Advertisement

Therapeutic Plasma Exchange for Venom-Induced Thrombotic Microangiopathy Following Hump-Nosed Pit Viper (Genus: Hypnale) Bites: A Prospective Observational Study

Published:October 13, 2022DOI:https://doi.org/10.1016/j.wem.2022.07.012

      Abstract

      Introduction

      —Thrombotic microangiopathy (TMA), which is the triad of acute kidney injury (AKI), microangiopathic hemolytic anemia (MAHA), and thrombocytopenia, is a rare complication of snakebites, and in Sri Lanka, it is commonly seen with hump-nosed pit viper (HNPV) bites.

      Methods

      —We conducted a prospective observational study of patients with AKI caused by HNPV bites in Teaching Hospital, Ratnapura, Sri Lanka for 6 y, commencing in June 2015. Some patients with TMA underwent therapeutic plasma exchange (TPE) and some did not. These 2 groups were compared. Statistical analysis was carried out using Minitab 18.1. Data were presented as median (IQR).

      Results

      —There were 52 (8%) patients with TMA, of whom 21 (45%) were in the TPE group and 26 (55%) were in the non-TPE group. TPE improved time to platelet correction (4 d [IQR, 4–5 d] vs 7 d [IQR, 5–9 d]; P=0.009), time to MAHA correction (5 d [IQR, 3–4 d] vs 7 d [IQR, 6–9 d]; P=0.004), time to prothrombin time (PT)/international normalized ratio (INR) correction (1 d [IQR, 1–2 d] vs 3 d [IQR, 3–4 d]; P=0.003), and time to 20 min whole blood clotting test (WBCT20) correction (2 d [IQR, 1–2 d] vs 3 d [1QR 2–3 d]; P=0.020). Renal recovery was predicted by TPE (P=0.048) and highest creatinine level (P=0.001). There was no association between TPE and dialysis dependency at discharge (P=0.597), length of hospital stay (P=0.220), and the number of dialysis cycles prior to discharge (P=0.540). TPE did not improve the number of blood transfusions (5 packs [IQR, 3–8.5 packs] vs 4 packs [IQR, 0–9 packs]; P=0.290).

