Snake bite associated with acute kidney injury

Acute kidney injury, coagulopathy, and deep vein thrombosis following a haemotoxic snakebite: A case report from a resource-limited setting

BACKGROUND

The green pit viper (Trimeresurus gramineus) is a venomous snake commonly encountered in South Asia, particularly in Bangladesh, and responsible for many snakebite incidents. Management of its envenoming is challenging due to the lack of a specific antivenom, requiring symptomatic and supportive care to address complications. The following case report represents the complexities in managing such envenomation with associated renal and venous thrombotic complications.

CASE PRESENTATION

A 35-year-old female was admitted with left lower-limb swelling and ecchymosis following a snakebite. She was transferred from a primary-level hospital with acute kidney injury (serum creatinine 4.0 mg/dL) and venom-induced consumption coagulopathy (VICC) (high levels of d-dimer (15 mg/L), prothrombin time (28 seconds) and activated partial thromboplastin time (>120 sec). Duplex ultrasound confirmed presence of femoral vein thrombosis. The patient was treated with fresh frozen plasma along with other supportive measures. His renal function improved, with creatinine levels normalizing in days.

CONCLUSION

The management of green pit viper envenomation requires close monitoring of coagulation parameters and renal function, along with supportive care. The occurrence of unusual complications, such as deep vein thrombosis, necessitates a conservative and individualized approach to treatment. Further research is needed to better understand the pathophysiology and improve the therapeutic strategies for managing the sequelae of such envenomations.

Acute kidney injury induced by snakebites in pediatric patients

BACKGROUND

Snakebites are a significant public health problem worldwide, with a global prevalence estimated 2.7 million envenomings and 81,000 to 138,000 deaths annually. Acute kidney injury (AKI) is the main complication of snakebites, most associated with the Bothrops species in South and Central America. However, the reported incidence of AKI induced is not well established in the pediatric population. We aimed to evaluate the frequency of AKI and its risk factors in child victims of Bothrops snakebites.

METHODS

Children aged 0-18 years who were victims of Bothrops snakebites in Santa Catarina, Brazil, from 2014 to 2020 were retrospectively enrolled and evaluated for AKI using the Kidney Disease Improving Global Outcomes (KDIGO) definition and staging.

RESULTS

A total of 463 cases of bothropic accidents were studied. Of those, 15.9% (n = 74) of patients developed AKI, 94.5% (n = 70) being classified in stage I. The most affected age group was 8-12 years old (28.3%). Medical care occurred in less than 3 h in 82.6% of cases. Pain (93.3%) and edema (93.5%) were the main symptoms observed. Complications were as follows: secondary infection (10.7%), compartment syndrome (0.8%), and skin necrosis at the site of the bite (1.7%). In contrast to children who did not develop AKI, children who developed AKI had leukocytosis (p = 0.017), alteration of urinalysis (p = 0.012), severe initial classification (p < 0.001), compartment syndrome, and local necrosis (p < 0.001).

CONCLUSION

The frequency of AKI was 15.9%. Risk factors for AKI included severe initial classification, presence of leukocytosis, changes in urinalysis, compartment syndrome, and local necrosis.

Urinary exosomes as promising biomarkers for early kidney disease detection

Kidney injury and disease pose a significant global health burden. Despite existing diagnostic methods, early detection remains challenging due to the lack of specific molecular markers to identify and stage various kidney lesions. Urinary exosomes, extracellular vesicles secreted by kidney cells, offer a promising solution. These vesicles contain a variety of biomolecules, such as proteins, RNA, and DNA. These biomolecules can reflect the unique physiological and pathological states of the kidney. This review explores the potential of urinary exosomes as biomarkers for a range of kidney diseases, including renal failure, diabetic nephropathy, and renal tumors. By analyzing specific protein alterations within these exosomes, we aim to develop more precise and tailored diagnostic tools to detect kidney diseases at an early stage and improve patient outcomes. While challenges persist in isolating, characterizing, and extracting reliable information from urinary exosomes, overcoming these hurdles is crucial for advancing their clinical application. The successful implementation of urinary exosome-based diagnostics could revolutionize early kidney disease detection, enabling more targeted treatment and improved patient outcomes.

