CLINICAL KIDNEY JOURNAL

Clinical Kidney Journal, 2016, vol. 9, no. 2, 201–204

doi: 10.1093/ckj/sfw004
Advance Access Publication Date: 28 February 2016
Original Article

ORIGINAL ARTICLE

Wasp sting-induced acute kidney injury

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Jeyachandran Dhanapriya, Thanigachalam Dineshkumar,
Ramanathan Sakthirajan, Palaniselvam Shankar, Natarajan Gopalakrishnan
and Thoppalan Balasubramaniyan
Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai,
India
Correspondence to: Jeyachandran Dhanapriya; E-mail: [email protected]

Abstract
Background: Wasp stings are a common form of envenomation in tropical countries, especially in farmers. The aim of this
study was to document the clinical presentation, treatment and outcomes of patients with acute kidney injury (AKI) due to
multiple wasp stings in a tertiary care hospital.

Methods: We conducted a retrospective observational study of patients with multiple wasp stings and AKI at the Department of
Nephrology between July 2011 and August 2015. The clinical features, laboratory data, treatment details and outcomes were
noted.

Results: A total of 11 patients were included. All were from rural areas. All of them were males with age ranging from 21 to 70
years, mean age 45 ± 23 years. Six had oliguria and two had hypotension. All 11 patients had evidence of rhabdomyolysis and
three also had hemolysis. Ten patients required hemodialysis with a mean number of hemodialysis sessions of 8.7 ± 2.8. Renal
biopsy carried out on four patients, showed acute interstitial nephritis (AIN) in one patient, acute tubular necrosis (ATN) in two
patients, and one patient had both AIN and ATN. The two patients with AIN were given steroids, while all other patients were
managed with supportive measures. One patient died within 48 h of presentation due to shock. At a mean follow-up of 24
months, one had progressed to chronic kidney disease and the remaining nine had normal renal function.

Conclusions: Wasp sting is an occupational hazard. AKI was most commonly due to rhabdomyolysis. Early renal biopsy is
indicated in those patients who do not respond to supportive measures. Timely dialysis and steroid in the case of AIN improves
renal survival.

Key words: acute kidney injury, hemodialysis, rhabdomyolysis, steroids, wasp stings

Introduction ranging from acute kidney injury (AKI), hepatic/cardiac dysfunc-

tion to coagulopathy [2]. AKI is due to acute tubular necrosis
Animal toxin envenomation is an important health problem in (ATN) as a result of intravascular hemolysis, rhabdomyolysis or
tropical countries. As a highly vascularized organ, the kidney is shock [3]. Rarely it can be due to acute interstitial nephritis
more vulnerable to toxins [1]. Vespida (wasps and bees) stings (AIN), which responds to steroids. Here we present a case series
cause mortality by anaphylaxis and multiorgan involvement of 11 patients with multiple wasp stings and AKI.

Received: October 12, 2015. Accepted: January 11, 2016

© The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
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201
CLINICAL KIDNEY JOURNAL
202 | J. Dhanapriya et al.

Table 1. Clinical features, laboratory values and outcome of 11 patients with wasp stings

Variables Pt1 Pt2 Pt3 Pt4 Pt5 Pt6 Pt7 Pt8 Pt9 Pt10 Pt11

Age (years) 21 70 40 38 85 35 51 45 35 42 33
No. of stings 24 30 72 42 48 22 27 12 33 14 30
Blood urea (mg/dL) 172 98 120 86 107 106 100 65 102 99 55
Serum creatinine (mg/dL) 14 7.5 8.5 9.1 7.1 6.5 5.2 4.5 7.5 7.0 4.0
Serum potassium (mEq/L) 3.7 3.2 5.8 4.0 5.6 34.5 4.2 4.1 6.2 4.8 3.8
Serum CPK (IU/L) 549 412 3328 650 983 1040 1120 620 1500 890 560
Serum LDH (IU/L) 123 128 728 108 340 480 367 300 750 306 379
Total no. of hemodialysis sessions 5 5 11 7 8 11 12 Not done 12 12 2
Duration of HD (days) 10 8 20 12 10 17 18 – 14 18 2
Improvement of oliguria (days) 4 8 12 7 5 8 9 2 13 8 Died
–

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Creatinine at discharge (mg/dL) 0.9 1 0.9 0.8 0.9 1.1 1.1 0.9 1.9 1.2
Creatinine at mean follow-up (mg/dL) 0.9 1.1 1 0.9 1 1.2 1.2 0.9 3.5 1 –

