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Morris CAD, Donaldson RE. Mechanical ventilation in snake envenomation of dogs and cats. Front Vet Sci 2023; 10:1071257. [PMID: 37065246 PMCID: PMC10090310 DOI: 10.3389/fvets.2023.1071257] [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: 10/16/2022] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
Envenomation by snakes in Elapidae and Viperidae families have been associated with respiratory failure in dogs and cats. Mechanical ventilation may be required for hypoventilation due to neuromuscular paralysis or hypoxemia due to pulmonary hemorrhage or aspiration pneumonia. Median incidence of dogs and cats with snake envenomation that require mechanical ventilation is 13% (0.06-40%). Standard treatment of snake envenomation in dogs and cats includes prompt administration of appropriate antivenom and management of envenomation complications such as coagulopathy, rhabdomyolysis and acute kidney injury. When mechanical ventilation is required, overall prognosis is good with appropriate treatment. Standard anesthetic protocols and mechanical ventilator settings are generally appropriate, with lung protective ventilation strategies typically reserved for patients with pulmonary disease. Median survival to discharge for cats and dogs with elapid envenomation is 72% (76-84%) with 33 h (19.5-58 h) median duration of mechanical ventilation and 140 h (84-196 h) median hospitalization. This article reviews indications for mechanical ventilation in cats and dogs with snake envenomation, and discusses ventilator settings, anesthetic and nursing considerations, complications and outcomes specific to this disease.
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Affiliation(s)
- Cameron A. D. Morris
- Critical Care Department, Queensland Veterinary Specialists, Brisbane, QLD, Australia
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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] [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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Sarkar S, Sinha R, Chaudhury AR, Maduwage K, Abeyagunawardena A, Bose N, Pradhan S, Bresolin NL, Garcia BA, McCulloch M. Snake bite associated with acute kidney injury. Pediatr Nephrol 2021; 36:3829-3840. [PMID: 33559706 DOI: 10.1007/s00467-020-04911-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 11/30/2020] [Accepted: 12/23/2020] [Indexed: 01/03/2023]
Abstract
Acute kidney injury (AKI) is a well-known life-threatening systemic effect of snake envenomation which commonly happens secondary to snake bites from families of Viperidae and Elapidae. Enzymatic toxins in snake venom result in injuries to all kidney cell types including glomerular, tubulo-interstitial and kidney vasculature. Pathogenesis of kidney injury due to snake envenomation includes ischaemia secondary to decreased kidney blood flow caused by systemic bleeding and vascular leakage, proteolytic degradation of the glomerular basement membrane by snake venom metalloproteinases (SVMPs), deposition of microthrombi in the kidney microvasculature (thrombotic microangiopathy), direct cytotoxic action of venom, systemic myotoxicity (rhabdomyolysis) and accumulation of large amounts of myoglobin in kidney tubules. Clinical features of AKI include fatigue, loss of appetite, headache, nausea, vomiting, oliguria and anuria. Monitoring of blood pressure, fluid balance, serum creatinine, blood urea nitrogen and serum electrolytes is useful in managing AKI induced by snake envenomation. Early initiation of anti-snake venom and early diagnosis of AKI are always desirable. Biomarkers which will help in early prediction of AKI are being explored, and current studies suggest that urinary clusterin, urinary neutrophil gelatinase-associated lipocalin, and serum cystatin C may play an important clinical role in the future. Apart from fluid and electrolyte management, kidney support including early and prompt initiation of kidney replacement therapy when indicated forms the bedrock in managing snake bite-associated AKI. Long-term follow-up is important because of chances of progression towards CKD.
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Affiliation(s)
- Subhankar Sarkar
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 11, Dr Biresh Guha Street, Kolkata, West Bengal, 700017, India
| | - Rajiv Sinha
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 11, Dr Biresh Guha Street, Kolkata, West Bengal, 700017, India. .,Department of Pediatrics, Apollo Gleneagles Hospital, Kolkata, India.
| | | | - Kalana Maduwage
- Department of Biochemistry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Asiri Abeyagunawardena
- Department of Pediatrics, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Niladri Bose
- Department of Pediatrics, Apollo Gleneagles Hospital, Kolkata, India
| | - Subal Pradhan
- Department of Pediatrics, Sardar Vallabhbai Patel Post Graduate Institute of Pediatrics (SVPPGIP), Cuttack, India
| | | | | | - Mignon McCulloch
- Pediatric Renal and Solid Organ Transplant Unit, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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Xie C, Bittenbinder MA, Slagboom J, Arrahman A, Bruijns S, Somsen GW, Vonk FJ, Casewell NR, García-Vallejo JJ, Kool J. Erythrocyte haemotoxicity profiling of snake venom toxins after nanofractionation. J Chromatogr B Analyt Technol Biomed Life Sci 2021; 1176:122586. [PMID: 33839052 PMCID: PMC7613003 DOI: 10.1016/j.jchromb.2021.122586] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Abstract
Snakebite is classified as a priority Neglected Tropical Disease by the World Health Organization. Understanding the pathology of individual snake venom toxins is of great importance when developing more effective snakebite therapies. Snake venoms may induce a range of pathologies, including haemolytic activity. Although snake venom-induced erythrocyte lysis is not the primary cause of mortality, haemolytic activity can greatly debilitate victims and contributes to systemic haemotoxicity. Current assays designed for studying haemolytic activity are not suitable for rapid screening of large numbers of toxic compounds. Consequently, in this study, a high-throughput haemolytic assay was developed that allows profiling of erythrocyte lysis, and was validated using venom from a number of medically important snake species (Calloselasma rhodostoma, Daboia russelii, Naja mossambica, Naja nigricollis and Naja pallida). The assay was developed in a format enabling direct integration into nanofractionation analytics, which involves liquid chromatographic separation of venom followed by high-resolution fractionation and subsequent bioassaying (and optional proteomics analysis), and parallel mass spectrometric detection. Analysis of the five snake venoms via this nanofractionation approach involving haemolytic assaying provided venom-cytotoxicity profiles and enabled identification of the toxins responsible for haemolytic activity. Our results show that the elapid snake venoms (Naja spp.) contained both direct and indirect lytic toxins, while the viperid venoms (C. rhodostoma and D. russelii) only showed indirect lytic activities, which required the addition of phospholipids to exert cytotoxicity on erythrocytes. The haemolytic venom toxins identified were mainly phospholipase A2s and cytotoxic three finger toxins. Finally, the applicability of this new analytical method was demonstrated using a conventional snakebite antivenom treatment and a small-molecule drug candidate to assess neutralisation of venom cytotoxins.
