Introduction:
Paraquat, a potent herbicide used extensively in agriculture, has become a troubling method of suicide, especially in agricultural communities like East Godavari district, India. While paraquat poisoning is rare in developed countries, its ease of availability and low cost have made it increasingly common in regions like ours, which are heavily reliant on agriculture. This surge in paraquat-related acute kidney injury (AKI) poses significant challenges, as current treatment protocols and outcome predictors remain poorly defined. This study aims to address this gap by examining factors influencing clinical outcomes in patients with paraquat-induced AKI. By identifying key determinants of survival and recovery, we seek to refine treatment strategies and highlight the need for further research in managing this escalating issue.
Methods:
This retrospective study was conducted over a period from February 2022 to March 2024 at Smart Emergency Hospital, Rajahmundry, Andhra Pradesh. All patients presenting to the ER following oral paraquat ingestion were considered, and only those who consumed paraquat within 8 hours prior to ER presentation were included in the study. All patients underwent hemoperfusion using either a charcoal filter (Baxter) or the MG 250 Hemoperfusion cartridge (Biosky) for 2 hours, followed by intravenous corticosteroid and cyclophosphamide therapy. Acute kidney injury (AKI) developed in all patients, and additional hemodialysis sessions were administered based on clinical indications. Data collected included demographics, time since paraquat consumption, alleged volume consumed, type of hemoperfusion filter used, development of acute hepatitis, requirement for extra hemodialysis, day (since admission) of onset of tachypnea, and occurrence of thrombocytopenia and dyselectrolytemia. The primary endpoints were successful discharge from the hospital and survival at 3 months. Statistical analysis was performed to identify factors influencing these outcomes, including correlation and regression analyses to assess relationships between the studies variables and the endpoints.
Results:
1. Patient Demographics and Characteristics: The study included 68 patients (50 males and 18 females) with a mean age of 32 years (range 16-54 years).
2. Correlation Between Age and Outcomes: There was a weak negative correlation between age and spontaneous resolution of AKI, indicating a slight decrease in the likelihood of spontaneous recovery with increasing age. • A weak positive correlation was observed between age and the need for extra hemodialysis, suggesting a slightly increased need for extra hemodialysis with advancing age
3. Influence of Paraquat Consumption Volume and Timing:
A. Volume Consumed: There was no significant correlation between the alleged volume of paraquat consumed and the requirement for extra hemodialysis during the hospital stay.
B. Time Since Consumption: A significant positive relationship was identified between the time since paraquat ingestion and the need for extra hemodialysis. Patients presenting later after ingestion were more likely to require additional hemodialysis. Additionally, an increased time since consumption correlated with a decreased likelihood of spontaneous AKI resolution.
4. Impact of Hemoperfusion Filter Type: A statistically significant association was found between the type of filter used (charcoal filter vs. MG 250 Hemoperfusion cartridge) and successful discharge from the hospital, with a moderate association favoring the hemoperfusion cartridge.
5. Electrolyte Abnormalities and Outcomes:
A. Hypokalemia: No significant independent correlation was found between hypokalemia and successful discharge.
B. Hyponatremia: Although 100% of patients with hyponatremia died in the hospital, the association was not statistically significant, likely due to the small sample size.
6. Paraquat Consumption with Alcohol: Patients who consumed paraquat with alcohol had a higher mortality rate (92.31%) compared to those who did not (67.27%). The trend toward increased risk was noted, but statistical significance was borderline (p = 0.092)
7. Shock at Presentation: A weak negative correlation was found between shock at presentation and the length of hospital stay for patients who died, indicating a potential trend toward faster death in those presenting with shock. However, this relationship was not statistically significant.
8. Extra Hemodialysis and Long-Term Survival: A significant association was observed between the requirement for extra hemodialysis during the hospital stay and decreased survival at 3 months. Patients who required extra hemodialysis had a notably lower survival rate at 3 months.
9. Thrombocytopenia and In-Hospital Death: No significant correlation was found between thrombocytopenia and in-hospital death when controlling for other factors.
10. Delayed Onset of Tachypnoea: A moderate negative correlation was found between the alleged volume of paraquat consumed and the delayed onset of tachypnoea. Higher volumes of consumption were associated with an earlier onset of tachypnoea.
11. Acute Hepatitis and In-Hospital Death: Although there is a strong association between acute hepatitis and in-hospital death among patients requiring extra hemodialysis (with infinite odds ratio and relative risk), this association is not statistically significant (p = 0.108).
12. Acute Hepatitis and Mortality at Three Months (Post-Discharge): Among patients successfully discharged, there is no statistically significant association between acute hepatitis and mortality at three months (p = 0.6148). While the mortality rate is higher in those with acute hepatitis (38.46% vs. 20.00%), the wide confidence interval (0.29 to 12.64) reflects considerable uncertainty.
The most significant predictor of in-hospital death was the absence of spontaneous AKI resolution.
Conclusions:
Key Determinants of Outcomes: Time since consumption significantly impacted the need for extra hemodialysis and spontaneous AKI resolution, underscoring the importance of early intervention.
Treatment Implications: The type of hemoperfusion filter used was associated with successful discharge, indicating a potential benefit of the MG 250 Hemoperfusion cartridge.
Further Research: Additional factors influencing paraquat poisoning outcomes, such as the role of alcohol co-ingestion, thrombocytopenia and electrolyte imbalances, warrant further investigation with larger sample sizes.
I have no potential conflict of interest to disclose.
I used generative AI and AI-assisted technologies in the writing process.
During the preparation of this work the author(s) used ChatGPT in order to improve upon grammar, language and readability. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication.