Rao P Sai Kameshwar, Priyamvada P S, Bammigatti Chanaveerappa
Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India.
Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India.
Trans R Soc Trop Med Hyg. 2025 Jul 1;119(7):780-787. doi: 10.1093/trstmh/trae114.
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.
蛇咬伤是热带国家一个被忽视的公共卫生问题。蛇咬伤中毒相关的急性肾损伤（SBE-AKI）是一种主要并发症，导致显著的发病率和死亡率。SBE-AKI的发病机制可能是多因素的，包括继发于血流动力学改变的肾前性AKI、肾实质损伤、免疫相关机制、毒液诱导的消耗性凝血病和毛细血管渗漏综合征。流行病学因素包括蛇的种类、蛇咬伤的持续时间和严重程度、传统治疗师和本土药物以及获得现代医疗保健和抗蛇毒血清的机会。观察到的肾脏组织病理学表现包括急性肾小管坏死、间质性肾炎、皮质坏死、弥散性血管内凝血、横纹肌溶解和血栓性微血管病。肾小球受累罕见。蛋白尿很少出现，血尿更常见，最常见的原因是毒液诱导的凝血病或溶血；仅在极少数情况下是由于肾损伤。治疗包括支持性治疗和在有指征时进行肾脏替代治疗。进展为慢性肾脏病仍然是SBE-AKI最令人担忧的问题之一。因此，鉴于肾活检的风险以及在间质性肾炎病例中获得的益处，肾活检的作用和时机仍存在争议。各种生物标志物，包括胱抑素C、中性粒细胞明胶酶相关脂质运载蛋白、簇集素和β-2-糖蛋白，已显示出预测AKI以及预测进展为慢性肾脏病的趋势。
