Schistocyte quantitation, thrombotic microangiopathy and acute kidney injury in Australian snakebite coagulopathy [ASP28]

Introduction: The major systemic manifestation of hemotoxicity in human snakebite envenoming is venom-induced consumption coagulopathy (VICC). A subset of patients with VICC develop thrombotic microangiopathy (TMA), in which acute kidney injury (AKI) occurs. We aimed to investigate the association between schistocytosis in snakebite patients with VICC and AKI, compared to non-envenomed patients. Methods: Serial blood films collected from a prospective cohort of snakebite patients (Australian Snakebite Project) were examined. Cases were classified a priori as non-envenomed snakebites (normal controls), envenomed without VICC, partial VICC without AKI, complete VICC without AKI, and VICC with AKI based on defined clinical and laboratory criteria. The percentage of schistocytes between groups was compared and correlated by Kendall's tau b test. Results: Seven hundred and eighty blood films from 234 snakebite cases were analyzed. There was a statistically significant correlation (τ =.69, SE.03, P <.001) for schistocytosis between the ordered groups of non-envenomed snakebites, envenomed without VICC, partial VICC without AKI, complete VICC without AKI, and VICC with AKI groups. Patients with VICC and AKI had a platelet nadir median of 42 × 10⁹/L (interquartile range [IQR] :25-130 × 10⁹/L), hemoglobin nadir of median 107 g/L (IQR 66-122 g/L), and maximum LDH median of 1128 U/L (IQR 474-3255 U/L). A 1.0% threshold for schistocytosis yielded 90% sensitivity (95% CI: 67%-98%) and 71% specificity (95% CI: 62%-79%) for predicting AKI in patients with VICC. Conclusion: Schistocyte quantitation has good diagnostic utility in snakebite patients with VICC. A definition of snakebite TMA as MAHA with ≥1.0% schistocytes and thrombocytopenia, would appear to be appropriate.