Abstract
Background
To evaluate the treatment of sustained low-efficiency hemodialysis (SLED) against patients with multiple organ dysfunction syndrome (MODS) following wasp stings.
Methods
Clinical data of 35 patients with MODS following wasp stings were retrospectively analysed. These patients were divided into three groups according to the treatment strategy used: 1) hemodialysis (HD) group, 2) continuous veno-venous hemofiltration (CVVH)/HD group, and 3) SLED/HD group. The clinical parameters, treatment outcome, and safety findings were compared among the three groups.
Results
The recovery rate (76.92% vs 77.78% vs 91.67%, p = 0.621) and mortality rate (15.38% vs 11.11% vs 8.33%, p = 0.999) were similar among the three groups. When compared to the HD group, patients treated with CVVH/HD or SLED/HD required a shorter period of time to enter into polyuria stage [(24.7 ± 4.3) days vs (20.2 ± 4.7) days vs (18.2 ± 3.0) days, F = 9.11, p = 0.0007], and required a shorter time for serum creatinine to return to normal [(45.7 ± 13.4) days vs (33.1 ± 9.4) days vs (31.9 ± 9.8), F = 5.83, p = 0.0069]; while such parameters had no significant differences between SLED/HD group and CVVH/HD group. The adverse events of hypotension and arrhythmia were found in the HD group, while no adverse events were reported in the SLED/HD and CVVH/HD groups. There was no significant difference in the cost of blood purification treatment between the SLED/HD group and HD group.
Conclusion
The use of SLED, CVVH and HD provided a comparable recovery and survival rates in patients with MODS secondary to wasp stings. Compared to HD, the use of SLED is recommended as a treatment strategy because of the efficacy on recover of renal function, satisfactory safety outcome, as well as the reasonable treatment cost.
Similar content being viewed by others
Background
The incidences of wasp stings are frequently reported in rural areas. The outcomes can range from a mild local anaphylactic reaction to a severe systemic reaction, like multiple organ dysfunction syndrome (MODS) [1, 2]. The severe wasp sting injuries have been occurring more often in countries including India, Vietnam, Thailand, Malaysia, and China [2, 9, 10]. In contrast to the occasional incidence in previous reports, the wasp stings have been occurring more frequently in China, causing a considerable mortality among victims [3, 11]. Patients with wasp stings reported in developed countries were usually suffered from a single sting, and an anaphylactic reaction is the main clinical feature of such patients. In China, however, patients were attacked by a crowd of wasps, resulting in severe hemolysis and rhabdomyolysis that greatly injured the kidneys [3]. Blood purification therapy is thus often applied to these patients. The current study showed that the three treatment strategies (HD, CVVH/HD, and SLED/HD) could provide a similar mortality and recovery rates. A previous case report described the successful outcomes after using CVVH to treat MODS secondary to wasp attacks [12]; nevertheless, a meta-analysis study did not find the survival advantage of using CVVH over HD to treat MODS patients with acute renal failure [13]. Our study also suggested that the use of SLED, CVVH, or HD provided similar clinical outcomes when treating patients with wasp sting induced MODS.
Renal failure is frequently observed in patients with wasp sting. These patients usually presented acute tubular necrosis or acute interstitial nephritis [14], and oliguria is rapidly observed with electrolyte imbalance. Blood purification treatment is thus important of these patients. Among the different blood purification methods, CVVH provided several advantages, including the improved hemodynamic stability that will allow better clearance of small−/macro-molecule of metabolites and recovery of renal function. On the other hand, HD has advantages of flexibility, cost-effectiveness, and is effective in removing small molecules such as potassium. It is also beneficial for reducing bleeding caused by anticoagulation. For critically ill patients, there has been no consensus on the ideal treatment that should be used, but combination treatment strategy has been suggested [15]. SLED provides advantages of both CVVH and HD. It is administered using conventional dialysis technology but over a prolonged period, thereby allowing for gradual removal of fluid with less hemodynamic perturbation [16,17,18]. For patients with critical acute kidney injury requiring renal replacement, the use of SLED and CVVH provides similar outcome in terms of overall mortality and renal function recovery [18].
The safety profiles of patients treated with SLED/HD or CVVH/HD were similar, in which there were no adverse events reported during the blood purification process. In addition, no significant difference was found between the two groups entering polyuria stage and the time when Scr returned to normal, indicating both of the blood purification methods could promote the recovery of renal function at about the same time. In comparison between SLED/HD group and HD group, patients in the SLED/HD group required a shorter time period to enter into the polyuria stage and had the Scr returned to normal level, also the incidence of hypotension was reduced. This could be due to the prolonged treatment time. Indeed, a study showed that the prolonged HD treatment could increase the clearance of urea and provide a more stable hemodynamic, when compare to the conventional HD [19]. Overall, the use of SLED/HD or CVVH/HD could provide a similar efficacy in renal function recovery.
The release of large amount of inflammatory mediators may contribute to the development of MODS [3, 20]. We found that on Day 3 of the treatment, patients in the SLED/HD group had a lower APACHE II score and a lower level of WBC when compared to the HD group, suggesting patients treated with SLED had a better improvement in general health condition and inflammatory reactions.
The cost of the treatment is an important factor when considering a treatment, especially for patients in rural area. It is well known that the expense of SLED treatment is higher than that of the HD. However, we found that in the current study the expenses are comparable between SLED/HD group and HD group. Both of these treatments had a lower cost than the CVVH/HD. The patients treated with SLED/HD required a shorter time period to enter into the polyuria stage and had a reduced number of treatments when compared to that of the HD group. Both of these factors contributed to the reduced cost of SLED treatment.