Snakebite envenomation-associated acute kidney injury: a South-Asian perspective

Snakebite is a neglected public health problem in tropical countries. Snakebite envenomation-associated acute kidney injury (SBE-AKI) is a major complication accounting for significant morbidity and mortality. The pathogenesis of SBE-AKI may be multifactorial, including prerenal AKI secondary to hemodynamic alterations, intrinsic renal injury, immune-related mechanisms, venom-induced consumptive coagulopathy and capillary leak syndrome. Epidemiological factors include snake species, duration and severity of snakebite, traditional healers and native medication and accessibility to modern healthcare and antisnake venom. Renal histopathology observed consist of acute tubular necrosis, interstitial nephritis, cortical necrosis, disseminated intravascular coagulation, rhabdomyolysis and thrombotic microangiopathy. Glomerular involvement is rare. Proteinuria can be present rarely, hematuria is more common, most often due to venom-induced coagulopathy or hemolysis; it is only rarely due to renal injury. Management includes supportive care and renal replacement therapy when indicated. Progression to chronic kidney disease remains one of the biggest concerns of SBE-AKI. Hence the role and timing of renal biopsy remain controversial, given the risk involved and the benefit obtained in cases of interstitial nephritis. Various biomarkers, including cystatin C, neutrophil gelatinase-associated lipocalin, clusterin and beta-2-glycoprotein, have shown a tendency to predict AKI and also predict progression to chronic kidney disease.

Snakebite-associated acute kidney injury in South Asia: narrative review on epidemiology, pathogenesis and management

Snakebite-associated acute kidney injury (AKI) poses a significant health burden in the South Asia region, resulting in considerable morbidity and mortality. Multiple factors contribute to the pathogenesis of AKI following snakebites, including hypotension, intravascular haemolysis, disseminated intravascular coagulation, rhabdomyolysis, thrombotic microangiopathy (TMA) and direct nephrotoxicity. Clinical features manifest as anuria, oliguria, haematuria, abdominal pain and hypertension. Diagnosis is supported by elevated serum creatinine levels and urine output monitoring. Renal histology studies revealed a spectrum of lesions, including acute tubular necrosis, renal cortical necrosis, glomerulonephritis and TMA. Management strategies centre around timely administration of antivenom, fluid and electrolyte balance and dialysis to improve renal outcomes. While dialysis has demonstrated efficacy in reducing AKI-related mortality rates, the use of fresh frozen plasma and therapeutic plasma exchange may be the subject of some controversy. Understanding the pathophysiological link between coagulopathy, TMA and AKI is important for tailoring effective treatment approaches. Species-specific randomized controlled trials are imperative to evaluate targeted interventions. In tackling the complexities of snakebite-associated AKI and chronic kidney disease, a multidisciplinary approach integrating clinical management with rigorous research efforts is essential. This collaborative endeavour aims to confront the challenges posed by these conditions and improve patient outcomes in the affected regions.

Pediatric acute kidney injury and adverse health outcomes: using a foundational framework to evaluate a causal link

Acute kidney injury (AKI) is a major global health problem, expensive to manage, and its associations with negative pediatric health outcomes have been clearly demonstrated. One of the most fundamental questions to consider as we use previous epidemiological information to advance research and care paradigms is the strength of the causal link between pediatric AKI and health outcomes. In this review, we apply the foundational framework of the Bradford Hill criteria to evaluate the extent to which a causal link exists between AKI and the associated adverse outcomes in children. Available data in children support a causal link between AKI and short-term outcomes including mortality, length of stay, and ventilation time. Clarifying the causal nature of longer term associations requires further high-quality observational studies in children, careful consideration of what defines the most meaningful and measurable longer term outcomes after pediatric AKI, and integration of evolving biological data related to mechanisms of disease. Preventing or mitigating AKI should lead to improved outcomes. Demonstrating such reversibility will solidify confidence in the causal relationship, improve child health, and highlight an aspect which is highly relevant to clinicians, scientists, and policy makers.

