Journal
EXPERT REVIEW OF CLINICAL PHARMACOLOGY
Volume 16, Issue 6, Pages 559-574Publisher
TAYLOR & FRANCIS LTD
DOI: 10.1080/17512433.2023.2220963
Keywords
acute kidney injury; antivenom; fresh frozen plasma; schistocytes; snakes; snakebite; therapeutic plasma exchange; thrombotic microangiopathies
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Snakebite is a neglected public health issue in resource poor countries, causing death and disability. Snakebite-associated thrombotic microangiopathy (TMA) leads to acute kidney injury and a risk of chronic kidney disease. The current evidence for therapeutic interventions in snakebite-associated TMA is limited and further research is needed.
IntroductionSnakebite is a neglected public health issue causing death and disability, disproportionately affecting tropical and subtropical resource poor countries globally. Snakebite-associated thrombotic microangiopathy (TMA) occurs in a subset of snakebites and is associated with acute kidney injury (sometimes requiring renal replacement therapy) and a risk of chronic kidney disease.Areas coveredThis expert review synthesizes current evidence on therapeutic interventions in snakebite-associated TMA via PubMed search for cohort studies and randomized controlled trials (RCTs) in snakebite-associated TMA from 1970 to October 2022.Expert opinionThere are no interventional RCTs in snakebite-associated TMA. Recent cohort studies from Sri Lanka, India, and Australia report clinical and laboratory endpoint outcomes for intervention with antivenom and therapeutic plasma-exchange (TPE). TPE is a resource intense and costly treatment using large volumes of blood donor plasma. There is no consistent evidence supporting TPE in snakebite-associated TMA with respect to patient survival, dialysis-free survival, or hospital length of stay. Antivenom is the standard of care for patients with snake envenoming, but there is no specific evidence of benefit in snakebite-associated TMA. Emerging new therapies in snakebite more broadly are untested in snakebite-associated TMA. RCTs are needed to improve the evidence for treatment of snakebite-associated TMA.
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