CJASN ePress. Published on September 5, 2013 as doi: 10.2215/CJN.

12081112
Article

Recovery from AKI Following Multiple Wasp Stings: A

Case Series
Ling Zhang,* Yingying Yang,* Yi Tang,* Yuliang Zhao,* Yu Cao,† Baihai Su,* and Ping Fu*

Summary
Background and objective To observe the outcomes of AKI following multiple wasp stings.
*Division of
Design, setting, participants, & measurements Eighty-one patients (mean age 6 SD, 45.5614.7 years; 55 men and Nephrology and
26 women; mean Acute Physiology and Chronic Health Evaluation II score, 16.8562.78) with AKI following †
Division of
multiple wasp stings between 1997 and 2011 were retrospectively analyzed. Data on their demographic char- Emergency, West
acteristics, initial modalities of renal replacement therapy (RRT), urine output, serum creatinine, bilirubin, China Hospital of
myoglobin, and other variables were collected. Renal outcomes included complete recovery of kidney function, Sichuan University,
Sichuan, Chengdu,
CKD, and death. Subgroup analysis was performed according to initial modality of RRT in the first 48 hours, China
including continuous veno-venous hemofiltration (CVVH), intermittent hemodialysis (IHD), and CVVH plus
plasma exchange (PE). Correspondence:
Dr. Fu Ping, Division
Results Of the 75 patients available for follow-up, 7 (9.3%) died, and 8 (10.7%, all in the IHD group) developed of Nephrology, West
CKD. The average RRT time was 18.268.4 days, and the average kidney function recovery time was 36.0 (29.0, China Hospital of
Sichuan University,
41.0) days. Subgroup analysis showed no difference in the mortality rates between the CVVH, CVVH + PE, and No. 37, Guoxue Alley,
IHD groups (8.0%, 7.1%, and 11.1%, respectively; P.0.99). The recovery time for kidney function was signifi- Chengdu, Sichuan
cantly shorter in the CVVH and CVVH + PE groups than in the IHD group (31.968.5 days, 28.669.4 days, and Province, China.
41.668.1 days, respectively; P,0.001). Email: fupinghx@163.
com

Conclusions This is a large case series report on the outcomes of patients with AKI following multiple wasp stings.
Most patients survived with complete recovery of their kidney function. Despite the lack of difference in
mortality rates, the patients who began RRT with CVVH and CVVH + PE experienced a better and more rapid
recovery of kidney function than those initiated with IHD.
Clin J Am Soc Nephrol 8: ccc–ccc, 2013. doi: 10.2215/CJN.12081112

Introduction on the differing modalities of renal replacement ther-

Wasps and bees are members of the order Hymenop-
tera (1). Wasp and bee stings are associated with a
wide variety of reactions, ranging from mild local
reactions (such as edema, erythema, and urticaria)
to fatal systemic complications (such as anaphylactic
shock, rhabdomyolysis, AKI, myocardial infarction,
acute hepatic failure, and encephalitis) (2–5). AKI is
usually caused by intravascular hemolysis, rhabdo-
myolysis, shock, and the direct toxic effects of the
venom; the triad of AKI, hemolysis, and rhabdomyol-
ysis often occurs in patients subjected to multiple
wasp or bee stings (6). Renal biopsy usually reveals
acute tubular necrosis (5,6), as well as occasional
acute interstitial nephritis (7). More than half of the
victims who experience multiple wasp or bee stings
develop AKI, and most of these patients require in-
termittent hemodialysis (IHD) or peritoneal dialysis
(PD) (4,8–10). The mortality rate of patients who ex-
perience AKI due to wasp stings has been reported to
be as high as 25% (6). Few large case series have ad-
dressed the outcomes of wasp or bee sting–induced
AKI, and to our knowledge no studies have focused
apy (RRT) in these patients. In this study, we ana-
lyzed patients with multiple wasp stings at our
hospital during a 15-year period who were treated
with IHD, continuous veno-venous hemofiltration
(CVVH), or plasma exchange (PE) to observe the out-
comes of AKI following multiple wasp stings.
Materials and Methods
Patients
Data from 103 patients with multiple wasp stings
(.50 stings) admitted to West China Hospital of Si-
chuan University between 1997 and 2011 were in-
cluded in our analysis. None of the patients had a
history of CKD. The diagnosis and staging of AKI
were determined according to the 2012 Kidney Dis-
ease: Improving Global Outcomes guidelines (11).
Among the 103 patients, 81 (78.6%) developed oliguric
AKI and received RRT. The clinical course and renal
outcomes of these 81 patients were observed; subgroup
analysis was performed according to the initial modal-
ities of RRT in the first 48 hours.