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Affiliation(s)
- Chunfang Xie
- Amsterdam Institute of Molecular and Life Sciences, Division of BioAnalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, the Netherlands; Centre for Analytical Sciences Amsterdam (CASA), 1098 XH Amsterdam, the Netherlands
| | - Matyas A Bittenbinder
- Amsterdam Institute of Molecular and Life Sciences, Division of BioAnalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, the Netherlands; Centre for Analytical Sciences Amsterdam (CASA), 1098 XH Amsterdam, the Netherlands; Naturalis Biodiversity Center, Darwinweg 2, 2333 CR Leiden, the Netherlands
| | - Julien Slagboom
- Amsterdam Institute of Molecular and Life Sciences, Division of BioAnalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, the Netherlands; Centre for Analytical Sciences Amsterdam (CASA), 1098 XH Amsterdam, the Netherlands
| | - Arif Arrahman
- Amsterdam Institute of Molecular and Life Sciences, Division of BioAnalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, the Netherlands; Centre for Analytical Sciences Amsterdam (CASA), 1098 XH Amsterdam, the Netherlands
| | - Sven Bruijns
- Department of Molecular Cell Biology and Immunology, Amsterdam Infection and Immunity Institute, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 HZ Amsterdam, the Netherlands
| | - Govert W Somsen
- Amsterdam Institute of Molecular and Life Sciences, Division of BioAnalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, the Netherlands; Centre for Analytical Sciences Amsterdam (CASA), 1098 XH Amsterdam, the Netherlands
| | - Freek J Vonk
- Amsterdam Institute of Molecular and Life Sciences, Division of BioAnalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, the Netherlands; Centre for Analytical Sciences Amsterdam (CASA), 1098 XH Amsterdam, the Netherlands; Naturalis Biodiversity Center, Darwinweg 2, 2333 CR Leiden, the Netherlands
| | - Nicholas R Casewell
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK; Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Juan J García-Vallejo
- Department of Molecular Cell Biology and Immunology, Amsterdam Infection and Immunity Institute, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 HZ Amsterdam, the Netherlands
| | - Jeroen Kool
- Amsterdam Institute of Molecular and Life Sciences, Division of BioAnalytical Chemistry, Department of Chemistry and Pharmaceutical Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, the Netherlands; Centre for Analytical Sciences Amsterdam (CASA), 1098 XH Amsterdam, the Netherlands.
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Kumar M, Arcot Thanjan M, Gopalakrishnan N, Jeyachandran D, Thanigachalam D, Ramanathan S. Snake envenomation-induced acute kidney injury: prognosis and long-term renal outcomes. Postgrad Med J 2021; 98:264-268. [PMID: 33692155 DOI: 10.1136/postgradmedj-2020-139021] [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: 09/16/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Snake bite continues to be a significant cause of acute kidney injury (AKI) in India. There is paucity of data regarding long-term outcomes of such patients. In this study, we aim to assess the prognosis and long-term renal outcomes of such patients. METHODS We analysed the hospital records of snake envenomation-induced AKI from January 2015 to December 2018. Predictors of in-hospital mortality were assessed. Survivors were advised to visit follow-up clinic to assess their kidney function. RESULTS There were 769 patients with evidence of envenomation and of them, 159 (20.7%) had AKI. There were 112 (70.4%) males. Mortality occurred in 9.4% of patients. Logistic regression analysis identified shock (OR 51.949, 95% CI 4.297 to 628.072) and thrombocytopenia (OR 27.248, 95% CI 3.276 to 226.609) as predictors of mortality. Forty-three patients attended the follow-up. The mean follow-up duration was 30.4±15.23 months. Adverse renal outcomes (eGFR <60 mL/min/1.73 m2 or new-onset hypertension (HTN) or pre-HTN or urine protein creatinine ratio >0.3) occurred in 48.8% of patients. Older age (mean age (years) 53.3 vs 42.8, p=0.004) and longer duration on dialysis (median duration (days) 11.5 vs 5, p=0.024) were significantly associated with adverse renal outcomes. CONCLUSIONS The incidence of AKI in snake envenomation was 20.7%. The presence of shock and thrombocytopenia were associated with mortality. Adverse renal outcomes occurred in 48.8% of patients in the long term.
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Affiliation(s)
- Manoj Kumar
- Institute of Nephrology, Madras Medical College, Chennai, Tamil Nadu, India
| | - Maasila Arcot Thanjan
- Nephrology, Government Vellore Medical College and Hospital, Vellore, Tamil Nadu, India
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Tchaou BA, de Tové KMS, N'Vènonfon CFT, Mfin PK, Aguemon AR, Chobli M, Chippaux JP. Acute kidney failure following severe viper envenomation: clinical, biological and ultrasonographic aspects. J Venom Anim Toxins Incl Trop Dis 2020; 26:e20200059. [PMID: 33335542 PMCID: PMC7724935 DOI: 10.1590/1678-9199-jvatitd-2020-0059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Acute kidney injury (AKI) is a frequent complication of snakebite envenomation, which is still little known in sub-Saharan Africa. This study aims to describe the clinical, biological and ultrasonographic aspects of AKI following severe snakebite envenomation managed in the intensive care unit. Method: A prospective observational survey was performed in Benin over a period of 18 months. All patients suffering severe snakebite envenomation (SBE) were included. The diagnosis of AKI was made using the KDIGO criteria. Kidney ultrasound exam was performed in all patients to assess internal bleeding and morphological and structural abnormalities of the kidneys. Results: Fifty-one cases of severe SBE were included. All patients presented inflammatory syndrome and showed abnormal WBCT whereas bleeding was found in 46 of them (90%). The median time to hospital presentation was three days. The majority of patients were male (M/F sex ratio = 1.55) and the median age was 26. Sixteen patients (31%) showed AKI according to the KDIGO criteria. Severe AKI (KDIGO stage 2 and 3) was observed in three patients, including one stage 2 and two stage 3. Kidney ultrasound revealed three cases of kidney capsular hematoma (6%), two cases of kidney hypertrophy (3%), three cases of kidney injury (4%), two stage 1 KDIGO and one stage 2 KDIGO. Only one patient benefited from hemodialysis. All patients showing AKI recovered without sequels. The median duration of hospital stays was four days. Seven patients died (14%) including four among the 16 AKI patients. Antivenom has been administered to 41 patients (80%). The comparison between patients without and with AKI did not show any significant difference except gender (p = 10-2). Conclusion: AKI is a common complication of severe snakebite envenomation. Resulting from inflammatory and hemorrhagic disorders, AKI may prove to be a short-term life-threatening factor.
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Affiliation(s)
- Blaise Adelin Tchaou
- Department of Anesthesia-Resuscitation and Emergency, Borgou-Alibori University Hospital Center, Parakou, Bénin
| | - Kofi-Mensa Savi de Tové
- Department of Radiology and Medical Imaging, Borgou-Alibori University Hospital Center, Parakou, Bénin
| | | | - Patrick Kouomboua Mfin
- Department of Anesthesia-Resuscitation and Emergency, Borgou-Alibori University Hospital Center, Parakou, Bénin
| | - Abdou-Rahman Aguemon
- Department of Anesthesia-Resuscitation and Emergency, Borgou-Alibori University Hospital Center, Parakou, Bénin
| | - Martin Chobli
- Department of Anesthesia-Resuscitation and Emergency, Borgou-Alibori University Hospital Center, Parakou, Bénin
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Yan H, Xiang P, Zhang J, Xie L, Shen M. Dynamic changes of serum protein in rats with acute intoxication of Chinese cobra snake venom by proteomic analysis. Forensic Sci Res 2020; 5:309-321. [PMID: 33457049 PMCID: PMC7782176 DOI: 10.1080/20961790.2017.1405565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
To elucidate the toxic mechanism of snake venom at the protein level, proteomics technology was applied to investigate the effect of venom on circulation in the mammalian body. Temporal proteomic analysis was performed to profile the dynamic changes in the sera of Sprague–Dawley rats administered with Chinese cobra venom or saline. Using 8-plex iTRAQ analysis, 392 and 636 serum proteins were identified to be linearly upregulated or downregulated over time in the low-dose group and high-dose group, respectively. These proteins were mainly associated with the acute phase response pathway, complement system, and liver X receptor (LXR)/retinoid X receptor (RXR) and farnesoid X receptor (FXR)/RXR activation pathways. Compared with the low-dose group, the immune response and integrin pathways were inhibited in the high-dose group, although no obvious effect was observed. With consistently higher or lower expression in the high-dose group compared to the low-dose group throughout the whole process of venom poisoning, two proteins, Kininogen-1 (KNG1) and orosomucoid 1 (ORM1), which are involved in metabolism and immune response, occupied a core position in the pathway network and are considered venom dose-dependent biomarker candidates.
