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Thrombotic Microangiopathy: An Under-Recognised Cause of Snake-bite-related Acute Kidney Injury

Indu Ramachandra Rao¹, Attur Ravindra Prabhu¹, Shankar Prasad Nagaraju¹

¹Department of Nephrology, Kasturba Medical College and Hospital, Manipal Academy of Higher Education, Manipal, Karnataka, India.

Indian Journal of Nephrology

|October 2, 2019

Abstract

Introduction:

Thrombotic microangiopathy (TMA) as a cause of snake-bite-induced acute kidney injury (AKI) is rarely reported. Very little is known about the clinical course, optimal management, and prognosis of this entity. We describe a series of snake-bite-induced TMA and compare their outcomes with those without TMA.

Methods:

This was a single-center retrospective study of patients with AKI following snake envenomation admitted between January 2012 and December 2017. Demographic profile, clinical parameters, and outcomes were studied. TMA was diagnosed based on presence of triad of microangiopathic hemolytic anemia, thrombocytopenia, and AKI, and groups with and without TMA were compared.

Results:

Of 103 patients with AKI following snake bite, 19 (18.5%) had clinical evidence of TMA. All patients with TMA had advanced azotemia (mean peak serum creatinine 9.5 ± 3.0 mg/dL), with 18 (95%) requiring renal replacement therapy (RRT). Thirteen (68%) had either complete or partial recovery of renal functions, two (10%) progressed to end-stage renal disease, and one died (three patients were lost to follow-up). Age ≥50 years, presence of oliguria/anuria, anti-snake venom dose ≥10 vials, and urea ≥80 mg/dL at presentation were independently associated with TMA (P < 0.05). RRT requirement (95% vs. 57%), mean number of RRT sessions (18 vs. 4.5 sessions), and hospital stay ≥7 days (84% vs. 58%) were higher in patients with TMA (P < 0.05), but patient outcomes did not differ.

Conclusions:

In conclusion, TMA was seen in 18.5% of patients with snake-bite-related AKI in our study and was associated with almost universal need for RRT, longer duration on RRT, and hospital stay compared with patients without TMA.

Insights

Thrombotic microangiopathy (TMA) following snake bites caused acute kidney injury (AKI) in 18.5% of patients. This condition necessitated renal replacement therapy (RRT) and prolonged hospital stays, though patient outcomes were similar to those without TMA.

Area of Science:

Nephrology
Hematology
Toxicology

Background:

Thrombotic microangiopathy (TMA) is a rare cause of snake-bite-induced acute kidney injury (AKI).
Limited data exists on the clinical course, management, and prognosis of snake-bite-induced TMA.
This study investigates snake-bite-induced TMA and compares outcomes with non-TMA cases.

Purpose of the Study:

To describe the clinical characteristics of snake-bite-induced TMA.
To compare outcomes of AKI patients with and without TMA following snake envenomation.
To identify factors associated with TMA in snake-bite AKI.

Main Methods:

Retrospective single-center study of 103 patients with AKI post-snake envenomation (Jan 2012-Dec 2017).
TMA diagnosis based on microangiopathic hemolytic anemia, thrombocytopenia, and AKI.
Comparison of demographic, clinical parameters, and outcomes between TMA and non-TMA groups.

Main Results:

18.5% of AKI patients (19/103) exhibited TMA.
TMA patients had advanced azotemia, with 95% requiring renal replacement therapy (RRT).
Age ≥50, oliguria/anuria, high anti-snake venom dose, and elevated urea were associated with TMA.

Conclusions:

TMA occurred in 18.5% of snake-bite AKI cases, universally requiring RRT.
Patients with TMA experienced longer RRT duration and hospital stays.
Despite differences in RRT and stay, overall patient outcomes did not significantly differ between groups.

Read full analysis

Keywords:

Acute kidney injury hemolytic uremic syndrome snake envenomation thrombotic microangiopathy

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