www.cjasn.org Vol 8 November, 2013 Copyright © 2013 by the American Society of Nephrology 1
2 Clinical Journal of the American Society of Nephrology
Data Collection
Patient demographic characteristics, including age, sex,
disease history, and RRT modality administered, were re-
corded. Important measures, such as mean arterial pres-
sure, urine output, serum creatinine, creatine kinase, lactate
dehydrogenase, total bilirubin, myoglobin, electrolytes,
and adverse events, were collected.
Observation of Clinical Course and Renal Outcomes
Patients were followed up for at least 3 months. Renal
outcomes included a complete recovery of kidney function,
CKD, and death. Complete recovery of kidney function
was defined as a decrease in the creatinine level to within a
normal range with normal urine output. CKD was defined
as an estimated GFR of ,60 ml/min per 1.73 m2 or the
occurrence of albuminuria 3 months after the onset of AKI,
ESRD was defined as the requirement of maintenance di-
alysis 3 months after the onset of AKI, and CKD staging
was performed according to the 2002 Kidney Disease Out-
comes Quality Initiative guidelines (12,13). The recovery
time of kidney function, causes of death, and changes in
important laboratory measures were also recorded.
Indication of RRT
Patients were treated with RRT when they had AKI with
oliguria (urine output ,100 ml in a 6-hour period or ,400 ml
per day) or complicated by hyperkalemia, metabolic acidosis,
or acute pulmonary edema.
Available RRT modalities included IHD, CVVH, and PE.
Patients received different RRT modalities mainly on the
basis of illness severity. Compared with IHD, CVVH was
always performed on patients with more severe symptoms,
especially when the AKI was complicated by multiple organ
dysfunctional syndromes (MODS). PE was considered
when patients had severe hemolysis and rhabdomyolysis.
RRT was stopped when urine output was .1500 ml/d
without fluid overload and the serum creatinine level
was ,3 mg/dl.
Statistical Analyses
Continuous variables were expressed as mean 6 SD or
as the median (25th and 75th percentiles), as appropriate.
Subgroup analysis was conducted according to the initial
RRT modalities. One-way ANOVA, the Scheffe test, or the
Kruskal-Wallis test was used to make comparisons be-
tween groups. Categorical variables were expressed as
proportions and were compared using the chi-squared
test or Fisher exact test. P values , 0.05 were considered
to represent statistically significant differences. All statis-
tical analyses were conducted using SPSS software, ver-
sion 20.0 (SPSS Inc., Chicago, IL).
Results
General Characteristics
Of the 103 patients with multiple wasp stings, 87 (84.5%)
had AKI, and 60 (68.9%) presented with MODS complica-
tions. Of the patients who developed AKI, 6 (6.9%) had
nonoliguric AKI and recovered without RRT. Of the 81
patients (93.1%; Acute Physiology and Chronic Health
Evaluation [APACHE] II score, 16.8562.78) who received
RRT, 6 (2 in the CVVH group and 4 in the IHD group)
were lost to follow-up within 3 months from AKI onset.
These patients still had impaired kidney function at their
last follow-up, and the final outcomes were unknown.
Twenty patients (24.7%) started RRT at AKI stage 2; 61
patients (75.3%) at AKI stage 3; and none at AKI stage 1.
The important laboratory measures of these patients are
listed in Table 1.
General Therapies
Local wounds were washed with normal saline and
underwent hydropathic compress protection. Nutrition
support and short-term glucocorticoids were also admin-
istered. Blood transfusions were performed as necessary.
Modalities of RRT and Subgroup Analysis
According to the initial RRT modality received, the pa-
tients were divided into three groups. (1) CVVH group:
CVVH was performed (B. Braun Diapact, Diacap Acute M,
1.5 m2) using predilution bicarbonate replacement fluid
at a rate of 30–35 ml/kg per hour with a blood flow rate
of 150–200 ml/min. Citrate was considered the first choice
for anticoagulation, and low-molecular-weight heparin
was used as an alternative when patients had contraindi-
cations to citrate, such as severe liver dysfunction or per-
sistent poor tissue perfusion. CVVH was performed for at
least 48 hours and then was replaced by IHD when the
condition of the patient became stable. (2) CVVH + PE
group: In addition to the CVVH and IHD therapies re-
ceived by the CVVH group, the CVVH + PE group re-
ceived PE once daily on day 1 and day 2 with a 2000- to
2500-ml exchange volume each time using fresh-frozen
plasma. (3) IHD group: IHD was performed (Gambro
AK-200 or B. Braun Dialog) three times per week for
4 hours per session using low-molecular-weight heparin
or heparin for anticoagulation with a blood flow rate of
200–250 ml/min and a Kt/V ratio of 1.2–1.4.
The subgroup analysis showed no significant differences
between the treatment groups with regard to mean arterial
pressure, hemoglobin, lactate dehydrogenase, APACHE II
score, or AKI stage at the baseline readings, but there were
significant differences in the creatinine, total bilirubin,
myoglobulin, and creatine kinase levels, as well as in the
proportion of patients with MODS, between the different
treatment groups (Table 1). The average treatment times for
the CVVH and CVVH + PE groups were 51.4618.8 and
49.6622.1 hours, respectively (P=0.37). The IHD group re-
ceived an average of 12.468.4 dialysis sessions.
Survival and Recovery of Kidney Function
Of the 75 patients available for follow-up, 7 patients died,
which corresponded to a mortality rate of 9.3%; the causes
of death were acute pulmonary edema (n=3), MODS (n=3),
and acute digestive tract hemorrhage (n=1). Kidney func-
tion completely recovered in 60 patients (80.0%). Of the 8
patients (10.7%) in the IHD group who developed CKD, 3
were in CKD stage 2, 3 were in CKD stage 3, and 2 devel-
oped ESRD. Two of the patients with CKD stage 2–3 pre-
sented mild proteinuria (0.5 and 0.7 g/24 hours). The
average time required for RRT was 18.268.4 days, and it
took an average of 36.0 (29.0, 41.0) days for patients to
recover kidney function (Table 2).
Clin J Am Soc Nephrol 8: ccc–ccc, November, 2013 AKI Following Multiple Wasp Stings, Zhang et al. 3

