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Ramazan Danis, Sehmus Ozmen, Mustafa Kemal Celen, Davut Akin, Celal
Ayaz & Orhan Yazanel
To cite this article: Ramazan Danis, Sehmus Ozmen, Mustafa Kemal Celen, Davut Akin, Celal
Ayaz & Orhan Yazanel (2008) Snakebite-Induced Acute Kidney Injury: Data from Southeast
Anatolia, Renal Failure, 30:1, 51-55, DOI: 10.1080/08860220701742021
CLINICAL STUDY
LRNF
Davut Akin
Dicle University School of Medicine, Department of Nephrology, Diyarbakir, Turkey
Celal Ayaz
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Orhan Yazanel
Dicle University School of Medicine, Department of Nephrology, Diyarbakir, Turkey
51
52 R. Danis et al.
Patients Data WBC were significantly higher in the AKI group when
compared to the non-AKI group (p = 0.001). None of the
There was no difference between groups regarding patients had hemorrhage.
age, arrival time to hospital, and hospital stay (see Table 1).
Both groups received similar hydration and therapy at
admission. All detectable bites were seen on exposed parts DISCUSSION
of the body: 99 (26%) on the foot, 77 (20%) toe, 74 (19%)
fingers, 64 (17%) hands, 41 (11%) legs, 21 (6%) arms, and Snakebite evenomation is not an uncommon etiological
two faces. Death was due to sepsis (n = 1), multiorgan factor for acute renal failure (ARF) in developing countries.
failure (n = 1), and anaphylactic reaction (n = 1). Nearly all venomous snakes in Turkey and Southeast
Anatolia are members of the Viperidae family and show
poisonous local and hematoxic effects. Venomous snakes
Laboratory Evaluation of Rhabdomyolysis seen in Turkey are subgroups of V.ammodytes, V. barani, V.
ursunii, V. raddei, V. kaznokovi, V. pontica, V. wagneri, V.
Serum CK levels were high in both groups. But the labetina, V. xanthina, Walterinnesea aegyptia, Malpolon
difference was insignificant. The number of subjects with monspessulanus, and Telescopus fallaks. Most snakebites
a CK increased five-fold of upper limits was higher in the are caused by non-venomous snakes.[5]
AKI group than the non-AKI group, though the difference
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was insignificant.
Prevalence of ARF
Hematology and Coagulation Time The prevalence of AKI our study was 8% (n = 16) and
mortality rate of AKI was 18% (n = 3). Dialysis was required
There was no significant difference regarding hemo- in 25% (n = 4) patients. The remaining 13 patients recovered
globin, platelet levels, and prothrombin time at admission. their renal functions completely, and no patient remained
The prevalence of thrombocytopenia (<150000 K/UL) was dialysis-dependant. The significant recovery of the GFR in
60% in AKI group and 40% in non-AKI group (p > 0.05). almost all patients of the ARF group confirmed the acute
nature of the renal insult. The incidence of acute renal failure
caused by these snakes varies from 5% to 29%, depending on
Table 1 the species of snake and the severity of envenoming.[68] The
Characteristics of patients with snakebite highly venomous snakes most commonly encountered are
AKI(+) AKI(-) p
Russells viper (subfamily viperinae), snakes of the bothtrops
species (subfamily crotalinea), and rattlesnakes. The inci-
Age (years) 40.3 18.8 34.5 16 NS dence of ARF following Russells viper bite has been esti-
Sex (F/M) 8/8 97/87 NS mated to be 1332%,[1] and the prevalence of ARF following
Urea (g/dL) 113 78 38 14 p < 0.001 bothtrops snakebite ranges from 210%.[68].