Long journey on the role of long non-coding RNA (lncRNA) in acute kidney injury (AKI)

Acute kidney injury (AKI) has a high rate of morbidity, death, and medical expenses, making it a worldwide public health problem. There are still few viable treatment plans for AKI despite medical advancements. A subclass of non-coding RNAs with over 200 nucleotides in length, long non-coding RNAs (lncRNAs) have a wide range of biological roles. Lately, lncRNAs have become important mediators of AKI and prospective biomarkers. However, current studies show that, via constructing the lncRNA/microRNA/target gene regulatory axis, abnormal expression of lncRNAs has been connected to significant pathogenic processes associated with AKI, such as the inflammatory response, cell proliferation, and apoptosis. In order to compete with mRNAs for binding to the same miRNAs and affect the expression of transcripts targeted by miRNAs, lncRNAs may function as competing endogenous RNAs (ceRNAs). The most widely used approach for researching the biological roles of lncRNAs is the construction of ceRNA regulation networks. Our goal in this article is to deliver an updated review of lncRNAs in AKI and to provide more knowledge on their possible applications as therapeutic targets and AKI biomarkers.

Clinical characteristics of snake envenomation-related acute kidney injury in South Korea

Acute kidney injury (AKI) is a common complication of bites by Viperidae snakes. The main venomous snakes in South Korea are members of the Viperidae family, but there is limited information on snake-bite induced AKI in South Korea. Therefore, we investigated snake envenomation-related AKI and the performance of surrogate baseline creatinine to diagnose true AKI. This retrospective, case-control study divided 71 patients with baseline serum creatinine into two groups according to the development of envenomation-related AKI determined based on Kidney Disease Improving Global Outcome Classification. The incidence of AKI was 14.1% with 10% having stage-3 AKI. During hospitalization, the AKI group did not develop venom-induced consumption coagulopathy more frequently than did the non-AKI group. Only one patient needed renal replacement therapy, and no patients died. The serum creatinine concentration at presentation underestimated the incidence of AKI, while the lowest creatinine concentration during hospitalization overestimated the incidence of AKI. After discharge, the incidence of chronic kidney disease did not increase in the AKI group. Snake envenomation-related AKI is characterized by a relatively lower incidence and severity, has no correlation with coagulation disturbance, and has favorable short- and long-term outcomes in South Korea. Based on this study, it is recommended that future envenomation-related AKI studies would utilize the baseline creatinine for diagnosing AKI. If not, envenomation-related AKI studies should include the definition of baseline creatinine used to diagnose AKI and report bias if a baseline creatinine surrogate is used.

Dual therapy with phospholipase and metalloproteinase inhibitors from Sinonatrix annularis alleviated acute kidney and liver injury caused by multiple snake venoms

Snakebite envenomation often induces acute kidney injury (AKI) and acute liver injury (ALI), leading to augmented injuries and poor rehabilitation. Phospholipase A2 (PLA2) and metalloproteinase (SVMP) present in venom are responsible for the envenomation-associated events. In this study, mice envenomed with Deinagkistrodon acutus, Naja atra, or Agkistrodon halys pallas venom exhibited typical AKI and ALI symptoms, including significantly increased plasma levels of myoglobin, free hemoglobin, uric acid, aspartate aminotransferase, and alanine aminotransferase and upregulated expression of kidney NGAL and KIM-1. These effects were significantly inhibited when the mice were pretreated with natural inhibitors of PLA2 and SVMP isolated from Sinonatrix annularis (SaPLIγ and SaMPI). The inhibitors protected the physiological structural integrity of the renal tubules and glomeruli, alleviating inflammatory infiltration and diffuse hemorrhage in the liver. Furthermore, the dual therapy alleviated oxidative stress and apoptosis in the kidneys and liver by mitigating mitochondrial damage, thereby effectively reducing the lethal effect of snake venom in the inhibitor-treated mouse model. This study showed that dual therapy with inhibitors of metalloproteinase and phospholipase can effectively prevent ALI and AKI caused by snake bites. Our findings suggest that intrinsic inhibitors present in snakes are prospective therapeutic agents for multi-organ injuries caused by snake envenoming.