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Affiliation(s)
- Hui Yan
- Shanghai Key Laboratory of Forensic Science, Shanghai Forensic Platform, Department of Forensic Toxicology, Academy of Forensic Science, Shanghai, China
| | - Ping Xiang
- Shanghai Key Laboratory of Forensic Science, Shanghai Forensic Platform, Department of Forensic Toxicology, Academy of Forensic Science, Shanghai, China
| | - Jingshuo Zhang
- College of Pharmaceutical Sciences, Soochow Universtity, Suzhou, Jiangsu, China
| | - Liqi Xie
- Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Min Shen
- Shanghai Key Laboratory of Forensic Science, Shanghai Forensic Platform, Department of Forensic Toxicology, Academy of Forensic Science, Shanghai, China
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Martinez J, Londoño LA, Schaer M. Retrospective evaluation of acute kidney injury in dogs with pit viper envenomation (2008-2017): 56 cases. J Vet Emerg Crit Care (San Antonio) 2020; 30:698-705. [PMID: 32975046 DOI: 10.1111/vec.13007] [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: 10/11/2018] [Revised: 01/24/2019] [Accepted: 02/25/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the clinicopathological characteristics of dogs that develop acute kidney injury (AKI) secondary to pit viper envenomation, and to describe the association between development of AKI and clinical course and outcome. DESIGN Retrospective study. SETTING University teaching hospital. ANIMALS Client-owned dogs treated with at least 1 vial of antivenom following pit viper envenomation and that had at least 2 plasma creatinine concentrations measured during the course of hospitalization. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Sixty-three dogs met the inclusion criteria. One was excluded due chronic kidney disease, and 6 were excluded due to nonsteroidal anti-inflammatory drug administration. Of the 56 dogs included in the study, 16 developed AKI (29%). Dogs with AKI received a significantly higher dose of antivenom, 8.7 ± 6.8 total vials versus dogs in the non-AKI group that received 4.2 ± 2.6 vials (P = 0.006). Dogs in the AKI group were significantly more tachycardic (P = 0.028), hypotensive (P = 0.002), had a higher shock index (P = 0.012), and were more likely to receive transfusions with packed red blood cells (P = 0.042) than dogs in the non-AKI group. No significant association was identified between the development of AKI and length of hospitalization. The only factors that were significantly associated with degree of severity of AKI included the receipt of blood transfusion (P = 0.006) and number of vials of antivenom administered (P = 0.03). The development of AKI was significantly associated with outcome (P < 0.001), with 5 of 16 (31%) dogs in the AKI group surviving to discharge, 7 of 16 (44%) dying, and 4 of 16 (25%) being euthanized versus 39 of 40 (98%) surviving to discharge in the non-AKI group and 1 of 40 (2%) dying in hospital. CONCLUSION Development of AKI in dogs following pit viper envenomation carries an increased risk of mortality that is associated with severity of shock at presentation and increased doses of antivenom administration.
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Affiliation(s)
- Jennifer Martinez
- Department of Small Animal Clinical Sciences, University of Florida, Gainesville, Florida
| | - Leonel A Londoño
- Department of Small Animal Clinical Sciences, University of Florida, Gainesville, Florida
| | - Michael Schaer
- Department of Small Animal Clinical Sciences, University of Florida, Gainesville, Florida
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Sampley S, Sakhuja V, Bhasin D, Singh K, Singh H. Plasmapheresis for Pulmonary Hemorrhage Following Viperine Snakebite: A Case Report with Review of Literature. Indian J Crit Care Med 2020; 24:986-990. [PMID: 33281328 PMCID: PMC7689129 DOI: 10.5005/jp-journals-10071-23635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Introduction Snakebites are one of the commonest occupational hazards in tropical countries and viperine bites are potential to cause systemic toxicity. Coagulopathies and acute kidney injury (AKI) have been documented and easily dealt with in past, but pulmonary hemorrhage has been rarely seen and plasmapheresis has shown promising result for the same. This case reports highlight the effective use of plasmapheresis for pulmonary hemorrhage post-snakebite. Background Viperine snakebite has been associated with high morbidity and mortality due to its toxic systemic envenomization. The important systemic manifestations are coagulopathy, neuromuscular paralysis, AKI, myotoxicity, and cardiovascular collapse. Antivenomization, renal replacement therapy, steroids, and other supportive care are considered to be the mainstay of treatment till date. Pulmonary hemorrhage has been an unusual manifestation of viper bite and rarely reported and steroids have been used in such scenario but with mixed results. Role of plasmapheresis has been documented in the management of snakebite but especially for hematological problems and in limb preservation/salvage strategies. The use of same, for pulmonary hemorrhage has not been studied yet. Here, we present a rare case of pulmonary hemorrhage along with renal failure following viper bite which was successfully treated with plasmapheresis. To the best of our knowledge, it is a rare presentation and has not been reported in the literature reviewed till date. Case description A previously healthy, 36-year-old man presented to our hospital 48 hours after a viper bite. He developed local as well systemic manifestations evident as hemolysis and renal failure. Gradually, he started having hemoptysis followed by respiratory failure requiring ventilatory support. CT chest done was s/o bilateral pulmonary hemorrhages correlating clinically with ongoing tracheal bleed. He had no other bleeding manifestations and had normal coagulation profile. He was initially treated with methylprednisolone therapy, but then did not show any improvement and finally plasmapheresis was done as rescue therapy. Following this, he had improvement in respiratory parameters and settling tracheal bleed with resolution of radiological changes. He was successfully weaned off from the ventilation and also his renal failure also improved with near normalization of pulmonary and renal functions. Conclusion This case highlights the unusual presentation of pulmonary hemorrhage in a patient with viperine bite with normal coagulation and was aggressively managed with plasmapheresis. Hence, plasmapheresis can be used as life-saving modality in patients with systemic envenomization post-viperine bit. How to cite this article Sampley S, Sakhuja V, Bhasin D, Singh K, Singh H. Plasmapheresis for Pulmonary Hemorrhage Following Viperine Snakebite: A Case Report with Review of Literature. Indian J Crit Care Med 2020;24(10):986-990.