Materials and methods

A retrospective study was performed of patients admitted to our
department between July 2011 and August 2015 who presented
with multiple wasp stings and AKI. The diagnosis of wasp stings
was based on clinical history and findings on physical examin-
ation. Demographic details including age, sex, clinical history
and clinical findings were collected. Laboratory investigation
details including complete hemogram, renal function tests,
liver function test, creatine phosphokinase (CPK), serum lactate
dehydrogenase (LDH) and coagulation profile tests were noted.
All the patients received supportive care, and forced alkaline
diuresis was given when patients presented early without vol-
ume overload or oliguria. Indications for hemodialysis were oli-
guria (urine output <400 mL/day), hyperkalemia (>5.5 mEq/L),
metabolic acidosis and acute pulmonary edema. Mean duration
of dialysis dependency and mean number of dialysis sessions
were noted. Renal biopsy was done in patients who had persist-
Fig. 1. Renal biopsy showing interstitial infiltrates rich in eosinophils (H&E stain).
ent oliguria for >7 days and renal failure for >14 days despite sup-
portive treatment after obtaining written consent. Complete
recovery of kidney function was defined as a decrease in the
serum creatinine level to within a normal range. Chronic kidney
disease (CKD) was defined as estimated glomerular filtration rate
<60 mL/min/1.73 m2 at 3 months after the onset of AKI. For
statistical analysis, data are expressed as mean (± standard
deviation), percentage and range wherever appropriate.

Results
A total of 11 patients were included. All patients were males and
farmers by occupation. All had multiple sting marks varying in
number from 12 to 72. The time lag between sting and hospital-
ization ranged from 2 to 11 days. The clinical profiles, laboratory
data, treatment and outcomes are described in Table 1. Oliguria
was noted in six patients, hypertension in two and hypotension
in two. All patients had evidence of rhabdomyolysis with ele-
Fig. 2. Renal biopsy showing acute tubular injury with pigment casts (H&E stain).
vated serum CPK (>390 IU/L) and urine myoglobin was detected
in two patients. Three showed evidence of hemolysis with ele-
vated LDH (>400 IU/L), anemia and elevated bilirubin. One patient
had elevated transaminases. Mild thrombocytopenia was seen in CPK and LDH ranged from 5 to 11 days. Renal biopsy carried out in
two patient and altered coagulation parameters in one. Microhe- four patients showed AIN (Figure 1) in one patient, ATN with pig-
maturia was seen in four and proteinuria in two, with a mean ment cast (Figure 2) in two, of which one patient had positivity for
urine protein creatinine ratio of 1.2 ± 0.5. Hyperkalemia was histochemical stain for myoglobin, and one patient had both AIN
seen in three. No cardiac or neurological manifestations were and ATN. The two patients who showed AIN in the biopsy were
seen in any patient. treated with oral steroids 1 mg/kg, tapered off over the following
Ten patients required hemodialysis support and two patients 4 weeks. One patient died within 48 h of presentation due to
received alkaline diuresis. Time taken for normalization of serum shock. At a mean follow-up of 24 ± 8 months, nine patients had
CLINICAL KIDNEY JOURNAL
AKI due to multiple wasp stings | 203

complete recovery, and one patient had progressed to CKD with rhabdomyolysis in all and hemolysis in three patients. Altered
serum creatinine of 3.5 mg/dL. liver function tests were seen in 36%, mild thrombocytopenia in
18% and altered coagulation parameters in 18%. Coagulopathy in
wasp sting has been related to increased levels of antithrombin
Discussion and decreased levels of fibrinogen, high molecular weight kinino-
The important families of the order Hymenoptera [4] are Apoidea gen, factors V and VIII [10]. Vikrant et al. [11] reported three cases
(bees), Vespoidea (wasps, hornets and yellow jackets) and Formi- of acute renal failure following wasp sting but only two had evi-
cidae (ants). Toxins in wasp venom include enzymes such as dence of intravascular hemolysis.
phospholipase A2 and hyaluronidase, peptides such as melittin Ten patients required hemodialysis support with a mean
and chemotactic peptides, amines such as histamine, serotonin number of 8.7 ± 2.8 sessions over a time period of 16.2 ± 6.3
and catecholamines, and others such as mastoparan, kinins, days. Improvement of oliguria occurred over a mean duration of
apamine, acetylcholine, antigen 5 and neurotoxic cynines. 8.2 ± 1.7 days. Sigdel et al. [8] studied 18 patients in which all de-
Phospholipase A2 initiates inflammation, hyaluronidase causes veloped AKI requiring dialysis with the mean number of hemodi-

