Division of Nephrology, University of São Paulo Medical School, São Paulo, Brazil.
| | - Vivekanand Jha
- George Institute for Global Health, New Delhi, India, and University of Oxford, Oxford, UK
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15
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Dias L, Rodrigues MA, Rennó AL, Stroka A, Inoue BR, Panunto PC, Melgarejo AR, Hyslop S. Hemodynamic responses to Lachesis muta (South American bushmaster) snake venom in anesthetized rats. Toxicon 2016; 123:1-14. [DOI: 10.1016/j.toxicon.2016.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 10/01/2016] [Accepted: 10/04/2016] [Indexed: 11/25/2022]
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16
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SILVA NATHALIAA, ALBUQUERQUE CLEIDEM, MARINHO ALINED, JORGE ROBERTAJ, SILVA NETO ANTONIOG, MONTEIRO HELENAS, SILVA TÚLIOD, SILVA MÁRCIAV, CORREIA MARIATEREZAS, PEREIRA TICIANAP, MARTINS ALICEM, MENEZES DALGIMARB, XIMENES RAFAELM, MARTINS RENÉD. Effects of Tityus stigmurus (Thorell 1876) (Scorpiones: Buthidae) venom in isolated perfused rat kidneys. ACTA ACUST UNITED AC 2016; 88 Suppl 1:665-75. [DOI: 10.1590/0001-3765201620150253] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/24/2015] [Indexed: 11/22/2022]
Abstract
ABSTRACT Scorpions belonging to the Tityus genus are of medical interest in Brazil. Among them, Tityus stigmurus is the main scorpion responsible for stings in the Northeast region. After a sting, the scorpion venom distributes rapidly to the organs, reaching the kidneys quickly. However, there are few studies concerning the renal pathophysiology of scorpion poisoning. In this study, we evaluated the effects of T. stigmurus venom (TsV) on renal parameters in isolated rat kidneys. Wistar rats (n = 6), weighing 250-300 g, were perfused with Krebs-Henseleit solution containing 6 g/100 mL bovine serum albumin. TsV at 0.3 and 1.0 μg/mL was tested, and the effects on perfusion pressure (PP), renal vascular resistance (RVR), urinary flow (UF), glomerular filtration rate (GFR), and electrolyte excretion were analyzed. Effects were observed only at TsV concentration of 1.0 μg/mL, which increased PP (controlPP40' = 92.7 ± 1.95; TsVPP40' = 182.0 ± 4.70* mmHg, *p < 0.05), RVR (controlRVR40' = 3.28 ± 0.23 mmHg; TstRVR40' = 6.76 ± 0.45* mmHg, *p < 0.05), UF (controlUF50' = 0.16 ± 0.04; TstUF50' = 0.60 ± 0.10* mL/g/min,*p < 0.05), GFR and electrolyte excretion, with histological changes that indicate renal tubular injury. In conclusion, T. stigmurus venom induces a transient increase in PP with tubular injury, both of which lead to an augmented electrolyte excretion.
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17
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Behavioral, histopathological and biochemical impairments observed in mice envenomed by the scorpion: Hottentota gentili (Pallary, 1924). Toxicon 2015; 103:19-29. [DOI: 10.1016/j.toxicon.2015.06.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/21/2015] [Accepted: 06/08/2015] [Indexed: 11/17/2022]
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18
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Pharmacokinetics of Cryptelytrops purpureomaculatus (mangrove pit viper) venom following intravenous and intramuscular injections in rabbits. Int Immunopharmacol 2014; 17:997-1001. [PMID: 24455773 DOI: 10.1016/j.intimp.2013.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The pharmacokinetic profiles of Cryptelytrops purpureomaculatus (mangrove pit viper) venom following intravenous and intramuscular injections were investigated in rabbits. The serum levels of the venom were estimated using double-sandwich enzyme-linked immunosorbent assay (ELISA). After intravenous injection (0.2 mg/kg), the serum venom concentration–time course declined in a biexponential manner, consistent with a two-compartment model, with an α-phase half-life of 0.25 h and a β-phase half-life of 27.7 h. The volume of distribution by area was 2.19 L/kg and systemic clearance was 54.7 mL/h/kg. When the venom was injected intramuscularly (0.5 mg/kg), the serum level increased rapidly to reach a peak (500 ng/mL) at about 1 h, which then declined rapidly to a plateau (104–142 ng/mL) at 3–10 h before further gradual decline until the end of the 72-hour study. The terminal half-life (27.0 h), clearance (54.7 mL/h/kg) and volume of distribution (2.13 L/kg) of the venom for intramuscular route were not significantly different from the corresponding values for intravenous route, and the intramuscular bioavailability of the venom was estimated to be 41.6%.