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Affiliation(s)
- Supriya Sampley
- Department of Pulmonology and Critical Care, Medical Intensive Care Unit, Max Super Speciality Hospital, Mohali, Punjab, India
| | - Vinay Sakhuja
- Department of Nephrology, Max Super Speciality Hospital, Mohali, Punjab, India
| | - Deepak Bhasin
- Department of Pulmonology and Critical Care, Max Super Speciality Hospital, Mohali, Punjab, India
| | - Kuldeep Singh
- Department of Transfusion Medicine, Max Super Speciality Hospital, Mohali, Punjab, India
| | - Harpal Singh
- Department of Pulmonology and Critical Care, Max Super Speciality Hospital, Mohali, Punjab, India
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Zhang M, Cheng J, Sun Z, Kong H, Zhang Y, Wang S, Wang X, Zhao Y, Qu H. Protective Effects of Carbon Dots Derived from Phellodendri Chinensis Cortex Carbonisata against Deinagkistrodon acutus Venom-Induced Acute Kidney Injury. NANOSCALE RESEARCH LETTERS 2019; 14:377. [PMID: 31845094 PMCID: PMC6915193 DOI: 10.1186/s11671-019-3198-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/31/2019] [Indexed: 05/13/2023]
Abstract
BACKGROUND As an emerging nanomaterial, carbon dots (CDs) have been the focus of tremendous attention for biomedical applications. However, little information is available on their bioactivity of inhibiting acute kidney injury (AKI) induced by snake venom. METHODS This study reports the development of a green, one-step pyrolysis process to synthesize CDs using Phellodendri Chinensis Cortex (PCC) as the sole precursor, and their potential application as a protectant against Deinagkistrodon acutus (D. acutus) venom-induced AKI was investigated for the first time. The AKI model was established by injecting D. acutus venom into the abdominal cavity of mice and the potential protective effects of PCC Carbonisata-CDs (PCCC-CDs) on renal abnormalities including dysfunction, inflammatory reactions, tissue damage, and thrombocytopenia at six time points (1, 3, and 12 h, and 1, 2, and 5 days) were investigated. RESULTS These results demonstrated that PCCC-CDs significantly inhibited the kidney dysfunction (reduced serum creatinine (SCR), blood urea nitrogen (BUN), urinary total protein (UTP), and microalbuminuria (MALB) concentrations) and the production of chemoattractant (monocyte chemotactic protein 1 (MCP-1)), proinflammatory cytokines (interleukin (IL)-1β), and anti-inflammatory cytokine (IL-10) in response to intraperitoneal injection of D. acutus venom. The beneficial effect of PCCC-CDs on the envenomed mice was similar to that on the change in renal histology and thrombocytopenia. CONCLUSIONS These results demonstrated the remarkable protective effects of PCCC-CDs against AKI induced by D. acutus venom, which would not only broaden the biomedical applications of CDs but also provide a potential target for the development of new therapeutic drugs for AKI induced by D. acutus snakebite envenomation.
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Affiliation(s)
- Meiling Zhang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Jinjun Cheng
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Ziwei Sun
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Hui Kong
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Yue Zhang
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Suna Wang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Xiaoke Wang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Yan Zhao
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China.
| | - Huihua Qu
- Center of Scientific Experiment, Beijing University of Chinese Medicine, Beijing, 100029, China
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Ratnayake I, Mohamed F, Buckley NA, Gawarammana IB, Dissanayake DM, Chathuranga U, Munasinghe M, Maduwage K, Jayamanne S, Endre ZH, Isbister GK. Early identification of acute kidney injury in Russell's viper (Daboia russelii) envenoming using renal biomarkers. PLoS Negl Trop Dis 2019; 13:e0007486. [PMID: 31260445 PMCID: PMC6625728 DOI: 10.1371/journal.pntd.0007486] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 07/12/2019] [Accepted: 05/23/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a major complication of snake envenoming, but early diagnosis remains problematic. We aimed to investigate the time course of novel renal biomarkers in AKI following Russell's viper (Daboia russelii) bites. METHODOLOGY/PRINCIPAL FINDINGS We recruited a cohort of patients with definite Russell's viper envenoming and collected serial blood and urine samples on admission (<4h post-bite), 4-8h, 8-16h, 16-24h, 1 month and 3 months post-bite. AKI stage (1-3) was defined using the Acute Kidney Injury Network criteria. AKI stages (1-3) were defined by the Acute Kidney Injury Network (AKIN) criteria. There were 65 Russell's viper envenomings and 49 developed AKI: 24 AKIN stage 1, 13 stage 2 and 12 stage 3. There was a significant correlation between venom concentrations and AKI stage (p = 0.007), and between AKI stage and six peak biomarker concentrations. Although most biomarker concentrations were elevated within 8h, no biomarker performed well in diagnosing AKI <4h post-bite. Three biomarkers were superior to serum creatinine (sCr) in predicting AKI (stage 2/3) 4-8h post-bite: serum cystatin C (sCysC) with an area under the receiver operating curve (AUC-ROC), 0.78 (95%CI:0.64-0.93), urine neutrophil gelatinase-associated lipocalin (uNGAL), 0.74 (95%CI:0.59-0.87) and urine clusterin (uClu), 0.81 (95%CI:0.69-0.93). No biomarker was better than sCr after 8h. Six other urine biomarkers urine albumin, urine beta2-microglobulin, urine kidney injury molecule-1, urine cystatin C, urine trefoil factor-3 and urine osteopontin either had minimal elevation, and/or minimal prediction for AKI stage 2/3 (AUC-ROC<0.7). CONCLUSIONS/SIGNIFICANCE AKI was common and sometimes severe following Russell's viper bites. Three biomarkers uClu, uNGAL and sCysC, appeared to become abnormal in AKI earlier than sCr, and may be useful in early identification of envenoming.