Table 1. Demographic and clinical characteristics of patients with AKI at baseline

Total IHD CVVH CVVH + PE

Variable P Value
(n=81) (n=40) (n=27) (n=14)

Age (yr) 45.5614.7 42.6615.7 49.1613.5 47.1613.1 0.19

Men/women 55/26 29/11 17/10 9/5 0.69
Hypertension 7 3 3 1 0.87
Diabetes 6 3 1 2 0.38
MAP (mmHg) 98.9616.6 96.7615.4 98.6618.2 105.9615.9 0.20
Hemoglobin (g/dl) 10.0762.11 9.8561.73 10.4762.49 9.9362.36 0.48
White blood cell count 25.8768.12 25.1468.64 26.8268.31 26.1366.34 0.71
(3103/ml)
Creatinine (mg/dl) 3.2760.94 2.9860.76 3.6061.04a 3.3861.00 0.02
Total bilirubin (mg/dl) 4.5962.87 2.8161.47 4.9862.06a 8.8962.37a,b ,0.001
Alanine aminotransferase (U/L) 729.46629.1 629.26533.1 816.46781.9 847.66546.4 0.37
Myoglobulin (U/L) 1678368794 1231966149 1942868525a 2443568844a ,0.001
Creatine kinase (U/L) 20080610821 1470068121 2280469226a 30201611732a ,0.001
LDH (U/L) 537162665 503962642 569862783 569162568 0.55
APACHE II score 16.8562.78 16.3862.36 17.0063.33 17.9362.56 0.19
MODS 60/81 25/40 21/27 14/14a 0.01
Time from sting to RRT (h) 56.7628.4 61.1624.9 57.8631.4 42.57629.5 0.11
Time from admission to RRT (h) 8.964.9 8.364.8 9.764.6 9.265.2 0.49
AKI stage (stage 2/stage 3) (n/n) 20/61 13/27 3/24 4/10 0.12

