Early prediction of acute kidney injury by clinical features of snakebite patients at the time of hospital admission

Snake bite associated with acute kidney injury

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.

Retrospective evaluation of acute kidney injury in dogs with pit viper envenomation (2008-2017): 56 cases

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.

Prognosis and long-term outcomes of acute kidney injury due to snake envenomation

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.

Clinicopathological spectrum of snake bite-induced acute kidney injury from India

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.

Clinical and laboratory parameters associated with acute kidney injury in patients with snakebite envenomation: a prospective observational study from Myanmar

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.

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

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.

Clinical predictors of acute kidney injury following snake bite envenomation

Background:

Snake bite envenomation is a major public health concern in developing countries. Acute kidney injury (AKI) is as important cause of mortality in patients with vasculotoxic snake bite.

Aims:

This study was to evaluate the clinical profile of snake bite patients and to determine the predictors of developing AKI following snake bite.

Materials and Methods:

Two hundred and eighty-one patients with snake envenomation were included. Eighty-seven patients developed AKI (Group A) and 194 (Group B) did not. History, examination findings and investigations results were recorded and compared between the two groups.

Results:

In group A, 61 (70.11%) patients were male and in group B, 117 (60.30%) patients were male. Out of 281 patients, 232 had cellulitis, 113 had bleeding tendencies, 87 had oliguria, 76 had neuroparalysis, and 23 had hypotension at presentation. After multivariate analysis, bite to hospital time (P = 0.016), hypotension (P = 0.000), albuminuria (P = 0.000), bleeding time (P = 0.000), prothrombin time (P = 0.000), hemoglobin (P = 0.000) and total bilirubin (P = 0.010) were significant independent predictors of AKI.

Conclusions:

AKI developed in 30.96% of patients with snake bite, leading to mortality in 39.08% patients. Factors associated with AKI are bite to hospital time, hypotension, albuminuria, prolonged bleeding time, prolonged prothrombin time, low hemoglobin and a high total bilirubin.