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Affiliation(s)
- Indira Ratnayake
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- TACT, Department of Pharmacology, Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Pharmacy, Faculty of Allied Health Science, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Nephrology, Prince of Wales Hospital and Clinical School, University of New South Wales, Sydney, Australia
| | - Nicholas A. Buckley
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- TACT, Department of Pharmacology, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Indika B. Gawarammana
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Dhammika M. Dissanayake
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Pathology, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Umesh Chathuranga
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Mahesh Munasinghe
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Kalana Maduwage
- Department of Biochemistry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Shaluka Jayamanne
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Zoltan H. Endre
- Department of Nephrology, Prince of Wales Hospital and Clinical School, University of New South Wales, Sydney, Australia
| | - Geoffrey K. Isbister
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia
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Priyamvada PS, Jaswanth C, Zachariah B, Haridasan S, Parameswaran S, Swaminathan RP. Prognosis and long-term outcomes of acute kidney injury due to snake envenomation. Clin Kidney J 2019; 13:564-570. [PMID: 32905257 PMCID: PMC7467597 DOI: 10.1093/ckj/sfz055] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/09/2019] [Indexed: 12/28/2022] Open
Abstract
Background Snakebite is a common occupational hazard in tropical countries. To date, the literature on snakebite-related acute kidney injury (AKI) has been limited by retrospective study designs, lack of uniformity in case definitions of AKI and limited follow-up. This study aims to identify the in-hospital outcomes and long-term changes in kidney function that follow haemotoxic envenomation. Methods All adult patients admitted with AKI following haemotoxic envenomation from January 2016 to June 2017 were recruited and followed up until July 2018. Predictors of in-hospital mortality was assessed. Long-term follow-up data on kidney function were collected from survivors. Results In total, 184 patients with haemotoxic envenomation and AKI were recruited. The mean age of the subjects was 42.2 years [95% confidence interval (CI) 40.3–44.7]. The majority were male (71.2%). The mortality of patients with haemotoxic envenomation was 21.5%. The mortality was considerably higher in patients with Kidney Disease: Improving Global Outcomes (KDIGO) Stage 3 AKI [relative risk (RR) 4.45 (95% CI 1.14–17.42)] and those who met KDIGO urine output criteria [RR 20.45 (95% CI 2.84–147.23)]. A Cox regression model identified mechanical ventilation [odds ratio (OR) 5.59 (95% CI 2.90–10.81)], hypotension [OR 2.48 (95% CI 1.31–4.72)] and capillary leak syndrome [OR 2.02 (95% CI 1.05–3.88)] as independent predictors of mortality. Long-term follow-up data were available for 73 patients. A total of 21 patients (28.7%) developed adverse renal outcomes (glomerular filtration rate <60 mL/min/1.73 m2, urine albumin excretion >30 mg/g and new-onset hypertension or prehypertension). Conclusions AKI resulting from snake envenomation is associated with considerable risk of mortality. The greater the AKI stage the greater the likelihood of mortality. One-third of patients with AKI developed long-term complications like chronic kidney disease, prehypertension and hypertension over the follow-up period.
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Affiliation(s)
- P S Priyamvada
- Department of Nephrology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry 605006, India
| | - Challa Jaswanth
- Department of Nephrology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry 605006, India
| | - Bobby Zachariah
- Department of Biochemistry, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry 605006, India
| | - Satish Haridasan
- Department of Nephrology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry 605006, India
| | - Sreejith Parameswaran
- Department of Nephrology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry 605006, India
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Ghosh R, Mana K, Sarkhel S. Ameliorating effect of Alstonia scholaris L. bark extract on histopathological changes following viper envenomation in animal models. Toxicol Rep 2018; 5:988-993. [PMID: 30319940 PMCID: PMC6180435 DOI: 10.1016/j.toxrep.2018.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 09/04/2018] [Accepted: 10/03/2018] [Indexed: 11/30/2022] Open
Abstract
In the present paper, the histopathological changes of liver and kidney tissues associated with Vipera russelli envenomation and systemic venom neutralization potential of aqueous Alstonia scholaris Linn bark extract in animal models has been discussed. Histological alterations observed in liver sections of venom treated groups were mainly pyknosis, karyorrhexis, cytoplasmic vacuolation, necrosis, fatty changes and hepatocytes atrophy. Histological changes in venom treated kidney tissues were cell damage, peritubular congestion, degenerating changes in the proximal tubules in the form of cytoplasmic vacuolations, partially destroyed bowman’s capillaries with dilated Bowman’s space after staining with haematoxylin and eosin. Both Antivenom and Alstonia scholaris Linn extract could significantly reduce the venom induced histological as well as biochemical changes (serum AST,ALT and creatinine) in the affected tissues.
Objectives The primary symptoms associated with snake envenomation are both systemic and local. The local symptoms are characterized by pain, swelling, haemorrhage and myonecrosis at the site of bite. The present study investigates the ameliorating effect of the aqueous bark extract of Alstonia scholaris bark on viper venom induced histopathological and biochemical changes in liver and kidney of swiss albino mice models. Methods & materials Swiss albino mice (20 ± 2)g were treated with sublethal doses(0.5 μg and 1 μg) of Vipera russelli venom(VRV) intraperitonially The following groups were assigned in the study-Group I(saline control); Group II & III(Venom treated-0.5 μg ie ¼ LD50 and 1 μg ie 1/2 LD50) and Group IV &V(Venom-0.5 μg and 1 μg respectively incubated with Aqueous Alstonia scholaris (AAS) extract; 200 mg/kg bw) and Group VI (Antivenom serum (AVS) (2 mg/ml) followed by 1 μg Vipera russelli venom (VRV). The animals were sacrificed and their organs were immersed in Bouin's fixative for 24 h and stained with haematoxylin/eosin and observed under the microscope. The serum samples were collected from the animals and tested for serum Alanine transaminase (ALT) and Aspartate transaminases (AST) following the method of Reitman & Frankel(1957) and serum creatinine. Results The histological alterations observed in Group II and III liver sections were mainly pyknosis, karyorrhexis, cytoplasmic vacuolation, necrosis, fatty changes and hepatocytes atrophy. Sinusoidal dilatation, amyloidosis, portal vein thrombosis which was significantly reduced by AAS extract in Groups IV and V. A venom dose of 1 μg induced tubular cell acidophilia indicating cell damage, peritubular congestion, degenerating changes in the proximal tubules in the form of cytoplasmic vacuolations, partially destroyed bowman’s capillaries with dilated Bowman’s space in Group III that was significantly reduced by Aqueous Alstonia scholaris (AAS) (200 mg/kg bw) extract in Groups IV and Group V.AVS gave significant protection against venom induced action in Group VI. Conclusion The present paper thus highlights the histopathological changes associated with Vipera russelli venom and systemic venom neutralization potential of Aqueous Alstonia scholaris (AAS) in animal models.
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Affiliation(s)
- Rituparna Ghosh
- Department of Human Physiology with Community Health, Vidyasagar University, Paschim Medinipur-721102, West Bengal, India
| | - Koushik Mana
- Department of Human Physiology with Community Health, Vidyasagar University, Paschim Medinipur-721102, West Bengal, India
| | - Sumana Sarkhel
- Department of Human Physiology with Community Health, Vidyasagar University, Paschim Medinipur-721102, West Bengal, India
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Predicting acute renal failure in Bothrops snakebite patients in a tertiary reference center, Western Brazilian Amazon. PLoS One 2018; 13:e0202361. [PMID: 30118505 PMCID: PMC6097671 DOI: 10.1371/journal.pone.0202361] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 08/01/2018] [Indexed: 02/06/2023] Open
Abstract
Acute Kidney Injury (AKI) is the main systemic complication and cause of death in viperid envenomation. Although there are hypotheses for the development of AKI, the mechanisms involved are still not established. The aim of this study was to evaluate the clinical-laboratorial-epidemiological factors associated with AKI in victims of Bothrops sp envenomation. This is an observational study carried out at the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado. AKI was defined according to the guidelines of the Acute Kidney Injury Network (AKIN). Among the 186 patients evaluated, AKI was observed in 24 (12.9%) after 48 hours of admission. Stage I was present in 17 (70.8%) patients, II in 3 (12.5%) and III in 4 (16.7%). Epidemiological characterization showed predominance of men, occurrence in rural areas, aged between 16–60 years, feet as the most affected anatomical region, and time to medical assistance less than 3 hours. Hypertension and diabetes were the comorbidities identified. Most of the accidents were classified as moderate, and clinical manifestations included severe pain, mild edema, local bleeding and headache. Laboratory results showed blood uncoagulability, hypofibrinogenemia, leukocytosis, increase of creatine kinase, and high lactate dehydrogenase levels. Multivariate analysis showed an association with high LDH levels [AOR = 1.01 (95% CI = 1.01–1.01, p<0.002)], local bleeding [AOR = 0.13 (95%CI = 0.027–0.59, p<0.009)], and the presence of comorbidities [AOR = 60.96 (95%CI = 9.69–383.30; p<0.000)]. Herein, laboratory markers such as high LDH levels along with local bleeding and comorbidities may aid in the diagnosis of AKI.
