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Indian Pediatr 2015;52: 570-571 |
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Snakebite and Acute Kidney Injury: We Must do
Better!
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Sanjib Kumar Sharma
Department of Internal Medicine, BP Koirala Institute
of Health Sciences, Dharan, Nepal.
Email: [email protected]
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Snakebite is one of the most neglected public health
issues in rural areas causing significant death and disability. Actual
burden of snakebite remains elusive due to serious under-reporting.
Majority of victims die even before reaching hospital [1,2]. South Asia
is the most heavily affected region of the globe. The highest figures
reported from Asia, so far, come from a community-based survey conducted
in South-East Nepal in 2002 [1]. In India alone, about 45,900 people are
estimated to die from snake bites according to Million Death Study [2].
The Indian subcontinent is well known for its snake
biodiversity. However, species of the family of Elapidae and Viperidae
are responsible for most deaths and disabilities related to snakebite.
Among the true vipers, Russell’s viper (Daboiarusselii) is
associated with the highest morbidity and mortality. In Anuradhapura
District, Sri Lanka, up to 73% of all admitted snakebites were
attributed to this species [3], whose distribution extends from the
Indus valley of Pakistan in West and Kashmir, India in the North to the
foothills of the Himalayas in Nepal and Bhutan, and to Bangladesh in the
East.
Snake inflicted morbidity and death occurs through
cytotoxic, hematotoxic, or neurotoxic mechanisms. Apart from local
swelling and tissue damage, viperidae venom can also induce coagulopathy
and platelet dysfunction leading to systemic bleeding and hemorrhage
from the local site. Intracranial hemorrhage, including pituitary
hemorrhage, and multiorgan dysfunction may occur. In addition,
envenoming by Russell’s viper can cause generalized rhabdomyolysis
induced by Phospho-lipaseA2, which may cause myoglobinemia, hyperkalemia,
and acute kidney injury (AKI) [4]. AKI may also result from the direct
action of some venoms and associated hypotension due to bleeding.
Venomous snakebite accounts for a notable proportion of victims with AKI
in regions with viper envenoming including in India, as was also
witnessed in the study by Krishnamurthy, et al. [5] in this issue
of Indian Pediatrics.
Factors that determine the outcome of snakebite
management are multifactorial [6]. Delay in seeking health care due to
misbelief, difficult terrain, inadequate knowledge and skill of medical
fraternity, and lack of provision of appropriate antivenom and
appropriate supportive management of complications, are few examples. A
survey conducted in India and Pakistan showed that many doctors were
unable to recognize systemic signs of envenoming [7]. Similarly, most of
the time snakebite victims do not receive appropriate dose of antivenom
and/or assisted ventilation when needed [8]. Since AKI is seen to occur
in a majority of snakebite victims, lack of renal replacement therapy in
rural/remote areas where most snakebites occur, and late referral to the
center with facilities for dialysis and mechanical ventilation are some
of the major determinants of fatalities, which need to be addressed.
This preventable and reversible cause of AKI is more relevant in the
context of The International Society of Nephrology initiative, called "0
by 25" program, which aims to eliminate preventable death from AKI in
the poorest parts of Africa, Asia and Latin America by 2025 [9].
Education of the communities as well as caregivers on
how to avoid and protect from snakebites by wearing protective boots in
paddy fields or while performing outdoor activities, not sleeping on
ground, using mosquito nets, seeking early medical help, and avoiding
arterial tourniquet can help reduce consequences of snakebite and
envenoming [10]. This is especially relevant in pediatric snakebites as
the venom can affect children more quickly due to their low body mass.
This may help mitigate the death and disabilities related to snakebite
envenoming.
Funding: None; Competing interests: None
stated.
References
1. Sharma SK, Chappuis F, Jha N, Bovier PA, Loutan L,
Koirala S. Impact of snake bites and determinants of fatal outcomes in
southeastern Nepal. Am J Trop Med Hyg. 2004;71:234-8.
2. Mohapatra B, Warrell DA, Suraweera W, Bhatia P,
Dhingra N, Jotkar RM, et al. Snakebite mortality in India: A
nationally representative mortality survey. PLoS Negl Trop Dis.
2011;5:e1018.
3. Phillips RE, Theakston RD, Warrell DA, Galigedara
Y, Abeysekera DT, Dissanayaka P, et al. Paralysis, rhabdomyolysis
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Hyg. 2013;89:145-50.
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