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19
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Rodrigues MA, Dias L, Rennó AL, Sousa NC, Smaal A, Silva DAD, Hyslop S. Rat atrial responses to Bothrops jararacussu (jararacuçu) snake venom. Toxicology 2014; 323:109-24. [DOI: 10.1016/j.tox.2014.06.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 06/13/2014] [Accepted: 06/23/2014] [Indexed: 11/30/2022]
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20
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Hart AJ, Hodgson WC, O'Leary M, Isbister GK. Pharmacokinetics and pharmacodynamics of the myotoxic venom of Pseudechis australis (mulga snake) in the anesthetised rat. Clin Toxicol (Phila) 2014; 52:604-10. [PMID: 24940643 DOI: 10.3109/15563650.2014.914526] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Myotoxicity is a common clinical effect of snake envenoming and results from either local or systemic myotoxins in snake venoms. Although numerous myotoxins have been isolated from snake venoms, there has been limited study on the relationship between the time course of venom concentrations (pharmacokinetics) and the time course of muscle injury measured as a rise in creatine kinase (CK) (pharmacodynamics). OBJECTIVE The aim of this study was to develop an in vivo model of myotoxicity to investigate the time course of myotoxicity and the effect of antivenom. MATERIALS AND METHODS Anesthetised rats were administered Pseudechis australis (mulga snake) venom either through i.v., i.m. or s.d. route, including a range of doses (5-100 μg/kg). Serial blood samples were collected for measurement of venom using enzyme immunoassay and measurement of CK and creatinine. Antivenom was administered before, 1 and 6 h after venom administration to investigate its effect on muscle injury. Plots of venom and CK versus time were made and the area under the curve (AUC) was calculated. RESULTS There was a significant dose-dependent increase in CK concentration after administration of P. australis venom, which was greatest for i.v. administration. Timed measurement of venom concentrations showed a rapid absorption through s.d. and i.m. routes and a delayed rise in CK concentrations following any route. Antivenom prevented myotoxicity shown by a decrease in the CK AUC, which was most effective if given earliest. There was a rise in creatinine following i.v. venom administration. CONCLUSION The study shows the delayed relationship between venom absorption and the rise in CK, consistent with the delayed onset of myotoxicity in human envenoming. Antivenom prevented myotoxicity more effectively if given earlier.
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Affiliation(s)
- A J Hart
- Department of Pharmacology, Monash Venom Group, Monash University , Victoria , Australia
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21
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Yap MKK, Tan NH, Sim SM, Fung SY, Tan CH. Pharmacokinetics of Naja sumatrana (equatorial spitting cobra) venom and its major toxins in experimentally envenomed rabbits. PLoS Negl Trop Dis 2014; 8:e2890. [PMID: 24901441 PMCID: PMC4046969 DOI: 10.1371/journal.pntd.0002890] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 04/08/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The optimization of snakebite management and the use of antivenom depend greatly on the knowledge of the venom's composition as well as its pharmacokinetics. To date, however, pharmacokinetic reports on cobra venoms and their toxins are still relatively limited. In the present study, we investigated the pharmacokinetics of Naja sumatrana (Equatorial spitting cobra) venom and its major toxins (phospholipase A2, neurotoxin and cardiotoxin), following intravenous and intramuscular administration into rabbits. PRINCIPAL FINDINGS The serum antigen concentration-time profile of the N. sumatrana venom and its major toxins injected intravenously fitted a two-compartment model of pharmacokinetics. The systemic clearance (91.3 ml/h), terminal phase half-life (13.6 h) and systemic bioavailability (41.9%) of N. sumatrana venom injected intramuscularly were similar to those of N. sputatrix venom determined in an earlier study. The venom neurotoxin and cardiotoxin reached their peak concentrations within 30 min following intramuscular injection, relatively faster than the phospholipase A2 and whole venom (Tmax=2 h and 1 h, respectively). Rapid absorption of the neurotoxin and cardiotoxin from the injection site into systemic circulation indicates fast onsets of action of these principal toxins that are responsible for the early systemic manifestation of envenoming. The more prominent role of the neurotoxin in N. sumatrana systemic envenoming is further supported by its significantly higher intramuscular bioavailability (Fi.m.=81.5%) compared to that of the phospholipase A2 (Fi.m.=68.6%) or cardiotoxin (Fi.m.=45.6%). The incomplete absorption of the phospholipase A2 and cardiotoxin may infer the toxins' affinities for tissues at the injection site and their pathological roles in local tissue damages through synergistic interactions. CONCLUSION/SIGNIFICANCE Our results suggest that the venom neurotoxin is absorbed very rapidly and has the highest bioavailability following intramuscular injection, supporting its role as the principal toxin in systemic envenoming.