Comparisons among the three groups with respect to age, MAP, hemoglobin, white blood cell count, creatinine, total bilirubin, alanine
aminotransferase, myoglobulin, creatine kinase, LDH, APACHE II score, time from sting to RRT, and time from admission to RRT were
performed using ANOVA. Comparisons among the three groups based on sex, hypertension, diabetes, MODS, and AKI stage were
performed using the Fisher exact test. Pairwise comparisons among the three groups with respect to creatinine, total bilirubin, my-
oglobulin, and creatine kinase levels were performed using the Scheffe test. Pairwise comparisons among the three groups with respect
to the proportion of patients with MODS were performed using the chi-square test. IHD, intermittent hemodialysis; CVVH, continuous
veno-venous hemofiltration; PE, plasma exchange; MAP, mean arterial pressure; LDH, lactate dehydrogenase; APACHE II, Acute
Physiology and Chronic Health Evaluation II; MODS, multiple organ dysfunction syndrome; RRT, renal replacement therapy.
a
Significant differences when compared to IHD group.
b
Significant differences when compared to CVVH group.

Subgroup analysis showed no significant differences in
the mortality rates among the three treatment groups (IHD
group: 11.1%; CVVH group: 8.0%; CVVH + PE group: 7.1%;
P.0.99). However, compared with the CVVH and CVVH +
PE groups, the IHD group experienced a lower rate of com-
plete recovery of kidney function (IHD group: 66.7%; CVVH
group: 92.0%; CVVH + PE group: 92.9%; P=0.02) (Table 2).
By the 90th day after the onset of AKI, kidney function
recovered completely in all of the survivors in the CVVH
and CVVH + PE groups. However, in the IHD group,
8 patients (22.2%) developed CKD. Additionally, the total
time for RRT treatment was significantly shorter in the
CVVH and CVVH + PE groups than in the IHD group (IHD
group: 22.667.0 days; CVVH group: 14.467.2 days;
CVVH + PE group: 13.768.3 days; P,0.001). Similarly,
the time to recovery of kidney function was significantly
shorter in the CVVH and CVVH + PE groups (IHD group:
39.0 (36.8, 43.0) days; CVVH group: 32.0 (25.0, 38.0) days;
CVVH + PE group: 25.0 (19.5, 32.0) days; P,0.001) (Table 2).
Changes in Biochemical Measures
Serum levels of total bilirubin, myoglobulin, and creatine
kinase decreased steadily through the first 7 days of the
treatment course, and the serum level of creatinine fluctu-
ated (Figure 1).
Subgroup analysis showed that the IHD group had a
higher level of serum creatinine than the other two groups
on the 3rd and 7th days after AKI onset (P,0.001) (Table 3).
Additionally, the creatinine level rebounded on the 7th
day after AKI onset in the IHD group (P=0.002) (Table
3). Although the three groups did not significantly differ
in plasma creatine kinase, myoglobulin, and total bilirubin
levels on the 7th day after AKI onset (all P.0.05), these
values decreased at a faster rate in the CVVH and CVVH +
PE groups within the first 3 days of AKI onset relative to
the respective baseline levels (Figure 1). Furthermore, total
bilirubin decreased more in the CVVH + PE group than in
the CVVH group (P=0.007).
Adverse Events
The main complications associated with RRT were ar-
rhythmia, hypotension, and bleeding. No patients required
vasopressors before or during RRT.
The IHD group had a higher incidence of hypotension
than the other two groups (IHD group, 9 of 40; CVVH
group, 0 of 27; CVVH + PE group, 0 of 14; P=0.005). Pa-
tients in the CVVH group were most likely to have hypo-
phosphatemia (IHD group, 0 of 40; CVVH group, 7 of 27;
CVVH + PE group, 2 of 14; P,0.001), but this symptom
improved without additional interventions after the ces-
sation of CVVH. The three groups did not significantly
differ regarding other adverse events, such as arrhythmia,
hypertension, catheter-related infections, and bleeding
episodes.
4 Clinical Journal of the American Society of Nephrology

Table 2. Primary outcomes of patients overall and in the different groups

Total IHD CVVH CVVH + PE

Variable P Value
(n=75) (n=36) (n=25) (n=14)