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spread of venom, melittin has hemolytic, vasoactive, cellular alysis sessions being 7.4 ± 5.3 (range 1–20). Mean time to
antimembrane properties, histamine increases vascular perme- resolution of oliguria was 15.9 ± 9.5 days (range 2–35). Mean
ability and apamine is a neurotoxin [5]. length of hospital stay was 18.7 ± 13.4 days (range 1–46), with
Local reactions after wasp sting include pain and swelling, those having a higher number of stings having a longer stay.
while systemic allergic reactions may be mild, moderate (angioe- Xie et al. [9] showed presence of AKI in 21.0% of patients. Rhabdo-
dema/asthma) or severe (laryngeal edema/shock) [6]. Systemic myolysis was seen in 24.1% of patients, hemolysis in 19.2%, liver
complications include the renal, cardiac (myocarditis/myocar- injury in 30.1% and coagulopathy in 22.5%. Regression analysis
dial infarction), hepatic (centrilobular necrosis), neurological revealed that high creatinine level, shock, oliguria and anemia
(acute encephalopathy/stroke) and hematological (hemolysis/ were risk factors for death. One patient in our study died due to
disseminated intravascular coagulation/thrombocytopenia). shock.
Mostly, anaphylaxis results from single or a few wasp stings, The mechanisms of AKI include pigment-induced ATN, AIN,
whereas multiple wasp stings result in systemic complication [7]. and, rarely, acute cortical necrosis [12] and thrombotic microan-
The average number of sting marks, which were seen pre- giopathy. Mellitin and phospholipase in wasp venom cause
dominantly on the face, trunk and upper extremities, in our rhabdomyolysis and hemolysis. Myoglobin is freely filtered in
study was 36 as compared with 96.4 ± 70.1 (range 35–300) in one glomeruli; when it is present in high concentration, along with
study [8]. Xie et al. [9] showed that elevation of all laboratory para- dehydration and acidic urine, it is first transformed to ferrihema-
meters was higher in patients with >10 stings than in patients tin precipitates in the proximal tubule to form obstructive pigment
with ≤10 stings. The in-hospital mortality was five times higher casts [13]. It is also a potent inhibitor of nitric oxide and triggers in-
in the >10 stings group than that in the ≤10 stings group. Renal trarenal vasoconstriction and ischemia. A summary of venomous
failure or death may occur in the range of 20–200 wasp stings. animals, their toxins and the mechanism of AKI is given in Table 2.
The mean length of time between wasp sting and hospitalization Initial management of rhabdomyolysis consists of rapid ex-
was 10.7 h in one study [8], whereas it ranges from 2 to 11 days in pansion of intravascular volume by using normal saline to main-
our study. tain urine output at more than 200–300 mL/h followed by
The main clinical features at presentation included oliguria alkalinization of urine, which may prevent development of AKI
(55%), microhematuria (36%), hypertension (18%) and hypoten- [14, 15]. Alkaline diuresis was done in two patients; one did not
sion (18%), while oliguria, red urine and jaundice were the main require hemodialysis. The treatment of AKI with hemodialysis,
symptoms in a study of 18 patients with wasp stings [8]. None of hemofiltration or peritoneal dialysis has been described [16]. Ex-
the patients had eosinophilia or eosinophiluria. One patient had change transfusion or plasmapheresis should be reserved for the
history suggestive of anaphylaxis. There was evidence of treatment of life-threatening multisystem organ failure.

Table 2. Animal toxins and mechanisms of AKI

Incidence of Mechanism of
Animal Principal toxin AKI envenomation Characteristics of renal damage

Snakes Zinc metalloproteases, 5–50% Neurotoxic, myotoxic, ATN, AIN, myoglobinuria, renal
phospholipase A2, serine protease, hemotoxic, nephrotoxic cortical necrosis, thrombotic
hyaluronidase microangiopathy
Scorpion Histamine, serotonin, phospholipase 2–10% Hemotoxic, cardiotoxic, ATN, AIN
A2 myotoxic
Spiders Phospholipase D, collagenase, astacin 4–10% Proteolytic, dermonecrotic, ATN, myoglobinuria
like metalloproteinase hemolytic, nephrotoxic
Bees Melittin, phospholipase A2, acid 10–30% Hemotoxic, cardiotoxic, AIN, ATN, myoglobinuria,
phosphatase nephrotoxic hemoglobinuria
Wasps Phospholipase A1, hyaluronidase 20–50% Hemotoxic, myotoxic ATN, AIN, myoglobinuria
Caterpillars Lipocalin, cysteine protease 2–18% Hemotoxic, proteolytic, ATN, myoglobinuria, hemoglobinuria
fibrogenolytic
Raw bile carp Cyprinol 50–60% Direct nephrotoxicity, ATN
Jellyfish Catecholamines, serotonin, kinins 1–5% Myotoxic, hemotoxic ATN
Beetles Cantharidine 2–10% Direct nephrotoxicity ATN
consumption
CLINICAL KIDNEY JOURNAL
204 | J. Dhanapriya et al.

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