Introduction:
Paraquat (1, 1’-dimethyl-4, 4’-bipyridinium dichloride) is a fast-acting and non-selective contact herbicide with a high mortality rate in acute poisoning.Exposure occurs accidentally or intentionally as a suicide attempt. Paraquat poisoning is becoming a serious public health concern, especially in developing countries, due to its easy access and lack of awareness of potential harms. Multiple organ failure, including lung, kidney, and liver failure, occurs in severe poisoning. The most common cause of death is respiratory failure.There is still no standard and effective treatment.
Decreased absorption by gastric lavage and oral activated charcoal; elimination through different techniques conventional hemodialysis, hemoperfusion, continuous venovenous hemofiltration [CVVH], and continuous renal replacement therapy [CRRT]); decreased inflammatory response by the immunosuppressants (corticosteroids and cyclophosphamide); antioxidants (N-acetyl cysteine, Vitamin C, and Vitamin E); and a combination of different therapies have been used to treat patients with PQ intoxication with different outcomes for survival.
Methods:
AIM-To study the clinical profile and outcomes of acute kidney injury due to paraquat poisoning.
OBJECTIVES
1. To assess the outcomes of paraquat patients with AKI.
2. To Analyse the factors affecting mortality.
3. To Compare various modalities of KRT in patients of paraquat with AKI.
PATIENTS AND METHODS
STUDY DESIGN : Prospective observational study
STUDY POPULATION : 400 patients
DURATION OF STUDY : 10 years
STUDY SETTING : Tertiary care centre.
INCLUSION CRITERIA :
Patients who consumed paraquat of any quantity were included in the study.
Demographic details, latency of referral, lab parameters, mode of renal replacement therapy, outcomes of kidney injury and factors affecting mortality were assessed.
Amount of paraquat is defined as
Mild- <20ml
Moderate- 20-40ml
High->40ml
Results:
|
Variable
|
Mean ± SD
No(%)
|
|
Hemoglobin
|
11.65 ± 1.83
|
|
WBC
|
11998.88 ± 5013.7
|
|
Sr creatinine (mg/dl)
|
5.04 ± 3.4
|
|
Potassium
|
4.28 ± 0.75
|
|
PH
|
7.33 ± 0.11
|
|
Hco3
|
14.27 ± 4.28
|
|
Pco2
|
26.7 ± 8.25
|
|
Po2
|
84.79 ± 15.41
|
|
Total bilirubin
|
3.94 ± 4.25
|
|
Direct bilirurbin
|
2.26 ± 2.49
|
|
SGOT
|
92.08 ± 83.21
|
|
SGPT
|
101.5 ± 87.94
|
|
ALP
|
140.35 ± 99.14
|
|
ANION GAP
|
15 ± 4.9
|
Table 3 : Factors affecting mortality
|
|
Survivors
|
Non survivors
|
p value
|
|
Mean ± SD
|
Mean ± SD
|
|
|
|
Age
|
31.5 ± 12
|
30.6 ± 10.9
|
0.483
|
|
Sex
|
|
|
|
|
Males
|
71(67.6)
|
229(77.6)
|
0.042
|
|
Females
|
34(32.4)
|
66(22.4)
|
|
|
Latency to First Medical care (days)
|
1.24 ± 1.11
|
1.31 ± 1.28
|
0.644
|
|
Latency to Referral (days)
|
3.13 ± 1.91
|
3.28 ± 2.68
|
0.597
|
|
Systolic BP
|
119.5 ± 16.1
|
118.8 ± 14.7
|
0.678
|
|
Diastolic BP
|
76.1 ± 15.4
|
78.6 ± 7.5
|
0.119
|
|
Sr Creatinine
|
5.6 ± 3.3
|
4.9 ± 3.5
|
0.088