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Nasim F, Das S, Mishra R, Mishra R. Hematological alterations and splenic T lymphocyte polarization at the crest of snake venom induced acute kidney injury in adult male mice. Toxicon 2017; 134:57-63. [DOI: 10.1016/j.toxicon.2017.05.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 05/26/2017] [Accepted: 05/28/2017] [Indexed: 12/13/2022]
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Vikrant S, Jaryal A, Parashar A. Clinicopathological spectrum of snake bite-induced acute kidney injury from India. World J Nephrol 2017; 6:150-161. [PMID: 28540205 PMCID: PMC5424437 DOI: 10.5527/wjn.v6.i3.150] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/10/2016] [Accepted: 03/17/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To study the clinico-pathological spectrum of snake bite-induced acute kidney injury (AKI).
METHODS A retrospective study of patients admitted at Indira Gandhi Medical College Hospital, Shimla with snake bite-induced AKI from July 2003 to June 2016. Medical records were evaluated for patient’s information on demographic, clinical characteristics, complications and outcome. Outcomes of duration of hospital stay, requirement for intensive care unit support, treatment with dialysis, survival and mortality were analyzed. The survival and non survival groups were compared to see the difference in the demographic factors, clinical characteristics, laboratory results, and complications. In patients subjected to kidney biopsy, the findings of histopathological examination of the kidney biopsies were also analyzed.
RESULTS One hundred and twenty-one patients were diagnosed with snake bite-induced AKI. Mean age was 42.2 ± 15.1 years and majority (58%) were women. Clinical details were available in 88 patients. The mean duration of arrival at hospital was 3.4 ± 3.7 d with a range of 1 to 30 d. Eighty percent had oliguria and 55% had history of having passed red or brown colored urine. Coagulation defect was seen in 89% patients. The hematological and biochemical laboratory abnormalities were: Anemia (80.7%), leukocytosis (75%), thrombocytopenia (47.7%), hyperkalemia (25%), severe metabolic acidosis (39.8%), hepatic dysfunction (40.9%), hemolysis (85.2%) and rhabdomyolysis (68.2%). Main complications were: Gastrointestinal bleed (12.5%), seizure/encephalopathy (10.2%), hypertension, pneumonia/acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (9.1% each), hypotension and multi organ failure (MOF) (4.5% each). Eighty-two percent patients required renal replacement therapy. One hundred and ten (90.9%) patient survived and 11 (9.1%) patients died. As compared to the survival group, the white blood cell count (P = 0.023) and bilirubin levels (P = 0.006) were significant higher and albumin levels were significantly lower (0.005) in patients who died. The proportion of patients with pneumonia/ARDS (P = 0.001), seizure/encephalopathy (P = 0.005), MOF (P = 0.05) and need for intensive care unit support (0.001) was significantly higher and duration of hospital stay was significantly shorter (P = 0.012) in patients who died. Kidney biopsy was done in total of 22 patients. Predominant lesion on kidney biopsy was acute tubular necrosis (ATN) in 20 (91%) cases. In 11 cases had severe ATN and in other nine (41%) cases kidney biopsy showed features of ATN associated with mild to moderate acute interstitial nephritis (AIN). One patient only had moderate AIN and one had patchy renal cortical necrosis (RCN).
CONCLUSION AKI due to snake bite is severe and a high proportion requires renal replacement therapy. On renal histology ATN and AIN are common, RCN is rare.
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Aye KP, Thanachartwet V, Soe C, Desakorn V, Thwin KT, Chamnanchanunt S, Sahassananda D, Supaporn T, Sitprija V. Clinical and laboratory parameters associated with acute kidney injury in patients with snakebite envenomation: a prospective observational study from Myanmar. BMC Nephrol 2017; 18:92. [PMID: 28302077 PMCID: PMC5353953 DOI: 10.1186/s12882-017-0510-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/09/2017] [Indexed: 01/04/2023] Open
Abstract
Background Snakebite-related acute kidney injury (AKI) is a common community-acquired AKI in tropical countries leading to death and disability. The aims of this study were to (1) determine the occurrence of snakebite-related AKI, (2) assess factors at presentation that are associated with snakebite-related AKI, and (3) determine the outcomes of patients with snakebite-related AKI. Methods We conducted a prospective observational study of patients with snake envenomation at the three academic tertiary care hospitals in Yangon, Myanmar between March 2015 and June 2016. Patient data including baseline characteristics, clinical and laboratory findings, hospital management, and outcomes were recorded in a case report form. A stepwise multivariate logistic regression analysis using a backward selection method determined independent factors significantly associated with AKI. Results AKI was observed in 140 patients (54.3%), the majority of whom were AKI stage III (110 patients, 78.6%). AKI occurred at presentation and developed during hospitalization in 88 (62.9%) and 52 patients (37.1%), respectively. Twenty-seven patients died (19.3%), and 69 patients (49.3%) required dialysis. On multivariate logistic regression analysis, (1) snakebites from the Viperidae family (odds ratio [OR]: 9.65, 95% confidence interval [CI]: 2.42–38.44; p = 0.001), (2) WBC >10 × 103 cells/μL (OR: 3.55, 95% CI: 1.35–9.34; p = 0.010), (3) overt disseminated intravascular coagulation (OR: 2.23, 95% CI: 1.02–4.89; p = 0.045), (4) serum creatine kinase >500 IU/L (OR: 4.06, 95% CI: 1.71–9.63; p = 0.001), (5) serum sodium <135 mmol/L (OR: 4.37, 95% CI: 2.04–9.38; p < 0.001), (6) presence of microscopic hematuria (OR: 3.60, 95% CI: 1.45–8.91; p = 0.006), and (7) duration from snakebite to receiving antivenom ≥2 h (OR: 3.73, 95% CI: 1.48–9.37; p = 0.005) were independently associated with AKI. Patients bitten by Viperidae with normal renal function who had serum sodium <135 mmol/L had a significantly higher urine sodium-to-creatinine ratio than those with serum sodium ≥135 mmol/L (p < 0.001). Conclusions Identifying factors associated with snakebite-related AKI might help clinicians to be aware of snakebite patients who are at risk of AKI, particularly patients who demonstrate renal tubular dysfunction after Viperidae bites. Electronic supplementary material The online version of this article (doi:10.1186/s12882-017-0510-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kyi-Phyu Aye
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.,Medical Ward (I), 1000 Bedded Hospital, Naypyitaw, 15011, Myanmar
| | - Vipa Thanachartwet
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.