A longitudinal study of the blood and urine metabolome of Vipera berus envenomated dogs

Envenomation of dogs by the common European adder (Vipera berus) is associated with high morbidity. The cytotoxic venom of Vipera berus contains enzymes with the potential to cause acute kidney injury, among other insults, however robust biomarkers for such effects are lacking. A prospective observational follow-up study of naturally envenomated dogs and controls was conducted to fill knowledge gaps regarding canine Vipera berus envenomation, attempt to identify novel biomarkers of envenomation and related kidney injury, and elucidate potential long-term effects. Blood and urine samples were analyzed with a global metabolomics approach using liquid chromatography-mass spectrometry, uncovering numerous features significantly different between cases and controls. After data processing and feature annotation, eight features in blood and 24 features in urine were investigated in order to elucidate their biological relevance. Several of these are associated with AKI, while some may also originate from disturbed fatty acid β-oxidation and soft tissue damage. A metabolite found in both blood and a venom reference sample may represent identification of a venom component in case dogs. Our findings suggest that envenomated dogs treated according to current best practice are unlikely to suffer permanent injury.

Epidemiology of acute kidney injury in children: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference

The nephrology and critical care communities have seen an increase in studies exploring acute kidney injury (AKI) epidemiology in children. As a result, we now know that AKI is highly prevalent in critically ill neonates, children, and young adults. Furthermore, children who develop AKI experience greater morbidity and higher mortality. Yet knowledge gaps still exist that suggest a more comprehensive understanding of AKI will form the foundation for future efforts designed to improve outcomes. In particular, the areas of community acquired AKI, AKI in non-critically ill children, and cohorts from low-middle income countries have not been well studied. Longer-term functional outcomes and patient-centric metrics including social determinants of health, quality of life, and healthcare utilization should be the foci of the next phase of scholarship. Current definitions identify AKI-based upon evidence of dysfunction which serves as a proxy for injury; biomarkers capable of identifying injury as it occurs are likely to more accurately define populations with AKI. Despite the strength of the association, the causal and mechanistic relationships between AKI and poorer outcomes remain inadequately examined. A more robust understanding of the relationship represents a potential to identify therapeutic targets. Once established, a more comprehensive understanding of AKI epidemiology in children will allow investigation of preventive, therapeutic, and quality improvement interventions more effectively.

Systemic toxicity of snake venom metalloproteinases: Multi-omics analyses of kidney and blood plasma disturbances in a mouse model

Snakebite envenomation is classified as a Neglected Tropical Disease. Bothrops jararaca venom induces kidney injury and coagulopathy. HF3, a hemorrhagic metalloproteinase of B. jararaca venom, participates in the envenomation pathogenesis. We evaluated the effects of HF3 in mouse kidney and blood plasma after injection in the thigh muscle, mimicking a snakebite. Transcriptomic analysis showed differential expression of 31 and 137 genes related to kidney pathology after 2 h and 6 h, respectively. However, only subtle changes were observed in kidney proteome, with differential abundance of 15 proteins after 6 h, including kidney injury markers. N-terminomic analysis of kidney proteins showed 420 proteinase-generated peptides compatible with meprin specificity, indicating activation of host proteinases. Plasma analysis revealed differential abundance of 90 and 219 proteins, respectively, after 2 h and 6 h, including coagulation-cascade and complement-system components, and creatine-kinase, whereas a semi-specific search of N-terminal peptides indicated activation of endogenous proteinases. HF3 promoted host reactions, altering the gene expression and the proteolytic profile of kidney tissue, and inducing plasma proteome imbalance driven by changes in abundance and proteolysis. The overall response of the mouse underscores the systemic action of a hemorrhagic toxin that transcends local tissue damage and is related to known venom-induced systemic effects.

