We thank the readers for their interest in our study [1]. Our replies to the queries are as under:

(i)  Different clinical and laboratory parameters were already described in table I and II of the article, and some of the determinants  are similar to previous reports [2]. Reasons for discrepancy with published literature were mentioned in the discussion section of the article.

(ii)   Detailed baseline data were collected, but all of it could not be presented due to limitation on the size of the manuscript. Serum LDH and adrenal hemorrhage were not assessed in our study. We appreciate your concern about cardiac dysfunction, hemodynamic status etc, but different parameters (requirement of ventilation, serum potassium level, requirement of inotropes) mentioned in table I act as surrogate markers of them. We used logistic regression and adjusted odds ratio to remove confounders. Nephrotoxic drugs are avoided in viper-bite patients according to unit protocol in our set-up.

(iii)  In a previous research project in the same setting, the investigators noted some long-term toxicity of snakebite, as also previously reported [2]. Hence we decided on a follow-up period of 6 months.

(iv)  In the paper, we had mentioned the unit protocol for dialysis. Opinion of a nephrologist was sought before starting dialysis in all patients.

(v)   All study patients were followed up at our nephrology specialty clinic after discharge from hospital.

(vi)  If at any point of time during the hospital stay, the children developed AKI, we included them in the AKI group. The initial version of the manuscript had information on AKI grades, but it was later edited out on the suggestion of reviewers.

(vii) We did not perform renal biopsy in AKI settings. We considered renal biopsy in the children who developed permanent renal damage, as per opinion of nephrologist. Before doing renal biopsy, we took informed written consent from parents.

            Snake bite, being a medicolegal case, autopsy is done in every death. Samples from viscera are also routinely collected by forensic expert. We could convince parents of all such children for consent for renal histopathology examination.

(viii) We used the study population as denominator because we want to identify renal complication in children with hematotoxic bites, not in the surviving children.

(ix)  As the data are skewed, we had summarized it as median and interquartile range [1]. The mean (SD) number of vials required were 12.3 (9.1) and 21.5 (18.9) in AKI and no AKI groups, respectively.

(x)   It is the regression model used in the study.

(xi)  The mentioned time is only for those who did not develop AKI; it was higher for those who developed AKI (74.5 minutes) [1]. If we consider all children, mean time between bite and ASV administration was 51.2 minutes. Moreover, many of the children received the first dose of ASV at the place of initial medical care, before referral to our center. The study referred to by the readers was conducted in 2012-2016 and included both children and adults [3]. Due to the sustained awareness campaigns and easy availability of ASV, bite to needle time is gradually decreasing. Transport vehicles are also easily available for children under different government schemes. Moreover, our study included children with viper-bite only, which is symptomatic at early stage leading to early seeking of healthcare. 

REFERENCES

1. Islam K, Seth S, Roy A, Datta AK. Predictors of renal complications in children with hematotoxic snakebite. Indian Pediatr. 2020;57:427-30.

2. Aye KP, Thanachartwet V, Soe C, Desakorn V, Thwin KT, Chamnanchanunt S, et al. Clinical and laboratory para-meters associated with acute kidney injury in patients with snakebite envenomation: A prospective observational study from Myanmar. BMC Nephrol. 2017;18:92.

3. Jayawardana S, Arambepola C, Chang T, Gnanathasan A. Long-term health complications following snake envenoming. J Multidiscip Healthc. 2018;11:279-85.

4. Sarkhel S, Ghosh R, Mana K, Gantait K. A hospital based epidemiological study of snakebite in Paschim Medinipur district, West Bengal, India. Toxicol Rep. 2017;4:415-9.