Prolonged severe kidney dysfunction treated with intermittent hemodialysis following envenomation by a snake consistent with the Rhabdophis subminiatus species complex: a case report.

BACKGROUND: Members of the Rhabdophis subminiatus species complex are rear-fanged natricine snakes distributed throughout Southeast Asia. Envenomation is characterized predominantly by venom-induced consumption coagulopathy (VICC), severe hypofibrinogenemia, and systemic bleeding. Although kidney dysfunction has been reported following Rhabdophis envenomation, prolonged severe kidney dysfunction treated with intermittent hemodialysis has been rarely described.

CASE PRESENTATION: A 70-year-old Vietnamese man with no known history of chronic kidney disease was bitten on the right fourth finger by a snake that was subsequently killed and brought to the hospital. Based on a dorsal photograph and the geographic locality, an experienced herpetologist assessed the snake as being consistent with a member of the Rhabdophis subminiatus species complex; however, definitive species identification was not possible because molecular confirmation and comprehensive morphometric assessment were unavailable. Fourteen hours after the bite, the patient presented with gingival and persistent bite-site bleeding and severe VICC, characterized by prothrombin activity < 5%, international normalized ratio > 10, activated partial thromboplastin time > 180 s, fibrinogen < 0.10 g/L, thrombocytopenia, and markedly elevated D-dimer levels. Kidney dysfunction was already present on admission, with a serum creatinine concentration of 259 µmol/L. Because baseline renal measurements were unavailable, the magnitude and chronicity of the renal impairment could not be determined. Kidney dysfunction subsequently progressed to severe oliguric-anuric kidney dysfunction and was treated with at least 13 documented sessions of intermittent hemodialysis during hospitalization. Serum creatinine reached a maximum pre-dialysis concentration of 864 µmol/L at 459 h after envenomation. Although conventional coagulation parameters subsequently recovered, severe kidney dysfunction persisted. At discharge on hospital day 31, kidney dysfunction remained severe, with a serum creatinine concentration of 696 µmol/L, and ongoing intermittent hemodialysis was planned. At one-month follow-up after discharge, the patient and his daughter reported by telephone that intermittent hemodialysis was ongoing; however, the exact post-discharge dialysis frequency, most recent dialysis date, and contemporaneous renal measurements were unavailable.

CONCLUSION: Severe envenomation by a snake consistent with a member of the Rhabdophis subminiatus species complex was associated with profound VICC and prolonged severe kidney dysfunction treated with intermittent hemodialysis. In this patient, recovery of conventional coagulation parameters did not parallel recovery of kidney function. The mechanism of the renal dysfunction could not be established because baseline renal function was unavailable, renal biopsy was not performed, and thrombotic microangiopathy could neither be confirmed nor excluded. Prolonged renal monitoring may therefore be warranted after severe Rhabdophis envenomation, particularly when kidney dysfunction is already evident during the acute phase.