      Conclusions

      —TPE is effective for TMA in the early correction of platelet counts, MAHA, PT/INR, and WBCT20 in HNPV bites.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Wilderness & Environmental Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kasturiratne A.
        • Wickremasinghe A.R.
        • de Silva N.
        • Gunawardena N.K.
        • Pathmeswaran A.
        • Premaratna R.
        • et al.
        The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths.
        PLoS Med. 2008; 5: e218
        • Namal Rathnayaka RMMK
        • Nishanthi Ranathunga P.E.A.
        • Kularatne S.A.M.
        Thrombotic microangiopathy, haemolytic uremic syndrome and thrombotic thrombocytopenic purpura following hump-nosed pit viper (Genus: Hypnale) envenoming in Sri Lanka.
        Wilderness Environ Med. 2019; 30: 66-78
        • Namal Rathnayaka RMMK
        • Nishanthi Ranathunga P.E.A.
        • Kularatne S.A.M.
        Kidney injury following envenoming by hump-nosed pit viper (Genus: Hypnale) in Sri Lanka: proven and probable cases.
        Trans R Soc Trop Med Hyg. 2019; 113: 131-142
        • Joseph J.K.
        • Simpson I.D.
        • Menon N.C.S.
        • Jose M.P.
        • Kulkarni K.J.
        • Raghavendra G.B.
        • et al.
        First authenticated cases of life-threatening envenoming by the hump-nosed pit viper (Hypnale hypnale) in India.
        Trans R Soc Trop Med Hyg. 2007; 101: 85-90
        • Namal Rathnayaka RMMK
        • Nishanthi Ranathunga P.E.A.
        • Kularatne S.A.M.
        Thrombotic microangiopathy following Hypnale zara (hump-nosed pit viper) envenoming: the first known case report from Sri Lanka.
        Wilderness Environ Med. 2020; 31: 71-77
        • Namal Rathnayaka R.M.M.K.
        • Ranathunga P.E.A.N.
        • Kularatne S.A.M.
        Systemic bleeding including pulmonary haemorrhage following hump-nosed pit viper (Hypnale hypnale) envenoming: a case report from Sri Lanka.
        Toxicon. 2019; 170: 21-28
        • Namal Rathnayaka RMMK
        • Ranathunga P.E.A.N.
        • Kularatne S.A.M.
        Venom-induced consumption coagulopathy following hump-nosed pit viper (Genus: Hypnale) envenoming in Sri Lanka: uncertain efficacy of fresh frozen plasma.
        Wilderness Environ Med. 2020; 31: 131-143
        • Namal Rathnayaka RMMK
        • Nishanthi Ranathunga P.E.A.
        • Ranaweera J.
        • Jayasekara K.
        • Kularatne S.A.M.
        Cardiac arrest and atrial fibrillation in a patient after hump-nosed pit viper (Hypnale hypnale) envenoming.
        Toxicon. 2018; 148: 33-39
        • Szczepiorkowski Z.M.
        • Winters J.L.
        • Bandarenko N.
        • Kim H.C.
        • Linenberger M.L.
        • Marques M.B.
        • et al.
        Guidelines on the use of therapeutic apheresis in clinical practice-evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis.
        J Clin Apher. 2010; 25: 83-177
        • Herath N.
        • Wazil A.
        • Kularatne S.
        • Ratnatunga N.
        • Weerakoon K.
        • Badurdeen S.
        • et al.
        Thrombotic microangiopathy and acute kidney injury in hump-nosed viper (Hypnale species) envenoming: a descriptive study in Sri Lanka.
        Toxicon. 2012; 60: 61-65
        • Namal Rathnayaka RMMK
        • Nishanthi Ranathunga P.E.A.
        • Kularatne S.A.M.
        Therapeutic plasma exchange (plasmapheresis) for the treatment of hump-nosed pit viper (Hypnale spp.) envenoming.
        J Ratnapura Clin Soc. 2018; 3: 20-26
        • Yildirim C.
        • Bayraktaroğlu Z.
        • Gunay N.
        • Bozkurt S.
        • Köse A.
        • Yilmaz M.
        The use of therapeutic plasmapheresis in the treatment of poisoned and snake bite victims: an academic emergency department’s experiences.
        J Clin Apher. 2006; 21: 219-223
        • Pantanowitz L.
        • Andrzejewski C.
        Plasma exchange therapy for victims of envenomation: is this reasonable?.
        J. Clin. Apher. 2006; 21: 215-218
        • Zengin S.
        • Yilmaz M.
        • Yildrim C.
        • Yarbil P.
        • Kilic H.
        • Bozkurt S.
        • et al.
        Plasma exchange as a complementary approach to snake bite treatment: an academic emergency department’s experiences.
        Transfus Apher Sci. 2013; 49: 494-498
        • Wijewickrama E.S.
        • Gooneratne L.V.
        • Gnanathasan A.
        • Gawarammana I.
        • Gunatilake M.
        • Isbister G.K.
        Thrombotic microangiopathy and acute kidney injury following Sri Lankan Daboia russelii and Hypnale species envenoming.
        Clin Toxicol (Phila). 2020; 58: 997-1003
        • Casamento A.J.
        • Isbister G.K.
        Thrombotic microangiopathy in two tiger snake envenomations.
        Anaesth Intensive Care. 2011; 39: 1124-1127
        • Cobcroft R.G.
        • Williams A.
        • Cook D.
        • Williams D.J.
        • Masci P.
        Hemolytic uremic syndrome following taipan envenomation with response to plasmapheresis.
        Pathology. 1997; 29: 399-402
        • Noutsos T.
        • Currie B.J.
        • Lek R.A.
        • Isbister G.K.
        Snakebite associated thrombotic microangiopathy: a systematic review of clinical features, outcomes, and evidence for interventions including plasmapheresis.
        PLoS Negl Trop Dis. 2020; 14e0008936
        • Noutsos T.
        • Currie B.J.
        • Isoardi K.Z.
        • Brown S.G.A.
        • Isbister G.K.
        Snakebite-associated thrombotic microangiopathy: an Australian prospective cohort study [ASP30].
        Clin Toxicol (Phila). 2022; 60: 205-213
        • Mohan G.
        • Guduri P.R.
        • Shastry S.
        • Kandasamy D.
        Thrombotic microangiopathy in hematotoxic snakebites and its impact on the prognosis: an entity often overlooked.
        J Thromb Thrombolysis. 2019; 48: 475-482
        • Kularatne S.A.M.
        • Ratnatunga N.
        Severe systemic effects of Merrem’s hump-nosed viper bite.
        Ceylon Med J. 1999; 44: 169-170
      1. Bon C, Burnouf T, Gutiérrez JM, Padilla A, Ratanabanangkoon A, Warrell DA. WHO Guidelines for the Production, Control and Regulation of Snake Antivenom Immunoglobulins; WHO Technical Report Series; WHO: Geneva, Switzerland, 2010.

        • Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group
        KDIGO clinical practice guideline for acute kidney injury.
        Kidney Int Suppl. 2012; 2: 1-138
        • Barbour T.
        • Johnson S.
        • Cohney S.
        • Hughes P.
        Thrombotic microangiopathy and associated renal disorders.
        Nephrol Dial Transplant. 2012; 27: 2673-2685
        • Maduwage K.
        • Silva A.
        • Manamendra-Arachchi K.
        • Pethiyagoda R.
        A taxonomic revision of the South Asian hump-nosed pit vipers (Squamata: Viperidae: Hypnale).
        Zootaxa. 2009; 2232: 1-28
        • Karunatilake H.
        • Nayakarathna T.
        • Atapattu S.
        • Saparamadu T.
        • Dharmasena S.
        Thrombotic microangiopathy and fibrinolysis after hump-nosed viper envenomation.
        Ceylon Med J. 2012; 57: 45-46
        • Wijewickrama E.S.
        • Gooneratne L.V.
        • Gnanathasan A.
        • Gawarammana I.
        • Gunatilake M.
        • Isbister G.K.
        Severe acute kidney injury following Sri Lankan Hypnale spp. envenoming is associated with thrombotic Microangiopathy.
        Clin Toxicol (Phila). 2021; 59: 296-302
        • Kularatne S.A.M.
        • Wimalasooriya S.
        • Nazar K.
        • Maduwage K.
        Thrombotic microangiopathy following Russell’s viper (Daboia russelii) envenoming in Sri Lanka: a case report.
        Ceylon Med J. 2014; 59: 29-30
        • Namal Rathnayaka R.M.M.K.
        • Ranathunga P.E.A.N.
        • Kularatne S.A.M.
        Thrombotic microangiopathy and hemolytic uremic syndrome following Russell’s viper (Daboia russelii) bite.
        J Ratnapura Clin Soc. 2019; : 23-30
        • Namal Rathnayaka R.M.M.K.
        • Ranathunga P.E.A.N.
        • Kularatne S.A.M.
        Clinico-epidemiology of Russell’s viper (Daboia russelii) bite in wet zone of Sri Lanka: a high incidence of thrombotic microangiopathy.
        Ceylon Med J. 2018; 62: 90-91
        • Date A.
        • Pulimood R.
        • Jacob C.K.
        • Kirubakaran M.G.
        • Shastry J.C.M.
        Haemolytic-uraemic syndrome complicating snake bite.
        Nephron. 1986; 42: 89-90
        • Isbister G.K.
        • Little M.
        • Cull G.
        • McCoubrie D.
        • Lawton P.
        • Szabo F.
        • et al.
        Thrombotic microangiopathy from Australian brown snake (Pseudonaja) envenoming.
        Intern Med J. 2007; 37: 523-528
        • Seneviratne S.L.
        • Opanayaka C.J.
        • Ratnayake N.S.
        • Kumara K.E.S.
        • Sugathadasa A.M.
        • Weerasuriya N.
        • et al.
        Use of antivenom serum in snake bite: a prospective study of hospital practice in the Gampaha District.
        Ceylon Med J. 2000; 45: 65-68
        • Rao I.R.
        • Prabhu A.R.
        • Nagaraju S.P.
        • Rangaswamy D.
        Thrombotic microangiopathy: an under-recognised cause of snake-bite-related acute kidney injury.
        Indian J Nephrol. 2019; 29: 324-328