Creatine (mg/dL) 2.85 2 0.7 0.2 p < 0.001 In a retrospective study of 360 patients envenomed with
Albumin (g/dL) 2.9 05 3.7 0.8 p = 0.013 echis carinatus (saw-scaled viper), 62 (17%) patients devel-
LDH (U/L) 375 224 304 144 NS
oped acute renal failure (ARF), 44 patients (71%) needed
AST (U/L) 71 57 37 34 p = 0.002
dialysis, and 16 patients (25%) died.[9] Another prospective
ALT (U/L) 45 38 31 31.7 NS
CK (U/L) 545 652 369 635 NS observational study of 100 patients envenomed with crotalus
LDH (U/L) 375 224 304 144 NS durissus was reported, showing a 29% prevalence of ARF.
DIC (%) %25 %7.1 p = 0.014 Of those, 24% required dialysis and 10% died.[10] The preva-
WBC (K/UL) 19.3 3.7 14.5 5.4 p = 0.001 lence of ARF was reported to 28.6% after viperedia family
Hb (g/dL) 13.2 3.4 13.2 2.5 NS snake bites in India, yet antivenom administration rate was
Plt (K/UL) 138 137.9 175 96 NS only 8% in these patients.[1] The low prevalence in our study
PTZ (sn) 17.1 2.9 15 3.3 NS may be due to early and high antivenom administration rate.
CRP (mg/dL) 26.8 22.5 18.4 20 NS
Arrival time to 3.2 1.9 2.8 2.1 NS
hospital (hours) Risk Factors for Development of ARF
Duration of 6.7 3.6 7.82 4 NS
hospitalisation (day)
The finding that the delay to administer an adequate
AV dose 2.3 0.7 2.3 1.7 NS
dose of the antivenom increases more than 10 times the
54 R. Danis et al.
with that reported in literature (i.e., 13 hours).[14,15] The mortality rate was 25% in our patients and compatible
Disseminated intravascular coagulation (DIC) is a consis- with the literature.
tent feature in patients bitten by several species of snakes.[4,9] The presence of DIC is significantly higher in the AKI
Viper venom produces the activation of factor V with fibrinol- group than the non-AKI group (p = 0.014). Viper bite can
ysis, leading to DIC. This can result in hemorrhage, hypov- cause mild renal failure.[23] A low demand for dialysis in
olemia, and thrombin in the microvasculature and glomerular our study supports this finding. WBC count was signifi-
capillaries and a microangiopathic hemolytic anemia with cantly higher in the AKI group than those without AKI (p =
subsequent ARF.[16] DIC plays a major pathogenetic role in 0.001), and serum albumin was significantly lower in the
the renal lesions of snakebite-induced cortical necrosis.[4,16] AKI group than those without AKI (p = 0.013). Because
DIC was observed in the 25% of AKI group and was signifi- albumin is a relatively slow-reacting negative acute-phase
cantly higher than the non-AKI group (7.1%) (p = 0.014). reactant that may be associated with high mortality in acute
Rhabdomyolysis is a well-known cause of renal renal failure,[24] serum high WBC and low albumin may
injury.[17,18] The clinical diagnosis of rhabdomyolysis is reflect the severity of inflammation in our cases.
established when CK increases five or more times above
normal levels, with a suggestive clinical picture and without
heart and/or cerebral injury. Serum CK levels were increased CONCLUSION
in both groups, but the difference was insignificant. The per-
centage of subjects with a CK increased five-fold of upper AKI is an important complication of snakebite and a
limits was higher in AKI group than non-AKI group, though may lead mortality. Although it has some troublesome
again the difference was insignificant. A previous study aspects due to its retrospective design, this is a large series
reported high rhabdomyolysis prevalence in ARF group.[10] from Southeast Anatolia of Turkey in an adult population.
The insignificance in our study regarding the prevalence of Subjects with high WBC or low albumin or those compli-
rhabdomyolysis may be due to a low number of subjects cated with DIC should be closely followed up for develop-
with AKI or extracellular volume expansion administration ment of AKI.
to our all subjects. Because the most effective measure for
the prevention of ARF induced by rhabdomyolysis is extra-
cellular volume expansion with saline solution combined
with sodium bicarbonate and mannitol.[18,19] REFERENCES
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