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Wasp venom–induced acute kidney injury: a serious health hazard. To the Editor: Environmental toxins (snake, bee, and wasp venoms) and tropical infectious ...

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should be hospitalized for aggressive hydration and urine alkalinization to prevent the AKI secondary to hemolysis and rhabdomyolysis.

Wasp venom–induced acute kidney injury: a serious health hazard To the Editor: Environmental toxins (snake, bee, and wasp venoms) and tropical infectious diseases (malaria and leptospirosis) are important causes of acute kidney injury (AKI) that are peculiar to the countries of Asia and Latin America. Wasp venom–induced AKI is a potentially fatal complication that follows mass attacks. Although it has become a serious health problem in China, South Asia, and Southeast Asia, it is underestimated and underrecognized.1,2 Even in a recent review by Burdmann and Jha, it has received no consideration.3 We have published a large study of AKI after multiple hymenoptera stings.4 The main demographic and clinical characteristics of wasp venom–induced AKI are shown in Table 1. In attacks involving multiple stings, AKI or death may result from 10 to 200 wasp stings.2,4 Multiple stings result in a unique syndrome of intravascular hemolysis, rhabdomyolysis, AKI, and hepatitis.1 Most patients require dialysis and the reported mortality rate is up to 50%. Mortality is associated with the complications of acute respiratory distress syndrome and encephalopathy.4 The pathogenesis of AKI is likely to be mediated by pigment nephropathy caused by precipitation of hemoglobin and myoglobin casts in renal tubules. However, in some patients a direct nephrotoxic effect or acute interstitial nephritis from a hypersensitivity to insect venom may result in acute interstitial nephritis. The most common findings on renal histological examination are pigment-induced acute tubular necrosis. Acute interstitial nephritis alone or in combination with acute tubular necrosis is an important contributor to AKI.4 In conclusion, AKI is a serious complication of multiple wasp stings that carries a high mortality rate. Because there is no antivenom for wasp stings, treatment in all such cases is supportive. Patients with multiple wasp stings

Table 1 | Demographic and clinical characteristics of patients Variable Total number of patients Male n (%) Age (yr) Mean  SD (range) Number of stings Mean  SD (range) Oliguria n (%) Hematuria/Cola-colored urine n (%) Hemolysis n (%) Rhabdomyolysis n (%) Hepatic dysfunction n (%) Dialysis n (%) Died n (%)

1288

Value 32 20 (62.5) 42.7  16.7 (7–72) 44  23 (15–100) 26 (81.3) 19 (59.4) 29 (90.6%) 19 (59.4) 23 (71.9) 29 (90.6) 10 (31.3)

1. Xuan BH, Mai HL, Thi TX, et al. Swarming hornet attacks: shock and acute kidney injury—a large case series from Vietnam. Nephrol Dial Transplant. 2010;25:1146–1150. 2. Xie C, Xu S, Ding F, et al. Clinical features of severe wasp sting patients with dominantly toxic reaction: analysis of 1091 cases. PLoS One. 2013;8: e83164. 3. Burdmann EA, Jha V. Acute kidney injury due to tropical infectious diseases and animal venoms: a tale of 2 continents. Kidney Int. 2017;91: 1033–1046. 4. Vikrant S, Parashar A. Acute kidney injury due to multiple hymenoptera stings—a clinicopathological study. Clin Kidney J. 2017;10:532–538.

Sanjay Vikrant1 and Anupam Parashar2 1 Department of Nephrology, Indira Gandhi Medical College, Shimla (Himachal Pradesh), India; and 2Department of Community Medicine, Indira Gandhi Medical College, Shimla (Himachal Pradesh), India Correspondence: Sanjay Vikrant, Department of Nephrology, Indira Gandhi Medical College, SHIMLA (Himachal Pradesh), 171001 India. E-mail: [email protected]

Kidney International (2017) 92, 1288; http://dx.doi.org/10.1016/j.kint.2017.05.035

Copyright ª 2017, International Society of Nephrology. Published by Elsevier Inc. All rights reserved.

The Authors Reply: We appreciated the comments from Vikrant and Parashar.1 Because of space limitations, we did not ignore but only commented briefly about wasp, hornet, and yellow jacket venom–associated acute kidney injury (AKI) in our review.2 Indeed, accidents with insects from the family Vespidae (wasps, hornets, and yellow jackets) have been associated with AKI in Asia, but not in Latin America, where Africanized bees, from the family Apidae, are the main hymenoptera responsible for insect venom–induced AKI. Venoms from the two genera, Vespa and Apis, have different characteristics. Vespa venom lacks melittin, considered the main toxic component in bee venom, and has higher interspecies composition and toxicity variability. The main toxic constituents of Vespa venom are phospholipases, hyaluronidase, antigen 5, active amines (such as serotonin, histamine, tyramine, and catecholamine) and peptides, such as kinins and mastoparans. The Vespidae venom causes hemolysis, cytotoxicity (comprising rhabdomyolysis), increased vascular permeability, and organ failure, including AKI.3 The majority of cases of AKI associated with Vespa venom occurred after multiple stings in men from rural areas, and most of the information available comes from case reports or descriptions of relatively small retrospective case series, with mortality and chronic kidney disease development rates of 9.3% and 10.7%, respectively.4 The largest series is from China, in which an AKI frequency of 21% was reported among 1091 hospitalized patients with wasp stings.5 The most frequently described renal histological injury in Vespa venom–associated AKI is acute tubular necrosis, but cases of Kidney International (2017) 92, 1288–1291

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