Complete recovery (n) 60 24 23 13 0.02

CKD (n) 8 8 0 0 —
ESRD (n) 2 2 0 0 —
Death (n) 7 4 2 1 —
Mortality rate (%) 9.3 11.1 8.0 7.1 1.0
Required RRT time (d) 18.268.4 22.667.0 14.467.2a 13.768.3a ,0.001
Recovery of kidney 36.0 (29.0, 41.0) 39.0 (36.8, 43.0)a,b 32.0 (25.0, 38.0)a 25.0 (19.5, 32.0)a ,0.001
function (d)

Values expressed with a plus/minus sign are the mean 6 SD; data in parentheses are interquartile ranges. Comparisons among the
three groups with respect to the complete recovery rate and the mortality rate were performed using the Fisher exact test. Comparisons
among the three groups with respect to the time of requiring RRT was performed using the ANOVA test. Pairwise comparisons of the
three groups were performed using the Scheffe test. Comparisons among the three groups as well as pairwise comparisons with respect
to the time of recovery of kidney function were performed using the Kruskal-Wallis test. IHD, intermittent hemodialysis; CVVH,
continuous veno-venous hemofiltration; PE, plasma exchange; RRT, renal replacement therapy.
a
Significant differences when compared to IHD group.
b
Significant differences when compared to CVVH group.

Figure 1. | Changes in the biochemical measures in the three groups. (A) Serum creatinine (mg/dl), (B) total bilirubin (mg/dl), (C) myoglobin (U/L),
(D) creatine kinase (U/L). Conversion factors for units: creatinine in mg/dl to mmol/L, 388.4; total bilirubin in mg/dl to mmol/L, 317.1. CVVH,
continuous veno-venous hemofiltration; IHD, intermittent hemodialysis; PE, plasma exchange.