| | - Chit Soe
- Department of Rheumatology, University of Medicine 1, Lanmadaw, Yangon, 11131, Myanmar
| | - Varunee Desakorn
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - Khin-Thida Thwin
- Department of Nephrology, University of Medicine 1, Lanmadaw, Yangon, 11131, Myanmar
| | - Supat Chamnanchanunt
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - Duangjai Sahassananda
- Information Technology Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - Thanom Supaporn
- Division of Nephrology, Phramongkutklao Hospital, Bangkok, 10400, Thailand
| | - Visith Sitprija
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand.,Queen Saovabha Memorial Institute, Thai Red Cross, Bangkok, 10330, Thailand
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Singh RR, Uraiya D, Kumar A, Tripathi N. Early demographic and clinical predictors of developing acute kidney injury in snake bite patients: A retrospective controlled study from an Indian tertiary care hospital in North Eastern Uttar Pradesh India. Indian J Crit Care Med 2016; 20:404-8. [PMID: 27555694 PMCID: PMC4968062 DOI: 10.4103/0972-5229.186221] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Aims: This study was conducted retrospectively to define early demographic and clinical predictors for acute kidney injury (AKI) among snake bite patients at the time of hospital admission. Materials and Methods: We analyzed 138 cases with a poisonous snake bite. Patients were classified into two groups according to the presence and absence of AKI. The data regarding clinical features and demographic profile of these patients were collected from the hospital records in a prestructured pro forma and statistically compared. Results: Of the 138 patients of venomous snake bite, 62 developed AKI (44.92%). Patients who developed AKI were older in age. Moreover, prolonged bite to anti-snake venom (ASV) time had a significant relationship in developing AKI (P < 0.05). Among the clinical features, there was an independent positive association of AKI with abdomen pain, tenderness and vomiting, cellulitis, bleeding tendencies, myalgia, and black or brown urine (P < 0.05). Neurological features were inversely associated with renal involvement. Conclusion: We found that marked abdominal pain, tenderness and vomiting, myalgia, black or brown urine, bite site cellulitis, bleeding tendencies, and prolonged (>2 h) bite to ASV time were significantly associated with the development of AKI in snake bite patients.
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Affiliation(s)
- R R Singh
- Department of Medicine, Hind Institute of Medical Sciences, Barabanki, Uttar Pradesh, India
| | - Dharmendra Uraiya
- Department of Medicine, Hind Institute of Medical Sciences, Barabanki, Uttar Pradesh, India
| | - Anoop Kumar
- Department of Medicine, Hind Institute of Medical Sciences, Barabanki, Uttar Pradesh, India
| | - Neeraj Tripathi
- Department of Medicine, Hind Institute of Medical Sciences, Barabanki, Uttar Pradesh, India
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Nkwescheu A, Mbasso LCD, Pouth FBB, Dzudie A, Billong SC, Ngouakam H, Diffo JLD, Eyongorock H, Mbacham W. Snakebite in bedroom kills a physician in Cameroon: a case report. Pan Afr Med J 2016; 24:231. [PMID: 27800086 PMCID: PMC5075470 DOI: 10.11604/pamj.2016.24.231.7576] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 07/03/2016] [Indexed: 11/11/2022] Open
Abstract
The World Health Organization (WHO) classifies snake bites as neglected public health problem affecting mostly tropical and subtropical countries. In Africa there are an estimated 1 million snake bites annually with about half needing a specific treatment. Women, children and farmers in poor rural communities in developing countries are the most affected. Case management of snake bites are not adequate in many health facilities in developing countries where personnel are not always abreast with the new developments in snake bite management and in addition, quite often the anti-venom serum is lacking. We report the case of a medical doctor bitten by a cobra in the rural area of Poli, Cameroon while asleep in his bedroom. Lack of facilities coupled with poor case management resulted in a fatal outcome.
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Affiliation(s)
- Armand Nkwescheu
- Cameroon Society of Epidemiology, CaSE, Cameroon; Faculty of Medicine and Biomedical Science, University of Yaoundé I, Cameroon; Division of Health Operations Research, Ministry of Public Health of Cameroon, Cameroon; Laboratory of Public Health for Research Biotechnologies, Biotechnology Center, UY I, Cameroon
| | - Leopold Cyriaque Donfack Mbasso
- Faculty of Medicine and Biomedical Science, University of Yaoundé I, Cameroon; Expanded Program of Immunization, Ministry of Public Health of Cameroon, Cameroon; Central Africa Field Epidemiology and Laboratory Training Program (CAFELTP), Cameroon
| | - Franky Baonga Ba Pouth
- Cameroon Society of Epidemiology, CaSE, Cameroon; Expanded Program of Immunization, Ministry of Public Health of Cameroon, Cameroon; Central Africa Field Epidemiology and Laboratory Training Program (CAFELTP), Cameroon; Centre Régional de Prévention et la Lutte contre les Epidémies pour le Centre (CERPLE- C), Cameroon
| | - Anastase Dzudie
- Department of Medicine, Douala General Hospital, Douala, Cameroon
| | - Serge Clotaire Billong
- Faculty of Medicine and Biomedical Science, University of Yaoundé I, Cameroon; National AIDS Control Committee of Cameroon, Central Technical Group, Cameroon
| | - Hermann Ngouakam
- Cameroon Society of Epidemiology, CaSE, Cameroon; Synergies Africaines pour les Souffrances contre le SIDA, Yaoundé, Cameroon
| | - Joseph Le Doux Diffo
- Cameroon Herpetology, Conservation Biology Foundation (CAMHERP-CBF), Cameroon; Global Viral Cameroon (GVC), Cameroon
| | - Hanny Eyongorock
- National Medical Council of Pharmacists of Cameroon(ONPC), Cameroon; Directorate of Pharmacy, Medicines and Laboratory, Ministry of Public Health of Cameroon, Cameroon
| | - Wilfred Mbacham
- Cameroon Society of Epidemiology, CaSE, Cameroon; Faculty of Medicine and Biomedical Science, University of Yaoundé I, Cameroon; Laboratory of Public Health for Research Biotechnologies, Biotechnology Center, UY I, Cameroon
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Priyamvada PS, Shankar V, Srinivas BH, Rajesh NG, Parameswaran S. Acute Interstitial Nephritis Following Snake Envenomation: A Single-Center Experience. Wilderness Environ Med 2016; 27:302-6. [PMID: 26970860 DOI: 10.1016/j.wem.2015.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/05/2015] [Accepted: 12/07/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To identify the clinical and histopathological characteristics of patients who develop acute interstitial nephritis (AIN) following snake envenomation. METHODS A retrospective analysis of patients diagnosed with snake envenomation-induced AIN from October 2013 to November 2014. RESULTS After snake envenomation, 88 patients developed acute kidney injury (AKI). Biopsies were performed on 7 patients due to nonrecovery of kidney function. Among these, 5 patients had AIN. Thus, AIN accounted for 5.7% of snakebite-related acute kidney injury. All patients had severe envenomation at presentation and had prolonged renal failure. Kidney biopsy found a mixed infiltrate composed of predominantly lymphocytes, with variable proportions of other cells including eosinophils neutrophils and plasma cells. The response rate to corticosteroids was 80%. CONCLUSIONS AIN after snake bite is not uncommon. AIN needs to be considered in patients with persistent renal failure after snake envenomation. Identifying this complication is of utmost importance because of the potentially reversible nature.