Clinical Risk Factors Associated with Poor Outcomes in Snake Envenoming: A Narrative Review

Snakebite-related fatalities disproportionately affect populations in impoverished socio-economic regions, marked by limited access to adequate healthcare and constrained antivenom availability. Early medical intervention is pivotal in mitigating mortality and morbidity associated with snakebite envenoming (SBE). While clinical assessment remains fundamental in treating SBE, this review aims to spotlight objective parameters that could also affect outcomes. Selected studies that identify factors associated with poor outcomes are predominantly region-specific, single-site, and observational, yet collectively reveal similar findings. They consistently report factors such as treatment delays, susceptibility in vulnerable groups such as children and pregnant women, as well as various biochemical and haematological abnormalities. Acute kidney injury (AKI), low platelets, leucocytosis, abnormal coagulation, and elevated creatine kinase (CK) all show an association with poor outcomes. Furthermore, recognising rare and unusual SBE presentations such as adrenal insufficiency, severe hypertension, intracranial haemorrhage, acute angle closure glaucoma, and bowel ischaemia also has a bearing on outcomes. Despite the integration of these parameters into clinical decision tools and guidelines, the validation of this evidence is limited. This review underscores the imperative for high-quality, multi-centre studies aligned with consensus-driven Core Outcome Sets (COS) and Patient-Reported Outcome Measures (PROMS) to validate and strengthen the current evidence.

Fangs in the Ghats: Preclinical Insights into the Medical Importance of Pit Vipers from the Western Ghats

The socioeconomic impact of snakebites in India is largely attributed to a subset of snake species commonly known as the 'big four'. However, envenoming by a range of other clinically important yet neglected snakes, a.k.a. the 'neglected many', also adds to this burden. The current approach of treating bites from these snakes with the 'big four' polyvalent antivenom is ineffective. While the medical significance of various species of cobras, saw-scaled vipers, and kraits is well-established, the clinical impact of pit vipers from regions such as the Western Ghats, northeastern India, and the Andaman and Nicobar Islands remains poorly understood. Amongst the many species of snakes found in the Western Ghats, the hump-nosed (Hypnale hypnale), Malabar (Craspedocephalus malabaricus), and bamboo (Craspedocephalus gramineus) pit vipers can potentially inflict severe envenoming. To evaluate the severity of toxicity inflicted by these snakes, we characterised their venom composition, biochemical and pharmacological activities, and toxicity- and morbidity-inducing potentials, including their ability to damage kidneys. Our findings highlight the therapeutic inadequacies of the Indian and Sri Lankan polyvalent antivenoms in neutralising the local and systemic toxicity resulting from pit viper envenomings.

Effect of Several Naja atra Antivenom Injection Methods on the Rabbit Model of Naja naja atra Bite Poisoning

Snakebite is a global public health concern, which often occurs in tropical and subtropical underdeveloped areas, but it is often neglected. In the southern China, Naja naja atra (Chinese cobra) is a common venomous snake that causes swelling and necrosis of local tissues, even amputation and death. Currently, the main therapy is the administration of Naja atra antivenom, which greatly reduces mortality. However, the antivenom is not particularly effective in the improvement of local tissue necrosis. Clinically, antivenom is mainly administered intravenously. We speculated that the method of injection influences the efficacy of antivenom. In this study, the rabbit model was used to explore the effects of different antivenom injection methods on systemic and local poisoning symptoms. If topical injection of antivenom contributes to ameliorate tissue necrosis, then we need to reconsider the use of Naja atra antivenom.

Factors Associated with Chronic Kidney Disease of Unknown Etiology (CKDu): A Systematic Review

(1) Background: Despite ample research, the factors, specific causes, and pathways associated with chronic kidney disease of unknown etiology (CKDu) remain elusive. Therefore, we performed a systematic review to explore the potential etiologies for the development of CKDu globally. (2) Methods: A systematic literature review was conducted using databases CINAHL, Cochrane Library, Embase, Google Scholar, MEDLINE, and PsycINFO on the specific causes and pathophysiology related to CKDu from inception until April 2021. Study selection, data extraction of included articles, and quality appraisal were assessed. The narrative approach was used to summarize and comprehend the findings. (3) Results: Our study included 25 studies, considering 38,351 participants. Twelve studies were case-control, ten were cross-sectional, and three were cohort designs. All articles were from low-and middle-income countries (LMICs). The findings suggest 12 factors are associated with CKDu. Most studies (n = 8) identified farming and water sources as the factors related to CKDu, with heavy metal toxicity coming in second (n = 7). (4) Conclusion: The systematic review reported various factors associated with CKDu, from which most studies reported farming, water sources, and heavy metal poisoning. Considering the findings, the study recommends future strategies and public health initiatives to prevent the epidemiological/environmental factors contributing to CKDu.