Discussion to achieve complete kidney recovery; however, 9.3% of

This was a large case series report on the outcomes of them died, and 10.7% of them developed CKD.
AKI patients following multiple wasp stings. We found Apoidea (bees), Vespoidea (wasps, hornets, and yellow
that the incidence of AKI after multiple wasp stings was as jackets), and Formicidae (ants) are groups of the order
high as 84.5%. Eighty percent of the AKI patients were able Hymenoptera (1). Hymenoptera venoms are complex
Clin J Am Soc Nephrol 8: ccc–ccc, November, 2013
Table 3. Percentage decrease in the biochemical measures in the first 3 days
Variable Total (n=81) IHD (n=40)
Creatinine (%) 3.6 224.1
(230.9, 24.5) (256.6, 3.4)
Total bilirubin (%) 40.3 12.1
(21.4, 54.8) (225.6, 48.6)
Myoglobulin (%) 48.1 36.9
(29.2, 60.3) (14.8, 50.2)
Creatine kinase (%) 46.0 25.1
(20.8, 57.7) (250.0, 47.7)
Data are expressed as the medians (25th, 75th percentile) and were compared between groups using the Kruskal-Wallis test. IHD,
intermittent hemodialysis; CVVH, continuous veno-venous hemofiltration; PE, plasma exchange.
a
Significant differences when compared to IHD group.
b
Significant differences when compared to CVVH group.
mixtures of biologically active components primarily com-
posed of peptides, enzymes, and amines. Bee venom,
which has been studied to a greater extent than the venom
of other species within the order Hymenoptera, contains
melittin, phospholipase A2 (PLA2), mast cell–degranulating
peptide (peptide 401), hyaluronidase, and apamin, among
other constituents (1). Melittin, which makes up approxi-
mately 50% of the entire bee venom mixture (14), power-
fully disrupts cell membranes and has direct toxic effects
on renal tubular cells of the host (15–17). Wasp venom
does not contain melittin. Instead, wasp venom contains
antigen 5 as the main allergen; however, the bioactivity
of antigen 5 has not yet been fully determined (1). Vic-
tims attacked by wasps or bees can have mild local or
regional reactions (e.g., swelling, urticaria, erythema, and
pain), as well as severe systemic anaphylactic responses.
A description of the stinging insects by their victims, the
circumstances surrounding the sting episode, and the lo-
cal signs of stings can be helpful in differentiating be-
tween wasp and bee stings (Table 4) (18–20). Patients
with multiple wasp or bee stings could progress to AKI
or even MODS. Rhabdomyolysis, hemolysis, and cardio-
vascular depression caused by venom and direct neph-
rotoxicity are considered the main mechanisms of bee
venom–induced AKI (15,21–23).
In this retrospective study, we found that the mortality
rate of AKI following multiple wasp stings was 9.3%,
which is lower than that of previous reports, in which
patients with AKI following multiple wasp or bee stings
were treated with IHD and PD and had a mortality rate
between 16% and 25% (6,9,10). Previous studies also
showed that, among the patients who survived, 1–3
months was required to recover full kidney function
(4,6,8–10,24–26). In our study, the average recovery
time of kidney function was shorter in the CVVH or
CVVH + PE group than in IHD group, and we believe
that this might be partially related to the different RRT
modalities used.
In fact, six adult victims of wasp stings who were
admitted to our hospital between 1995 and 1996 received
PD treatment. Of these patients, one did not return for follow-
up, two died, and three developed ESRD. PD was sub-
sequently discontinued in patients with wasp sting–induced
AKI Following Multiple Wasp Stings, Zhang et al. 5
CVVH (n=27) CVVH + PE (n=14) P Value
24.8 19.2 ,0.001
(2.6, 50.5)a (3.5, 39.8)a
40.7 60.6 ,0.001
(26.6, 54.7)a (48.5, 67.6)a,b
49.5 61.1 ,0.001
(42.9, 61.4)a (48.1, 71.3)a
55.3 55.3 ,0.001
(33.3, 68.6)a (45.5, 66.8)a
AKI in our center. However, in some cases, patients, par-
ticularly children, received PD and recovered completely
(8,24). Because the number of patients with wasp sting–
induced AKI who were receiving PD was limited, we sus-
pect that the selection of patients and the experience of
clinical centers could have significantly influenced the
outcomes of these cases. In general, the effect of PD in
severe AKI remains controversial (27), and the role of
PD in patients with multiple wasp stings will require fur-
ther investigation. In this study, we found that .80% of
patients with multiple wasp stings developed AKI, .90%
of whom required RRT; these results are consistent with
those of recent case studies (9,10). However, we reported a
mortality rate of 9.3%, which is low relative to the 18.0%
(2 of 11 patients) (9) and 16.3% (7 of 43 patients) (10) rates
reported in earlier studies. Although the number of pa-
tients included in these studies was limited and some
patients were stung by different species of wasps and
bees, making direct comparisons of the severity of sick-
ness more difficult, we believe that the lower mortality
rate in our study could be partially related to the more
diversified RRT modalities used.
Mortality did not significantly differ among the IHD,
CVVH, and CVVH + PE groups, which could be partially
due to the limited number of patients. Although there
were no significant differences in the APACHE II scores
between any of the groups, patients who received CVVH
or CVVH + PE presented higher levels of total bilirubin,
myoglobulin, and creatine kinase, which indicated that
these patients experienced more severe rhabdomyolysis
and hemolysis. In addition, there were larger proportions
of patients with MODS in the CVVH and CVVH + PE
groups than in the IHD group. Notably, the patients who
developed CKD all belonged to the IHD group (8 of 36
[22.2%]). A previous study (10) that included 43 patients
with AKI after being stung by Africanized bees showed
that only 41.7% of patients had normal kidney function