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Affiliation(s)
- Michelle Khai Khun Yap
- CENAR and Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nget Hong Tan
- CENAR and Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Si Mui Sim
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shin Yee Fung
- CENAR and Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Choo Hock Tan
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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22
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Theakston RDG, Laing GD. Diagnosis of snakebite and the importance of immunological tests in venom research. Toxins (Basel) 2014; 6:1667-95. [PMID: 24859244 PMCID: PMC4052258 DOI: 10.3390/toxins6051667] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 05/09/2014] [Accepted: 05/14/2014] [Indexed: 11/16/2022] Open
Abstract
In many cases of envenoming following snake bite, the snake responsible for the accident remains unidentified; this frequently results in difficulty deciding which antivenom to administer to the systemically-envenomed victim, especially when only monospecific antivenoms are available. Normally the specific diagnosis of snake bite can be conveniently made using clinical and laboratory methods. Where clinical diagnosis depends upon the recognition of specific signs of envenoming in the patient, laboratory diagnosis is based on the changes which occur in envenomed victims including the detection of abnormalities in blood parameters, presence/absence of myoglobinuria, changes in certain enzyme levels, presence/absence of neurotoxic signs and the detection in the blood of specific venom antigens using immunologically-based techniques, such as enzyme immunoassay. It is the latter which is the main subject of this review, together with the application of techniques currently used to objectively assess the effectiveness of new and existing antivenoms, to assess first aid measures, to investigate the possible use of such methods in epidemiological studies, and to detect individual venom components. With this in mind, we have discussed in some detail how such techniques were developed and how they have helped in the treatment of envenoming particularly and in venom research in general.
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Affiliation(s)
- R David G Theakston
- Alistair Reid Venom Research Unit, Liverpool School of Tropical Medicine, University of Liverpool, Liverpool L3 5QA, UK.
| | - Gavin D Laing
- Alistair Reid Venom Research Unit, Liverpool School of Tropical Medicine, University of Liverpool, Liverpool L3 5QA, UK.
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23
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Martines MS, Mendes MM, Shimizu MHM, Melo Rodrigues V, de Castro I, Filho SRF, Malheiros DMAC, Yu L, Burdmann EA. Effects of Schizolobium parahyba extract on experimental Bothrops venom-induced acute kidney injury. PLoS One 2014; 9:e86828. [PMID: 24551041 PMCID: PMC3925091 DOI: 10.1371/journal.pone.0086828] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 12/13/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Venom-induced acute kidney injury (AKI) is a frequent complication of Bothrops snakebite with relevant morbidity and mortality. The aim of this study was to assess the effects of Schizolobium parahyba (SP) extract, a natural medicine with presumed anti-Bothrops venom effects, in an experimental model of Bothrops jararaca venom (BV)-induced AKI. METHODOLOGY Groups of 8 to 10 rats received infusions of 0.9% saline (control, C), SP 2 mg/kg, BV 0.25 mg/kg and BV immediately followed by SP (treatment, T) in the doses already described. After the respective infusions, animals were assessed for their glomerular filtration rate (GFR, inulin clearance), renal blood flow (RBF, Doppler), blood pressure (BP, intra-arterial transducer), renal vascular resistance (RVR), urinary osmolality (UO, freezing point), urinary neutrophil gelatinase-associated lipocalin (NGAL, enzyme-linked immunosorbent assay [ELISA]), lactate dehydrogenase (LDH, kinetic method), hematocrit (Hct, microhematocrit), fibrinogen (Fi, Klauss modified) and blinded renal histology (acute tubular necrosis score). PRINCIPAL FINDINGS BV caused significant decreases in GFR, RBF, UO, HcT and Fi; significant increases in RVR, NGAL and LDH; and acute tubular necrosis. SP did not prevent these changes; instead, it caused a significant decrease in GFR when used alone. CONCLUSION SP administered simultaneously with BV, in an approximate 10∶1 concentration, did not prevent BV-induced AKI, hemolysis and fibrinogen consumption. SP used alone caused a decrease in GFR.
