|Year : 2023 | Volume
| Issue : 1 | Page : 57-60
Clinical profile and outcome of AKI in snake bite in a tertiary care hospital, India
Aruna Acharya1, Haladhar Naik2
1 Associate Professor and HOD, Department of Nephrology, SCB Medical College, Cuttack, Odisha, India
2 Assistant Professor, Department of Surgery, SCB Medical College, Cuttack, Odisha, India
|Date of Submission||01-Dec-2022|
|Date of Decision||06-Feb-2023|
|Date of Acceptance||05-Mar-2023|
|Date of Web Publication||28-Apr-2023|
Assistant Professor, Department of Surgery, SCB Medical College Hospital, Cuttack, Odisha
Source of Support: None, Conflict of Interest: None
Introduction: Acute kidney injury (AKI) is one of the complications of envenomation that is frequently fatal. Aim: To evaluate the clinical profile and outcome of AKI in snake bite patients and to identify the predictors of mortality in these patients. Methods: All patients admitted with history of envenomation and AKI were included in the study. A detailed history was obtained from all the patients about the time of antisnake venom administration and time interval between the event and admission in hospital, and then hematological and biochemical investigations were performed. Results: A total of 202 patients were diagnosed with snake bite induced AKI, of which 8.6% had died. Majority of patients were males (82.7%). The dialysis requirement was significantly higher in patients who died as compared to those who survived (100% vs. 72.6%, p = 0.013). The disseminated intravascular coagulation was found to be higher in patients who died due to snake bite (p < 0.001). The median (range) length of hospitalization was shorter for the nonsurvivors than the survivors (3.0 [1.0–4.0] days vs. 8.0 [3.0–27.0] days; p < 0.001). Compared to patients who survived, the total leukocyte count and serum urea were significantly higher among patients who died due to snake bite induced AKI. Conclusion: The present study revealed that higher dialysis requirement, high complication rate, and lower duration of hospital stay were the risk factors associated with patients who died due to snake bite induced AKI.
Keywords: acute kidney injury, dialysis, disseminated intravascular coagulation, envenomation
|How to cite this article:|
Acharya A, Naik H. Clinical profile and outcome of AKI in snake bite in a tertiary care hospital, India. MAMC J Med Sci 2023;9:57-60
|How to cite this URL:|
Acharya A, Naik H. Clinical profile and outcome of AKI in snake bite in a tertiary care hospital, India. MAMC J Med Sci [serial online] 2023 [cited 2023 Jun 6];9:57-60. Available from: https://www.mamcjms.in/text.asp?2023/9/1/57/375339
| Introduction|| |
A snake bite is a public health issue as it is widely neglected in many tropical and subtropical countries. An estimated 5.4 million snake bites occur annually, resulting in approximately 81,410 to 137,880 deaths due to envenoming, of which India alone is responsible for 58,000 deaths. In tropical India, where farming is a major source of employment, snake bites are a common medical emergency and an occupational hazard.
Acute kidney injury (AKI) is one of the complications of envenomation that is frequently fatal. Therefore, to achieve a favorable patient outcome, proper supportive management following the administration of antisnake venom is vital.
Acute tubular necrosis is the main cause of snake bite induced AKI. Acute interstitial nephritis, cortical necrosis, glomerulonephritis, and vasculitis are other factors contributing to AKI. Hemorrhage can be caused due to vasoactive mediators, cytokines, and direct venom toxicity. The most common complications following hemotoxic snakebites include disseminated intravascular coagulation (DIC), renal failure, intravascular hemolysis, and acute respiratory disease syndrome., In India, patients with Russell’s Viper bites are more likely to develop acute renal damage, which can lead to mortality. By administering antisnake venom (ASV) early and by intervening in conjunction with appropriate measures, the fatality rate can be minimized.
The objective of this study was to evaluate the clinical profile and outcome of AKI in snake bite patients and to identify the predictors of mortality in these patients.
| Methods|| |
This was a prospective observational study conducted at a tertiary care hospital. All patients admitted with history of envenomation and intake of poison were included in the study. At the time of admission, a detailed history was obtained from all the patients about the time of ASV administration and time interval between the event and admission in hospital, and then hematological and biochemical investigations were performed at the bedside. The laboratory investigations included hemoglobin, total leukocyte counts, platelet counts, red cell counts, liver function tests, serum creatinine, urea, sodium, potassium, and blood sugar.
The presence of an AKI, which is defined as an abrupt increase in serum creatinine 0.3 mg/dL or more than 50% increase from baseline or oliguria ≤0.5 mg/kg/hr for ≥6 hour or serum creatinine ≥1.5 mg/dL measured at the time of admission and every alternate day till discharge. KDIGO (Kidney Disease Improving Global Outcomes) AKI guideline was used to categorize patients according to the severity of disease. All reported cases were of vasculotoxic snake bites caused by snakes belonging to the Viperidae species.
All the patients received the tetanus toxoid. As all these patients had renal failure, they were considered as having severe envenomation, and hence ASV was administered in a dose range of 1 to 10 vials (10 to 110 mL) as needed. To diagnose DIC, we used the guidelines for screening tests proposed by Yu et al.
Patients were classified as per outcome in the form of discharge (survivals) and death (nonsurvivals) and various parameters including demographic, clinical characteristics, and laboratory findings were compared between two groups.