at their last follow-up (average duration of follow-up,
25.2618.3 days). In our study, 66.7% of the patients in
the IHD group achieved complete kidney function recov-
ery by the 90th day of follow-up, but these patients
experienced a much longer recovery time for kidney
function than those in the CVVH and CVVH + PE
6 Clinical Journal of the American Society of Nephrology
Table 4. Differences between wasp and bee stings
Variable Bees
Body shape Fuzzy
Food Nectar and pollen
Circumstances of sting Usually near flowers or a beehive
incidents
Type of sting Sting only once, usually with a
stinger (with barbs) in the skin
Medically important Melittin (2.8 kD)
components in venom PLA2 (14.5 kD)
(references 30–32) Hyaluronidase (39 kD)
Acid phosphatase (43 kD)
PLA2, phospholipase A2; PLA1, phospholipase A1.
groups. Therefore, patients administered continuous RRT
seemed to have a better and more rapid kidney recovery
than patients who received IHD. The reasons for this ob-
servation are unclear, but we think that this difference
could be partially related to the more stable internal en-
vironment and smoother fluid balance control experi-
enced by the patients who were administered
continuous RRT. Patients in the IHD group received di-
alysis three times per week, and these patients experi-
enced more episodes of intradialytic hypotension,
which could have induced kidney ischemia.
Moreover, hemolysis and rhabdomyolysis play a pivotal
role in multiple wasp or bee sting–induced AKI. Compared
with IHD, CVVH and/or PE may have provided a more
effective clearance of some toxins with a large molecular
weight. Myoglobin (17,800 D), the “secondary toxin” pro-
duced by rhabdomyolysis following wasp and bee stings,
could be cleared by CVVH, which has sieving coefficients
that range from 0.23 to 0.60 (28,29). Most of the compo-
nents of wasp and bee venoms are also large molecules,
which makes these components subject to clearance by
CVVH (Table 4) (30). The main component of bee venom
is melittin, which is a 2800-D water-soluble polypeptide,
each peptide of which consists of 26 amino acid residues
(31), and PLA2, which has a molecular mass of 14,500 D
and is also water soluble (32). Antigen 5 and phospholi-
pase A1 (PLA1), the chief components of wasp venom,
have even larger molecular masses of 23,000 and 43,000
D, respectively (30). Theoretically, CVVH could remove
these toxins more effectively than conventional 4-hour,
standard-flux IHD. Unfortunately, our study provides
no direct evidence regarding the effect of RRT on remov-
ing wasp or bee venom components, and future studies
should investigate this possibility.
Although the mechanism remains unclear, myoglobulin,
creatine kinase, and total bilirubin decreased faster in the
CVVH group, and this effect appears to have been exag-
gerated by PE. PE has proven effective in patients who have
ingested poison and been bitten by a snake (33), but the
evidence of the efficacy of PE in patients with wasp or bee
stings is limited (34,35). We believe that PE is advantageous
in clearing the venom components, the secondary toxic
Wasps
Smooth
Insects and sweet substances (e.g., sap, nectar,
soft drinks, and cans)
Near, for example, open soft drink cans; when
performing outdoor activities that disturb
their nests
Sting repeatedly, normally without a stinger
(without barbs) in the skin
Antigen 5 (23 kD)
PLA1 (34 kD)
Hyaluronidase (38 kD)
agents, and the inflammation mediators in circulating
blood (36), but future studies should explore the optimal
initiation time and frequency of PE.
Some studies have shown that earlier RRT interventions
could improve the outcomes of patients with severe AKI
(37–39). However, in our study, 75.3% of the patients in
our study did not receive RRT until they reached stage 3
AKI. This delay in the initiation of RRT may arise par-
tially because most wasp attacks occurred in the country-
side or mountainous areas, requiring extra time for the
transport of patients from local clinics to hospitals capa-
ble of performing RRT. We also noted that all 7 patients
who did not survive died within 72 hours after admis-
sion, which may suggest that earlier RRT intervention
could be beneficial for AKI patients following multiple
stings. However, this observation needs to be confirmed
in future studies.
This study has some limitations. The study was a retro-
spective analysis, and the number of patients was limited.
The selection of RRT modalities was generally dependent
on the experience of the physician in charge and was based
on the general condition of the patient and various lab-
oratory measures. Six patients were lost to follow-up in this
study, which might, to some extent, overestimate the sur-
vival rate. However, the comparison of complete recovery
of kidney function rate would probably still show a trend in
favor of the CVVH or CVVH + PE group even if none the
six patients recovered kidney function. Furthermore, the
selection of RRT modality could have been influenced by
many factors beyond the severity of patient illness, such as
the financial status of patients. Further larger prospective
studies are needed to confirm our results.
In conclusion, this is a large case series report on the out-
comes of patients with AKI following multiple wasp stings.
Most patients survived with complete recovery of their
kidney function. Despite the lack of difference in mortality
rates, the patients initiated with CVVH and CVVH + PE ex-
perienced a better and more rapid recovery of kidney func-
tion compared with those initiated with IHD.
Disclosures
None.
Clin J Am Soc Nephrol 8: ccc–ccc, November, 2013
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Received: November 28, 2012 Accepted: June 20, 2013
L.Z. and Y.Y. contributed equally to this work.
Published online ahead of print. Publication date available at www.
cjasn.org.