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Affiliation(s)
- P S Priyamvada
- Departments of Nephrology (Drs Priyamvada, Shankar, and Parameswaran) and Pathology (Drs Srinivas and Rajesh), Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
| | - Vijay Shankar
- Departments of Nephrology (Drs Priyamvada, Shankar, and Parameswaran) and Pathology (Drs Srinivas and Rajesh), Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - B H Srinivas
- Departments of Nephrology (Drs Priyamvada, Shankar, and Parameswaran) and Pathology (Drs Srinivas and Rajesh), Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - N G Rajesh
- Departments of Nephrology (Drs Priyamvada, Shankar, and Parameswaran) and Pathology (Drs Srinivas and Rajesh), Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sreejith Parameswaran
- Departments of Nephrology (Drs Priyamvada, Shankar, and Parameswaran) and Pathology (Drs Srinivas and Rajesh), Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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21
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Feitosa EL, Sampaio VS, Salinas JL, Queiroz AM, da Silva IM, Gomes AA, Sachett J, Siqueira AM, Ferreira LCL, dos Santos MC, Lacerda M, Monteiro W. Older Age and Time to Medical Assistance Are Associated with Severity and Mortality of Snakebites in the Brazilian Amazon: A Case-Control Study. PLoS One 2015; 10:e0132237. [PMID: 26168155 PMCID: PMC4500501 DOI: 10.1371/journal.pone.0132237] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 06/11/2015] [Indexed: 01/13/2023] Open
Abstract
The Amazon region reports the highest incidence of snakebite envenomings in Brazil. We aimed to describe the epidemiology of snakebites in the state of Amazonas and to investigate factors associated with disease severity and lethality. We used a nested case-control study, in order to identify factors associated with snakebite severity and mortality using official Brazilian reporting systems, from 2007 to 2012. Patients evolving to severity or death were considered cases and those with non-severe bites were included in the control group. During the study period, 9,191 snakebites were recorded, resulting in an incidence rate of 52.8 cases per 100,000 person/years. Snakebites mostly occurred in males (79.0%) and in rural areas (70.2%). The most affected age group was between 16 and 45 years old (54.6%). Fifty five percent of the snakebites were related to work activities. Age ≤15 years [OR=1.26 (95% CI=1.03-1.52); (p=0.018)], age ≥65 years [OR=1.53 (95% CI=1.09-2.13); (p=0.012)], work related bites [OR=1.39 (95% CI=1.17-1.63); (p<0.001)] and time to medical assistance >6 hours [OR=1.73 (95% CI=1.45-2.07); (p<0.001)] were independently associated with the risk of severity. Age ≥65 years [OR=3.19 (95% CI=1.40-7.25); (p=0.006)] and time to medical assistance >6 hours [OR=2.01 (95% CI=1.15-3.50); (p=0.013)] were independently associated with the risk of death. Snakebites represent an occupational health problem for rural populations in the Brazilian Amazon with a wide distribution. These results highlight the need for public health strategies aiming to reduce occupational injuries. Most cases of severe disease occurred in the extremes of age, in those with delays in medical attention and those caused by Micrurus bites. These features of victims of snakebite demand adequate management according to well-defined protocols, including prompt referral to tertiary centres when necessary, as well as an effective response from surveillance systems and policy makers for these vulnerable groups.
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Affiliation(s)
- Esaú L. Feitosa
- Departamento de Ensino e Pesquisa, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Vanderson S. Sampaio
- Departamento de Ensino e Pesquisa, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil
- Núcleo de Sistemas de Informação, Fundação de Vigilância em Saúde do Amazonas, Manaus, Brazil
| | - Jorge L. Salinas
- Department of Medicine, Emory University, Atlanta, United States of America
| | - Amanda M. Queiroz
- Departamento de Ensino e Pesquisa, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Iran Mendonça da Silva
- Departamento de Ensino e Pesquisa, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil
| | - André A. Gomes
- Departamento de Ensino e Pesquisa, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Jacqueline Sachett
- Departamento de Ensino e Pesquisa, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil
| | - André M. Siqueira
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Luiz Carlos L. Ferreira
- Departamento de Ensino e Pesquisa, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil
| | | | - Marcus Lacerda
- Departamento de Ensino e Pesquisa, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil
- Instituto Leônidas & Maria Deane, Fundação Oswaldo Cruz, Manaus, Brazil
| | - Wuelton Monteiro
- Departamento de Ensino e Pesquisa, Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Brazil
- Escola Superior de Ciências da Saúde, Universidade do Estado do Amazonas, Manaus, Brazil
- * E-mail:
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22
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Mohamed F, Endre ZH, Buckley NA. Role of biomarkers of nephrotoxic acute kidney injury in deliberate poisoning and envenomation in less developed countries. Br J Clin Pharmacol 2015; 80:3-19. [PMID: 26099916 DOI: 10.1111/bcp.12601] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 12/17/2014] [Accepted: 01/29/2015] [Indexed: 12/20/2022] Open
Abstract
Acute kidney injury (AKI) has diverse causes and is associated with increased mortality and morbidity. In less developed countries (LDC), nephrotoxic AKI (ToxAKI) is common and mainly due to deliberate ingestion of nephrotoxic pesticides, toxic plants or to snake envenomation. ToxAKI shares some pathophysiological pathways with the much more intensively studied ischaemic AKI, but in contrast to ischaemic AKI, most victims are young, previously healthy adults. Diagnosis of AKI is currently based on a rise in serum creatinine. However this may delay diagnosis because of the kinetics of creatinine. Baseline creatinine values are also rarely available in LDC. Novel renal injury biomarkers offer a way forward because they usually increase more rapidly in AKI and are normally regarded as absent or very low in concentration, thereby reducing the need for a baseline estimate. This should increase sensitivity and speed of diagnosis. Specificity should also be increased for urine biomarkers since many originate from the renal tubular epithelium. Earlier diagnosis of ToxAKI should allow earlier initiation of appropriate therapy. However, translation of novel biomarkers of ToxAKI into clinical practice requires better understanding of non-renal factors in poisoning that alter biomarkers and the influence of dose of nephrotoxin on biomarker performance. Further issues are establishing LDC population-based normal ranges and assessing sampling and analytical parameters for low resource settings. The potential role of renal biomarkers in exploring ToxAKI aetiologies for chronic kidney disease of unknown origin (CKDu) is a high research priority in LDC. Therefore, developing more sensitive biomarkers for early diagnosis of nephrotoxicity is a critical step to making progress against AKI and CKDu in the developing world.
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Affiliation(s)
- Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka.,Clinical Pharmacology and Toxicology Group, Professorial Medicine Unit, The Prince of Wales Clinical School, University of New South Wales, NSW, Australia.,Department of Pharmacy, Faculty of Allied Health Science, University of Peradeniya, Sri Lanka
| | - Zoltan H Endre
- Department of Nephrology, Prince Of Wales Hospital and Clinical School, University of New South Wales, Sydney, Australia
| | - Nicholas A Buckley
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka.,Clinical Pharmacology and Toxicology Group, Professorial Medicine Unit, The Prince of Wales Clinical School, University of New South Wales, NSW, Australia.,Pharmacology, SOMS, Sydney Medical School, University of Sydney, NSW, Australia
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