Does snake envenoming cause chronic kidney disease? A cohort study in rural Sri Lanka

BACKGROUND

There is limited information on the risk of chronic kidney disease (CKD) following snakebite and its relationship with chronic interstitial nephritis in agricultural communities (CINAC). We aimed to investigate CKD in patients with a confirmed snakebite in rural Sri Lanka.

METHODS

Patients prospectively recruited to the Anuradhapura snakebite cohort with authenticated bites were followed up. Two groups of patients were followed up: 199 patients in group I with a snakebite (August 2013-October 2014), reviewed after 4 years, and 168 patients in group II with a snakebite (May 2017-August 2018), reviewed after one year, with serum creatinine (estimated glomerular filtration rate [eGFR]) and urinary albumin to creatinine ratio (ACR).

RESULTS

There were 12/199 (6%) in group I and 9/168 (5%) in group II with AKI following snakebite; 3/12 in group I and 2/9 in group II had haemodialysis. On review after 1 and 4 years, no patient had CKD and all had an eGFR ≥60 mL/min/1.73m². Of 234 patients with a creatinine measured on discharge, 17/140 in group I and 11/94 in group II had a low eGFR (<60mL/min/1.73m²). In group I, 14/17 had a normal eGFR after four years, including 11/12 who had AKI following snakebite, and the 3/17 with a low eGFR on review had CKD or co-morbidities for CKD. In group II, 10/11 had a normal eGFR after one year, including all nine patients with AKI following snakebite, and the one patient with a low eGFR on review had CKD. Fifty patients (25%) in group I and 43 (26%) in group II had a high urinary ACR on review, all but two in each group had microalbuminuria. Multivariate logistic regression showed in group I that only comorbidities for CKD were associated with high urinary ACR, and in group II comorbidities for CKD, snakebite associated AKI and snake type were associated with high urinary ACR. All nine patients from both groups with a low eGFR (CKD stages 3-5) had CKD prior to the snakebite or treatment for hypertension or diabetes.

CONCLUSION

There was no significant association between snakebite-associated AKI and CKD in patients followed up from a snakebite cohort post-bite. Microalbuminuria was common in these patients but likely associated with hypertension, diabetes mellitus and CINAC in this rural farming population.

Current situation of snakebites envenomation in the Neotropics: Biotechnology, a versatile tool in the production of antivenoms

Snakebite envenomation is a neglected tropical disease that affects millions of people around the world with a great impact on health and the economy. Unfortunately, public health programs do not include this kind of disease as a priority in their social programs. Cases of snakebite envenomations in the Neotropics are inaccurate due to inadequate disease management from medical records to the choice of treatments. Victims of snakebite envenomation are primarily found in impoverished agricultural areas where remote conditions limit the availability of antivenom. Antivenom serum is the only Food and Drug Administration-approved treatment used up to date. However, it has several disadvantages in terms of safety and effectiveness. This review provides a comprehensive insight dealing with the current epidemiological status of snakebites in the Neotropics and technologies employed in antivenom production. Also, modern biotechnological tools such as transcriptomic, proteomic, immunogenic, high-density peptide microarray and epitope mapping are highlighted for producing new-generation antivenom sera. These results allow us to propose strategic solutions in the Public Health Sector for managing this disease. Keywords: antivenom, biotechnology, neglected tropical disease, omics, recombinant antibody.