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Affiliation(s)
- Monique Silva Martines
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, São Paulo, São Paulo, Brazil
| | - Mirian M. Mendes
- Biological Science Institute, Goias Federal University, Jataí, Goiás, Brazil
| | - Maria H. M. Shimizu
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, São Paulo, São Paulo, Brazil
| | - Veridiana Melo Rodrigues
- Institute of Genetics and Biochemistry, Uberlandia Federal University, Uberlândia, Minas Gerais, Brazil
| | - Isac de Castro
- Division of Nephrology, University of Sao Paulo Medical School, São Paulo, São Paulo, Brazil
| | | | - Denise M. A. C. Malheiros
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, São Paulo, São Paulo, Brazil
| | - Luis Yu
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, São Paulo, São Paulo, Brazil
| | - Emmanuel A. Burdmann
- LIM 12, Division of Nephrology, University of Sao Paulo Medical School, São Paulo, São Paulo, Brazil
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Tan CH, Sim SM, Gnanathasan CA, Fung SY, Tan NH. Pharmacokinetics of the Sri Lankan hump-nosed pit viper (Hypnale hypnale) venom following intravenous and intramuscular injections of the venom into rabbits. Toxicon 2014; 79:37-44. [PMID: 24412778 DOI: 10.1016/j.toxicon.2013.12.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 11/26/2013] [Accepted: 12/30/2013] [Indexed: 10/25/2022]
Abstract
The knowledge of venom pharmacokinetics is essential to improve the understanding of envenomation pathophysiology. Using a double-sandwich ELISA, this study investigated the pharmacokinetics of the venom of hump-nosed pit viper (Hypnale hypnale) following intravenous and intramuscular injections into rabbits. The pharmacokinetics of the venom injected intravenously fitted a three-compartment model. There is a rapid (t1/2π = 0.4 h) and a slow (t1/2α = 0.8 h) distribution phase, followed by a long elimination phase (t1/2β = 19.3 h) with a systemic clearance of 6.8 mL h(-1) kg(-1), consistent with the prolonged abnormal hemostasis reported in H. hypnale envenomation. On intramuscular route, multiple peak concentrations observed in the beginning implied a more complex venom absorption and/or distribution pattern. The terminal half-life, volume of distribution by area and systemic clearance of the venom injected intramuscularly were nevertheless not significantly different (p > 0.05) from that of the venom injected intravenously. The intramuscular bioavailability was exceptionally low (Fi.m. = 4%), accountable for the highly varied median lethal doses between intravenous and intramuscular envenomations in animals. The findings indicate that the intramuscular route of administration does not significantly alter the pharmacokinetics of H. hypnale venom although it significantly reduces the systemic bioavailability of the venom.
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Affiliation(s)
- Choo Hock Tan
- Department of Pharmacology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Si Mui Sim
- Department of Pharmacology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | | | - Shin Yee Fung
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nget Hong Tan
- Department of Molecular Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Hrovat A, Schoeman J, de Laat B, Meyer E, Smets P, Goddard A, Nagel S, Daminet S. Evaluation of snake envenomation-induced renal dysfunction in dogs using early urinary biomarkers of nephrotoxicity. Vet J 2013; 198:239-44. [DOI: 10.1016/j.tvjl.2013.06.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 05/12/2013] [Accepted: 06/30/2013] [Indexed: 11/29/2022]
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Yap MKK, Tan NH, Sim SM, Fung SY. Toxicokinetics of Naja sputatrix (Javan spitting cobra) venom following intramuscular and intravenous administrations of the venom into rabbits. Toxicon 2013; 68:18-23. [PMID: 23537711 DOI: 10.1016/j.toxicon.2013.02.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 02/11/2013] [Accepted: 02/21/2013] [Indexed: 10/27/2022]
Abstract
Existing protocols for antivenom treatment of snake envenomations are generally not well optimized due partly to inadequate knowledge of the toxicokinetics of venoms. The toxicokinetics of Naja sputatrix (Javan spitting cobra) venom was investigated following intravenous and intramuscular injections of the venom into rabbits using double-sandwich ELISA. The toxicokinetics of the venom injected intravenously fitted a two-compartment model. When the venom was injected intramuscularly, the serum concentration-time profile exhibited a more complex absorption and/or distribution pattern. Nevertheless, the terminal half-life, volume of distribution by area and systemic clearance of the venom injected intramuscularly were not significantly different (p > 0.05) from that of the venom injected intravenously. The systemic bioavailability of the venom antigens injected by intramuscular route was 41.7%. Our toxicokinetic finding is consistent with other reports, and may indicate that some cobra venom toxins have high affinity for the tissues at the site of injection. Our results suggest that the intramuscular route of administration doesn't significantly alter the toxicokinetics of N. sputatrix venom although it significantly reduces the systemic bioavailability of the venom.