|
|
Hemoglobin
|
11.5 ± 2
|
11.7 ± 1.8
|
0.368
|
|
WBC
|
11119.5 ± 5668.6
|
12307 ± 4735.1
|
0.059
|
|
Potassium
|
4.2 ± 0.8
|
4.4 ± 0.8
|
0.146
|
|
PH
|
7.4 ± 0.1
|
7.4 ± 0.2
|
0.021
|
|
Po2
|
89.8 ± 12.9
|
83.1 ± 15.9
|
<0.001
|
|
Total bilirubin
|
3 ± 3.4
|
4.3 ± 4.5
|
0.002
|
|
Direct Bilirubin
|
1.6 ± 2.1
|
2.5 ± 2.6
|
<0.001
|
|
SGOT
|
66.5 ± 58.5
|
101.3 ± 88.8
|
<0.001
|
|
SGPT
|
77.3 ± 83.2
|
110.2 ± 88.2
|
0.001
|
|
ALP
|
140.8 ± 144.5
|
140.3 ± 77.2
|
0.970
|
|
Ventillatory Support
|
11(10.5)
|
105(35.6)
|
<0.001
|
|
Indication
|
|
|
<0.001
|
|
Metabolic Acidosis
|
8(10.5)
|
73(30.5)
|
|
|
oliguria
|
45(59.2)
|
115(48.1)
|
|
|
Anuria
|
1(1.3)
|
20(8.4)
|
|
|
Raised renal Parameters
|
22(28.9)
|
31(13)
|
|
|
Change of RRT
|
1(1.1)
|
12(5.4)
|
0.083
|
|
complication during RRT
|
5(6.7)
|
12(4.7)
|
0.742
|
|
Other system involvement
|
|
|
<0.001
|
|
AKI
|
1(1)
|
|
|
|
Liver
|
27(25.7)
|
48(16.3)
|
|
|
Lungs
|
2(1.9)
|
16(5.4)
|
|
|
Lungs + Liver
|
32(29.5)
|
200(67.5)
|
|
|
Baseline Charecteristics
|
Mean ± SD
No(%)
|
|
Age (in years)
|
30.77 ± 11.16
|
|
Gender
|
|
|
Males
|
300 (75)
|
|
Females
|
100 (25)
|
|
Amount of paraquat
|
|
|
Mild
|
212 (53)
|
|
Moderate
|
122 (30.5)
|
|
High
|
66 (16.5)
|
|
MOST COMMON REASON FOR CONSUMPTION
|
|
|
Sucidal
|
361 (90.3)
|
|
Latency to First Medical care (days)
|
1.28 ± 1.24
|
|
Latency of Nephrology Referral (days)
|
3.24 ± 2.5
|
|
Indication of RRT
|
|
|
Metabolic Acidosis
|
81 (25.7)
|
|
oliguria
|
160 (50.8)
|
|
Anuria
|
21 (6.7)
|
|
Raised renal Parameters
|
53 (16.8)
|
|
Renal Symptoms
|
|
|
Anuria
|
19(4.8)
|
|
oliguria
|
153(38.3)
|
|
Non oliguria
|
228(56.9)
|
|
Days Of Hospital Stay
|
6.9 ± 3.7
|
|
Ventillatory support
|
116(29)
|
|
Complication during RRT
|
17(4.2)
|
|
Outcome
|
|
|
Death
|
295(73.8)
|
|
Renal Recovery (complete)
|
93(17.5)
|
|
Renal Recovery (partial)
|
12 (3)
|
|
Cause of Death
|
|
|
ARDS
|
190(47.5)
|
|
Aspiration Pneumonia
|
1(0.3)
|
|
MODS
|
102(34.5)
|
|
Sudden cardiac death
|
2(0.5)
|
TABLE 5 : Comparision of various modalities of KRT
|
All cases
|
CRRT
|
HD
|
Hemoperfusion
|
PD
|
F value
|
P value
|
|
Mean ± SD
|
Mean ± SD
|
Mean ± SD
|
Mean ± SD
|
|
|
|
|
Age
|
29.49 ± 10.32
|
30.26 ± 10.27
|
32.29 ± 12.07
|
32.29 ± 13.02
|
1.309
|
0.266
|
|
LATENCY TO FIRST MEDICAL CARE
|
1.44 ± 1.35
|
1.49 ± 1.26
|
1.03 ± 1.22
|
0.94 ± 1.04
|
3.660
|
0.006
|
|
LATENCY OF REFERRAL IN DAYS
|
3.52 ± 3.06
|
3.91 ± 2.33
|
2.3 ± 2.3
|
2.43 ± 2
|
8.590
|
<0.001
|
|
SBP
|
118.43 ± 17.37
|
118.98 ± 14.65
|
118.84 ± 9.09
|
118.55 ± 20.07
|
0.314
|
0.869
|
|
DBP
|
78.69 ± 6.81
|
76.87 ± 11.91
|
78.32 ± 10.58
|
77.97 ± 7.38
|
1.804
|
0.127
|
|
DAYS OF STAY
|
7.03 ± 3.56
|
7.34 ± 4.59
|
6.41 ± 2.22
|
6.24 ± 2.9
|
1.481
|
0.207
|
|
Sr Cr ADMISSION
|
5.74 ± 3.83
|
6.43 ± 2.97
|
3.06 ± 2.76
|
3.31 ± 2.83
|
23.264
|
<0.001
|
|
Hemoglobin
|
11.76 ± 2.06
|
11.52 ± 1.76
|
11.54 ± 1.43
|
11.9 ± 2.24
|
1.068