Conclusion
The current study had small sample size and was retrospective in nature. A further study with a randomized control group is needed to validate the results. In summary, the use of SLED, CVVH or HD in treating MODS secondary to wasp stings provided a similar survival and recovery outcome. However, when compared to HD treatment, the use of SLED could provide a better recovery of renal function and improvement of general health condition at a reasonable cost. As such, we recommend the use of SLED as a treatment strategy for patients with MODS induced by wasp stings.
Availability of data and materials
The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.
Abbreviations
- ALT:
-
Alanine aminotransferase
- CPK:
-
Creatine phosphokinase
- CVVH:
-
Continuous veno-venous hemofiltration
- Hb:
-
Haemoglobin
- HD:
-
Hemodialysis
- MODS:
-
Multiple organ dysfunction syndrome
- Scr:
-
Serum creatinine
- SLED:
-
Sustained low-efficiency hemodialysis
- SU:
-
Serum urea
- TB:
-
Total bilirubin
- WBC:
-
White blood cell
References
Sharmila RR, et al. Multiple organ dysfunction syndrome following single wasp sting. Indian J Pediatr. 2007;74(12):1111–2.
Zhang L, et al. Multiple organ dysfunction syndrome due to massive wasp stings: an autopsy case report. Chin Med J. 2012;125(11):2070–2.
**e C, et al. Clinical features of severe wasp sting patients with dominantly toxic reaction: analysis of 1091 cases. PLoS One. 2013;8(12):e83164.
Franca FO, et al. Severe and fatal mass attacks by 'killer' bees (Africanized honey bees--Apis mellifera scutellata) in Brazil: clinicopathological studies with measurement of serum venom concentrations. Q J Med. 1994;87(5):269–82.
Vinsonneau C, et al. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet. 2006;368(9533):379–85.
Fliser D, Kielstein JT. Technology insight: treatment of renal failure in the intensive care unit with extended dialysis. Nat Clin Pract Nephrol. 2006;2(1):32–9.
Kumar VA, et al. Extended daily dialysis: a new approach to renal replacement for acute renal failure in the intensive care unit. Am J Kidney Dis. 2000;36(2):294–300.
Knaus WA, et al. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13(10):818–29.
Pramanik S, Banerjee S. Wasp stings with multisystem dysfunction. Indian Pediatr. 2007;44(10):788–90.
Loh HH, Tan CH. Acute renal failure and posterior reversible encephalopathy syndrome following multiple wasp stings: a case report. Med J Malaysia. 2012;67(1):133–5.
Lin CJ, et al. Multiorgan failure following mass wasp stings. South Med J. 2011;104(5):378–9.
Zhang L, et al. Hybrid renal replacement treatment in acute pulmonary edema with acute kidney injury following multiple wasp stings: a report of 3 cases. Blood Purif. 2010;30(2):106–7.
Ghahramani N, Shadrou S, Hollenbeak C. A systematic review of continuous renal replacement therapy and intermittent haemodialysis in management of patients with acute renal failure. Nephrology (Carlton). 2008;13(7):570–8.
Grisotto LS, et al. Mechanisms of bee venom-induced acute renal failure. Toxicon. 2006;48(1):44–54.
Wang AY, Bellomo R. Renal replacement therapy in the ICU: intermittent hemodialysis, sustained low-efficiency dialysis or continuous renal replacement therapy? Curr Opin Crit Care. 2018;24(6):437–42.
Fieghen HE, et al. The hemodynamic tolerability and feasibility of sustained low efficiency dialysis in the management of critically ill patients with acute kidney injury. BMC Nephrol. 2010;11:32.
Mishra, S.B., et al., A Pilot Randomized Controlled Trial of Comparison between Extended Daily Hemodialysis and Continuous Veno-venous Hemodialysis in Patients of Acute Kidney Injury with Septic Shock. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine, 2017. 21(5): p. 262–267.
Kitchlu A, et al. Outcomes of sustained low efficiency dialysis versus continuous renal replacement therapy in critically ill adults with acute kidney injury: a cohort study. BMC Nephrol. 2015;16:127.
Kumar N, Ahlawat RS. Extended daily dialysis in acute renal failure: a new therapeutic approach. Iran J Kidney Dis. 2007;1(2):63–72.
Yuan H, et al. Efficacy of two combinations of blood purification techniques for the treatment of multiple organ failure induced by wasp stings. Blood Purif. 2016;42(1):49–55.
Acknowledgements
None.
Funding
No funding was received for this study.
Author information
Authors and Affiliations
Contributions
TTY and YYD contributed to the conception and design of the study; RG and YM contributed to the acquisition of data; JMS contributed to the analysis of data; DH and TTY wrote the manuscript; All authors reviewed and approved the final version of the manuscript.
Corresponding author
Ethics declarations
Ethics approval and consent to participate
The study was approved by the Institutional Review Board of Ethics Committee of Renmin Hospital, Hubei University of Medicine and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The requirement for informed consent to participate was waived because the review of the patients’ data was anonymous.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
About this article
Cite this article
Ye, TT., Gou, R., Mao, YN. et al. Evaluation on treatment of sustained low-efficiency hemodialysis against patients with multiple organ dysfunction syndrome following wasp stings. BMC Nephrol 20, 240 (2019). https://doi.org/10.1186/s12882-019-1428-5
Received:
Accepted:
Published:
DOI: https://doi.org/10.1186/s12882-019-1428-5