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de Morais ICO, Torres AFC, Pereira GJDS, Pereira TP, Pessoa Bezerra de Menezes RRDP, Mello CP, Coelho Jorge AR, Bindá AH, Toyama MH, Monteiro HSA, Smaili SS, Martins AMC. Bothrops leucurus venom induces nephrotoxicity in the isolated perfused kidney and cultured renal tubular epithelia. Toxicon 2012; 61:38-46. [PMID: 23127898 DOI: 10.1016/j.toxicon.2012.10.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 10/08/2012] [Accepted: 10/10/2012] [Indexed: 12/24/2022]
Abstract
Bites from snake (Bothrops genus) cause local tissue damage and systemic complications, which include alterations such as hemostatic system and acute renal failure (ARF). Recent studies suggest that ARF pathogenesis in snakebite envenomation is multifactorial and involves hemodynamic disturbances, immunologic reactions and direct nephrotoxicity. The aim of the work was to investigate the effects of the Bothrops leucurus venom (BlV) in the renal perfusion system and in cultured renal tubular cells of the type MDCK (Madin-Darby Canine kidney). BlV (10 μg/mL) reduced the perfusion pressure at 90 and 120 min. The renal vascular resistance (RVR) decreased at 120 min of perfusion. The effect on urinary flow (UF) and glomerular filtration rate (GFR) started 30 min after BlV infusion, was transient and returned to normal at 120 min of perfusion. It was also observed a decrease on percentual tubular transport of sodium (%TNa(+)) at 120 min and of chloride (%TCl(-)) at 60 and 90 min. The treatment with BlV caused decrease in cell viability to the lowest concentration tested with an IC(50) of 1.25 μg/mL. Flow cytometry with annexin V and propidium iodide showed that cell death occurred predominantly by necrosis. However, a cell death process may involve apoptosis in lower concentrations. BlV treatment (1.25 μg/mL) led to significant depolarization of the mitochondrial membrane potential and, indeed, we found an increase in the expression of cell death genes in the lower concentrations tested. The venom also evoked an increase in the cytosolic Ca(2+) in a concentration dependent manner, indicating that Ca(2+) may participate in the venom of B. leucurus effect. The characterization of the effects in the isolated kidney and renal tubular cells gives strong evidences that the acute renal failure induced by this venom is a result of the direct nephrotoxicity which may involve the cell death mechanism.
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Inflammatory mediators release in urine from mice injected with Crotalus durissus terrificus venom. Mediators Inflamm 2011; 2011:103193. [PMID: 22174490 PMCID: PMC3235905 DOI: 10.1155/2011/103193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Revised: 09/03/2011] [Accepted: 09/06/2011] [Indexed: 11/29/2022] Open
Abstract
In this study, we investigated in groups of female BALB/c mice injected with Crotalus durissus terrificus venom (Cdt) the renal function based on creatinine clearance, percentage of fractional excretion cytokines and histological examination of renal tissue. Cdt caused renal alterations that induced proteinuria during the initial hours post-venom and reduced creatinine clearance 15 min. up to 2 hours post-venom administration. In urine from mice injected with Cdt induced a decrease in IL-4 levels. More pronounced increments of IL-5, IL-6 and IFN-γ were observed after 15 and 30 min, respectively. The highest levels of TNF and IL-10 were observed at 1 and 4 hs, respectively. The ratios of pro- and anti-inflammatory cytokines in animals injected with Cdt, which may be manifested in the inflammatory status during the envenoming. In groups of animals treated with Cdt were observed a decreasing in creatinine clearance and its effect on glomerular filtration rate was accompanied by decreased fractional excretion of cytokines and morphologic disturbances. This loss of change selectively in envenomation could thus explain why the relatively excretion of cytokines is reduced while of total proteins increases. In conclusion the fractional excretion of
cytokines is significantly reduced in mice injected with Cdt, despite proteinuria.
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Histological and functional renal alterations caused by Bothrops alternatus snake venom: Expression and activity of Na+/K+-ATPase. Biochim Biophys Acta Gen Subj 2011; 1810:895-906. [DOI: 10.1016/j.bbagen.2011.06.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 05/23/2011] [Accepted: 06/01/2011] [Indexed: 11/21/2022]
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Rodrigues Sgrignolli L, Florido Mendes GE, Carlos CP, Burdmann EA. Acute Kidney Injury Caused by Bothrops Snake Venom. ACTA ACUST UNITED AC 2011; 119:c131-6; discussion c137. [DOI: 10.1159/000324228] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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