|
0.372
|
|
wbc
|
11800.9 ± 4972.38
|
11858.46 ± 5756.63
|
12103.38 ± 3607.98
|
12584.49 ± 5011.11
|
0.294
|
0.882
|
|
Potassium
|
4.38 ± 0.81
|
4.27 ± 0.67
|
4.1 ± 0.66
|
4.48 ± 0.94
|
3.176
|
0.014
|
|
Po2
|
85.44 ± 12.54
|
83.02 ± 15.52
|
87.09 ± 14.89
|
82.53 ± 17.62
|
4.641
|
0.001
|
|
TSB
|
5.89 ± 5.81
|
4 ± 3.64
|
2.29 ± 2.32
|
3.87 ± 5.02
|
8.006
|
<0.001
|
|
DB
|
3.2 ± 3.16
|
2.4 ± 2.21
|
1.28 ± 1.5
|
2.27 ± 3.01
|
7.121
|
<0.001
|
|
SGOT
|
117.94 ± 98.23
|
96.68 ± 75.59
|
66.25 ± 55.15
|
90.39 ± 108.56
|
4.671
|
0.001
|
|
SGPT
|
131.32 ± 112.97
|
106.29 ± 80.7
|
74.53 ± 59.88
|
95.97 ± 98.39
|
5.016
|
0.001
|
|
ALP
|
144.81 ± 58.71
|
144.96 ± 117.6
|
136.62 ± 104.36
|
124.17 ± 80.94
|
0.636
|
0.637
|
|
ANION GAP
|
13.92 ± 4.15
|
15.36 ± 5.45
|
14.85 ± 4.23
|
15.71 ± 5.33
|
1.515
|
0.197
|
|
|
Hemoperfusion
|
no Hemoperfusion
|
p value
|
|
Mean ± SD
|
Mean ± SD
|
|
|
|
Age
|
32.46 ± 11.94
|
30.38 ± 10.95
|
0.144
|
|
Sex
|
|
|
|
|
Males
|
60(78.9)
|
240(74.1)
|
0.377
|
|
Females
|
16(21.1)
|
84(25.9)
|
|
|
Latency to First Medical care (days)
|
0.96 ± 1.21
|
1.36 ± 1.23
|
0.010
|
|
Latency to nephrology Referral (days)
|
2.21 ± 2.32
|
3.49 ± 2.48
|
<0.001
|
|
Systolic BP
|
119.56 ± 9.29
|
118.75 ± 16.11
|
0.675
|
|
Diastolic BP
|
78.56 ± 11.04
|
77.75 ± 10
|
0.536
|
|
serum creatinine
|
2.82 ± 2.57
|
5.56 ± 3.37
|
<0.001
|
|
Hemoglobin
|
11.4 ± 1.31
|
11.71 ± 1.93
|
0.188
|
|
wbc
|
12058.16 ± 3469.06
|
11984.85 ± 5318.43
|
0.909
|
|
Potassium
|
4.08 ± 0.68
|
4.32 ± 0.76
|
0.010
|
|
Po2
|
88.51 ± 14.76
|
83.91 ± 15.45
|
0.019
|
|
TSB
|
1.97 ± 1.64
|
4.4 ± 4.54
|
<0.001
|
|
DB
|
1.09 ± 1.22
|
2.53 ± 2.63
|
<0.001
|
|
SGOT
|
63.61 ± 52.59
|
98.76 ± 87.61
|
0.001
|
|
SGPT
|
68.97 ± 57.06
|
109.13 ± 92.13
|
<0.001
|
| |
137.49 ± 110.71
|
141.02 ± 96.4
|
0.780
|
|
ANION GAP
|
14.75 ± 3.92
|
15.06 ± 5.11
|
0.620
|
|
Ventillatory Support
|
2(2.6)
|
114(35.2)
|
<0.001
|
|
Indication
|
|
|
|
|
Metabolic Acidosis
|
|
81(25.7)
|
|
|
oliguria
|
|
160(50.8)
|
|
|
Anuria
|
|
21(6.7)
|
|
|
Raised renal Parameters
|
|
53(16.8)
|
|
|
Change of RRT
|
0(0)
|
13(4.5)
|
0.289
|
|
complication during RRT
|
0(0)
|
17(6.5)
|
0.392
|
|
Other system involvement
|
|
|
<0.001
|
|
AKI
|
0(0)
|
1(0.3)
|
|
|
Liver
|
4(5.3)
|
71(21.9)
|
|
|
Lungs
|
0(0)
|
18(5.5)
|
|
|
Lungs + Liver
|
68(89.5)
|
164(50)
|
|
TABLE 4 : COMPARISION BETWEEN HEMOPERFUSION AND NON HEMOPERFUSION
Conclusions:
1.Mean age of the study group was 30.77 ±11.16 years and 90.3% of paraquat consumption was suicidal.
2.With increased latency of referral, there was increased mortality.
3.Mortality among the study population was 73.8%.
4. Factors affecting mortality were metabolic acidosis, hypoxemia, raised serum creatinine, liver involvement, ventilatory support, need for renal replacement therapy and MODS.
5.The most common cause of death was MODS and ARDS.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.