Data were analyzed using statistical analysis using SPSS software (version 23). The qualitative data were expressed as number and frequency, whereas the quantitative data were expressed as mean (standard deviation [SD]) or median (range). Categorical and continuous variables were compared with the chi-square test and Mann–Whitney U test, respectively. Statistical significance was defined as p < 0.05.
| Results|| |
A total of 202 patients admitted with venomous snake bite induced AKI were included in this study, of which 186 survived and 16 died. The median (range) age was 36.0 (7.0–77.0) years, of them 14 were <18 years of age. Majority of patients were males (n = 167, 82.7%). The demographic and clinical characteristics of the study population are shown in [Table 1].
|Table 1 Demographic and Clinical Characteristics of Survival and Nonsurvival Groups|
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Out of 202 AKI patients, 30 patients underwent kidney biopsy; of them, 59.6% had acute tubular necrosis, 23% had acute cortical necrosis, and 8.6% had acute interstitial nephritis. According to KDIGO criteria, 38 (19.0%) patients had stage 1 AKI, 46 (22.5%) patients had stage 2 AKI, and 118 (58.5%) patients had stage 3 AKI. Among the stage III AKI patients, 8.6% became dialysis-dependent and required dialysis at the time of admission. These dialysis-dependent patients progressed to chronic kidney disease (CKD) and remained on maintenance hemodialysis. The bite-to-needle time and delayed ASV administration were higher in patients with more severe disease.
The age and sex were comparable between patients who survived and patients who died. The dialysis requirement was significantly higher in patients who died compared to patients who survived (100% vs. 72.6%, p = 0.013). The DIC was significantly higher among patients who died due to snake bite (p < 0.001).
Almost all the laboratory findings were comparable between survivors and nonsurvivors groups except total leukocyte count and serum urea level [Table 2]. The median (range) of the total leukocyte count was significantly higher among nonsurvivors compared to survivors (10,000 (7200–12,500) cells/mm3 vs. 8900 [4000–18,000] cells/mm3; p = 0.030). The median (range) serum urea level was significantly higher in the nonsurvivors (216.0 [210.0–224.0] mmol/L) than in the survivors (203.0 [98.0–258.0] mmol/L) (p = 0.015).
| Discussion|| |
Asia continues to be a significant source of AKI and CKD due to snake bites. The worldwide prevalence of developing AKI following snake bite was reported to be in the range of 8% to 43%.,,,,, About 5.6% to 3.8% of incidence of snake bite induced AKI was noted from India.,,,,, In developing countries such as India, snake bite AKI is generally attributed to visiting a traditional healer and tying tourniquets, which results in a higher incidence of sepsis and cellulitis. Here, in this study all the patients who developed AKI due to snake bite were included.
In the present study, majority of patients were males. Our findings were in accordance with those of earlier studies.,,, This may be because farming and other outdoor activities constitute the majority of their work, considering them as a major working population compared to females.
A mortality ranging from 9.1% to 52% has been reported in other studies of snake bite induced AKI.,, A recent study from India in patients with snake bite induced AKI reported mortality of 8.7%, which is in accordance with the present study. The median duration of hospitalization in the present study was significantly lower in patients who died. This is in agreement with the previous evidence-based literature., In this study, the mean duration of arrival at hospital after snake bite was 3.3 (0.9) days. In the present study, we observed swelling or oozing or fang marks at the bitten part are the earliest symptoms that are seen in the patients with snake bite. A study by Kumar S, et al. reported that snake bite victims usually arrived at the hospital 2.4 days after they were bitten. But his study further showed that the mean time to reach hospital after snake bite was increased to about 4.6 days in patients who died due to AKI. This indicates that timely referral is crucial when managing AKI after a snake bite. This observation is in agreement with the study done by Vikrant et al. In contrast, present study did not show any significant impact between time from snake bite to hospital administration and mortality.
The complications caused by snake bite include bleeding, hypotension, DIC, intravascular hemolysis, and rhabdomyolysis that enhance renal ischemia leading to AKI. DIC is characterized by the presence of microangiopathic hemolytic anemia, thrombocytopenia, and fibrin thrombi in renal microvasculature. This study revealed seven patients had DIC and all of them had died exhibiting its adverse impact on the survival of these patients.
When management of patients with snake bite induced AKI was compared between patients who died and those who survived, patients who died were more likely to required dialysis. Almost all of the patients who died due to snake bite induced AKI were on renal replacement therapy. However, Aye et al. reported comparable outcomes between patients who survived and died in terms of receiving renal replacement therapy and peritoneal dialysis as a dialysis method. Similar to this, Vikrant S, et al. reported no significant difference in the need for dialysis between the groups. Priyamvada et al. in their study reported need for dialysis found to be similar in patients with adverse kidney outcome and patients with normal kidney function. Even if our study reported significantly high requirement of dialysis in patients who died due to snake bite induced AKI, we did not observe any differences in the median number of dialysis requirement among patients who died.
In this study, there was no evidence that the severity of the envenomation affected the likelihood of future adverse renal events. There was no relationship between ASV dosage, time from snake bite to hospital administration, and serum creatinine level. Moreover, there were no significant differences in the biochemical parameters except total leukocyte count and serum urea between groups. Similar to this study, Priyamvada et al. reported significantly higher leukocyte count in patients who died but couldn’t find any relationship with serum urea. In contrast, Vikrant S, et al. reported that there was no significant difference in biochemical parameters between survival and nonsurvival groups.
Our study has some limitations. First, all the data came from single tertiary care hospital, which limits the generalizability of study outcomes. Second, we couldn’t record the information about the cause and type of snake bite. Third, renal biopsy was not included in the study, as it was done routinely for majority of patients at our center.
| Conclusion|| |
There is a substantial mortality risk associated with snake envenomation. The mortality for patients with snake bite induced AKI was found to be 8.6%. The present study revealed that higher dialysis requirement, high complication rate, and lower duration of hospital stay were the risk factors associated with patients who died due to snake bite induced AKI. However, government should take initiative by providing ASVs and all other necessary facilities in primary healthcare centers to prevent deaths due to snake bite.
Financial support and sponsorship
Conflicts of interest
Authors have nothing to disclose.
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[Table 1], [Table 2]