Envenomation is a significant yet underreported cause of community-acquired acute kidney injury (AKI) in warm tropical and subtropical areas of South Asia, Central and South America, the Middle East, Sub-Saharan Africa, Australia, and the Pacific Islands (1). Kidneys are specifically vulnerable to toxins from snakes, scorpions, spiders, bees, wasps, and certain marine animals. These “neglected tropical diseases” disproportionately affect populations with limited income in rural areas and children (2).
Snake envenomation
According to a recent World Health Organization estimate, approximately 5.4 million people worldwide are bitten by snakes, resulting in 1.8 to 2.7 million envenomations and 140,000 deaths each year (1). Snake envenomation is a medical emergency with severe kidney complications. Most venomous snakes belong to either the Elapidae or Viperidae family. Kidney involvement is more common with hemotoxic (Viperidae) and myotoxic (Viperidae, sea snakes) snakes, with AKI incidence ranging from 8% to 60% and mortality rates up to 45% (3). However, some Elapidae (neurotoxic) species can also cause local tissue injury, leading to rhabdomyolysis and AKI.
AKI following snake envenomation is multifactorial due to the direct and indirect effects of snake venom. The different mechanisms by which venom induces kidney damage include direct nephrotoxicity, a systemic inflammatory response causing oxidative stress, hemodynamic collapse leading to kidney ischemia, hemolysis leading to hemoglobinuria, rhabdomyolysis leading to myoglobinuria, and venom-induced consumption coagulopathy causing thrombi in renal microvasculature (4) (as shown in the visual graphic). Kidney histopathology may show acute tubular necrosis, cortical necrosis, pigment nephropathy, thrombotic microangiopathy, and acute interstitial nephritis. Rarely is proliferative glomerulonephritis with crescents reported with Russell's viper and Echis carinatus bites (5).
Early diagnosis and timely management are the keys to improved outcomes (Table). Clinical findings evolve with time, and AKI onset may vary from hours to days after envenomation, depending on the type and the amount of venom injected. Patients may present with bleeding, local tissue necrosis, hypotension, tachycardia, muscle cramps, oliguria, red- or brown-colored urine, elevated serum creatinine, and electrolyte imbalances. Management involves supportive care and prompt administration of species-specific antivenom to neutralize the circulating toxin. Outcomes range from death, persistent kidney failure requiring dialysis, and partial or complete kidney recovery. Progression to chronic kidney disease (CKD) is reported in up to 30%–40% of survivors (6). This can further strain the overwhelmed kidney care infrastructure in resource-limited countries, which are commonly affected by envenomation.
Dos and don'ts in the management of snake envenomation
Other venoms and kidney injury
Scorpion venom contains a variety of neurotoxins that disrupt ion channels, causing a massive release of neurotransmitters. This results in an “autonomic storm” characterized by severe circulatory disturbances with either hypertension or hypotension and arrhythmias. Kidney injury occurs due to direct nephrotoxicity or due to kidney ischemia (7). Management includes using antivenom, prazosin, and atropine if bradycardia is present. In some cases of wasp and bee stings, severe anaphylactic reactions and kidney injury can be seen due to hemolysis, rhabdomyolysis, hypotension, direct toxicity, and rarely acute interstitial nephritis (8, 9). Due to the lack of specific antivenoms, the management mainly includes supportive care.
Marine envenomation leading to AKI is generally caused by bites or stings from sea snakes, jellyfish, and sea anemones (10, 11). AKI results from severe muscle damage leading to acute tubular necrosis. Early identification and administration of venom-specific antidotes are warranted.
These sinister neglected tropical diseases caused by toxic envenomation mandate a call to action from the local and international medical fraternity. Vital strategies include sensitizing at-risk populations and improving access to early care, ensuring widespread availability to species-specific antivenom, minimizing the “bite-to-needle” time, standardized treatment protocols for supportive care, timely management of AKI and electrolyte disturbances, and long-term monitoring of kidney function in patients with partial kidney recovery.
Footnotes
References
- 1.↑
World Health Organization. Snakebite envenoming. https://www.who.int/health-topics/snakebite#tab=tab_1
- 2.↑
World Health Organization. Neglected tropical diseases. https://www.who.int/health-topics/neglected-tropical-diseases
- 3.↑
Sarkar S, et al. Snake bite associated with acute kidney injury. Pediatr Nephrol 2021; 36:3829–3840. doi: 10.1007/s00467-020-04911-x
- 4.↑
Kohli HS, Sakhuja V. Snake bites and acute renal failure. Saudi J Kidney Dis Transpl 2003; 14:165–176. https://journals.lww.com/sjkd/fulltext/2003/14020/snake_bites_and_acute_renal_failure.7.aspx
- 5.↑
Schabel F, et al. Glomerulonephritis following snake bite. Padiatr Padol 1980; 15:61–66. PMID: 7375118
- 6.↑
Waikhom R, et al. Long-term renal outcome of snake bite and acute kidney injury: A single-center experience. Ren Fail 2012; 34:271–274. doi: 10.3109/0886022X.2011.647297
- 7.↑
Angsanakul J, Sitprija V. Scorpion venoms, kidney and potassium. Toxicon 2013; 73:81–87. doi: 10.1016/j.toxicon.2013.06.023
- 8.↑
Dhanapriya J, et al. Wasp sting-induced acute kidney injury. Clin Kidney J 2016; 9:201–204. doi: 10.1093/ckj/sfw004
- 9.↑
Bezerra da Silva Junior G, et al. Acute kidney injury complicating bee stings—a review. Rev Inst Med Trop Sao Paulo 2017; 59:e25. doi: 10.1590/S1678-9946201759025
- 10.↑
Loy JS, et al. Rhabdomyolysis due to unidentified jellyfish envenomation in west Malaysian waters. Toxicon X 2023; 21:100170. doi: 10.1016/j.toxcx.2023.100170
- 11.↑
Mizuno M, et al. Acute renal failure after a sea anemone sting. Am J Kidney Dis 2000; 36:E10. doi: 10.1053/ajkd.2000.9006