Inflammation and Oxidative Stress in Snakebite Envenomation: A Brief Descriptive Review and Clinical Implications

Snakebite envenoming is a pathological condition which may occur in response to the injection of venom. Snake venoms contain a complex mixture of biologically active molecules which are responsible for a broad spectrum of clinical manifestations, ranging from local tissue injuries to fatal complications. Snake venom administration commonly provokes local tissue injury often associated with systemic effects, including neurotoxic and cardiotoxic manifestations, bleeding, acute kidney injury, and rhabdomyolysis. An important spectrum of pathogenesis of snake envenomation is the generation of reactive oxygen species (ROS), which can directly provoke tissue damage and also potentiate the deleterious consequences of inflammation at the bite site. Snake venom components known to induce oxidative stress include phospholipases A₂, metalloproteinases, three-finger toxins, and L-amino acid oxidase. Clear evidence is mounting suggesting that inflammation and oxidative stress participate in the destructive effects of envenoming, including acute renal failure, tissue necrosis, and unusual susceptibility to bleed (hemorrhage), mostly due to hypocoagulability, neuro/cardio toxicity, and myonecrosis. Impaired regulation of oxidative stress may also set the stage for secondary/long-term complications of snakebite envenomation such as musculoskeletal disabilities. Some aspects of natural antioxidant therapeutic options are discussed in this review.

Phospholipase A2 inhibitor varespladib prevents wasp sting-induced nephrotoxicity in rats

This study aimed to clarify whether varespladib, a phospholipase A₂ (PLA₂) inhibitor, can be used as a therapeutic agent for wasp sting-induced acute kidney injury (AKI). Rats were divided into control, AKI, and AKI + varespladib groups. The AKI model was established by subcutaneously injecting wasp venom at five different sites in rats. Varespladib treatment showed a significant inhibitory effect on wasp venom PLA₂in vitro and in vivo. Moreover, we observed that varespladib decreased the levels of rhabdomyolysis and hemolysis markers compared with that in the AKI group. Histopathological changes in the kidney decreased significantly, and rat serum creatinine levels were reduced after varespladib administration. The significantly regulated genes in the kidney of the AKI group were mostly involved in inflammatory response pathway, and the administration of varespladib remarkably attenuated the expression of these genes. Therefore, varespladib inhibited wasp sting-induced functional and pathological damage to the kidneys. We propose that the PLA₂ inhibitor varespladib protects the kidney tissue in a wasp sting-induced AKI model by inhibiting PLA₂ activity.

Neutrophil Gelatinase-Associated Lipocalin Acts as a Robust Early Diagnostic Marker for Renal Replacement Therapy in Patients with Russell's Viper Bite-Induced Acute Kidney Injuries

Snakebite-induced acute kidney injury (AKI) is frequently observed in patients following bites from vipers such as Russell's viper (Daboia russelii) in India. Currently, the levels of serum creatinine are mainly used as a marker to determine the necessity for renal replacement therapy (RRT) (haemodialysis) in severe cases of AKI. However, it takes up to 48 h to ascertain a distinct change in creatinine levels compared to its baseline level upon admission. The time lost between admission and the 48 h timepoint significantly affects the clinical management of snakebite victims. Moreover, early diagnosis of AKI and decision on the necessity for RRT in snakebite victims is critical in saving lives, reducing long-term complications, and minimising treatment costs arising from expensive haemodialysis. Neutrophil gelatinase-associated lipocalin (NGAL) has been recently studied as a robust early marker for AKI in non-snakebite patients. However, its suitability for clinical use in snakebite victims has not been rigorously established. Here, we demonstrate the clinical significance of plasma NGAL as a robust marker for RRT following AKI using a large cohort (309) of Russell's viper victims without any pre-existing health conditions. NGAL levels upon admission are positively correlated with creatinine levels at 48 h in different stages of AKI. Overall, NGAL acts as a robust early marker to ascertain the need for RRT following Russell's viper bites. The quantification of NGAL can be recommended as a routine test in hospitals that treat snakebites to decide on RRT at early time points instead of waiting for 48 h to confirm the increase in creatinine levels. The diagnostic use of NGAL in Russell's viper victims with pre-existing comorbidities and for other vipers should be evaluated in future studies.