Clinical Practice Recommendations: Snakebite-envenomation-associated Acute Kidney Injury

Snakebite is a neglected tropical disease of major public health importance in India, contributing to significant morbidity and mortality. Acute kidney injury (AKI) is among the most serious complications of envenomation, particularly with viperid and some elapid species, and is associated with long-term chronic kidney disease (CKD) risk.

This article aims to provide evidence-based recommendations for the recognition, evaluation, and management of snakebite-envenomation-associated AKI (SAKI), integrating global best practices with national treatment protocols and resource realities.

The authors reviewed available literature through PubMed and international recommendations, including the Government of India's Standard Treatment Guidelines (STG), World Health Organization (WHO) guidance, and Kidney Disease Improving Global Outcomes (KDIGO) AKI guidelines. As per the available evidence, the recommendations were formulated through expert panel deliberations.

Key recommendations include early recognition of envenomation syndromes, prompt administration of polyvalent antisnake venom (ASV), protocolized monitoring of coagulation and renal parameters, and standardized use of kidney replacement therapy (KRT) according to KDIGO indications. Supportive management of venom-induced consumption coagulopathy (VICC), rhabdomyolysis, and thrombotic microangiopathy (TMA) is emphasized. Special considerations have been outlined for children, pregnant women, patients with preexisting kidney disease, and those bitten by non-"Big Four" snakes.

SAKI is preventable and treatable with timely intervention, but survivors remain at risk of CKD. With these recommendations, the authors have tried to standardize the diagnostic and therapeutic approach across general medicine, nephrology, and critical care medicine teams in India, aiming to reduce mortality and improve renal outcomes.