Wasp sting-induced AKI complicates the management of multiple wasp stings by potentially delaying renal recovery, impacting patient outcomes. This study investigated the clinical characteristics and prognostic indicators of wasp sting-induced AKI using real-world data, examining susceptibility factors including patient demographics, inflammation biomarkers, and rhabdomyolysis signs. We identified four critical prognostic factors to construct a user-friendly prediction model, represented as a nomogram for straightforward visualization and application. The model underwent comprehensive evaluation and validation through ROC and calibration curves, and decision curve analysis (DCA). Additionally, its predictive accuracy was compared with a previous model, confirming its effectiveness in forecasting wasp sting-induced AKI17.
In our study, 33.6% of wasp sting victims developed AKI, a figure slightly higher than the 21% reported in a Chinese multi-center survey18 but consistent with the 30–50% incidence range found in other studies19,20. Despite advancements in managing wasp sting-induced AKI, particularly with renal replacement therapy21,22, the mortality rate remains high at 5.1–8.6%1,9,11,18. Our in-hospital mortality rate was 6.5%, similar to rates reported in the same western China region, reflecting regional consistency in outcomes18,23. Furthermore, in our study, 37.4% of patients underwent blood hemopurification, aligning with the 23.19–39.9% range reported by Zhang et al. and Tang et al. in similar regions of China11,23, and significantly exceeding the 12.4% reported by Wang et al16. Additionally, 13.6% of our patients required intubation and mechanical ventilation, higher than the 7.25% observed by Zhang et al.23, suggesting a more critical condition in our patient cohort.
Several prediction models exist to identify patients at elevated risk of acute kidney injury (AKI) following wasp stings. A study of 112 patients pinpointed leukocytes, myoglobin, and urinary monocyte chemotactic protein-1 as independent risk factors for post-wasp sting AKI24. Tang et al. developed a model incorporating sting count, AST, LDH, APTT, and time to hospital admission as predictors for wasp sting-induced AKI11. The Wasp Sting Severity Score (WSS), assessing factors such as tea-colored urine, sting count, serum LDH, and TBIL, facilitates early identification of patients needing blood purification12. However, the reliance on complex laboratory tests may delay patient assessment and intensive care unit (ICU) admission. The accuracy of recalling the wasp sting attack time further complicates the application of these models. The complexity and reliance on extensive laboratory testing limit the practicality of these models in emergency situations, especially in resource-limited settings typical of developing countries23,25. In response, our study presents an accessible, cost-effective risk prediction model based on simple biomarkers, including Complete Blood Count and clinical features. This model facilitates early detection of individuals at risk of AKI, enabling prompt initiation of organ support therapy to improve renal recovery. Moreover, our nomogram outperforms Tang et al.'s model in discrimination capability, as demonstrated by superior concordance index (C index), Net Reclassification Improvement (NRI), and Integrated Discrimination Improvement (IDI) metrics. Decision Curve Analysis (DCA) further confirms its enhanced predictive benefits for AKI, underscoring its value for application across various healthcare settings, particularly where resources are constrained.
The kidney's susceptibility to wasp venom, due to its high vascularity and excretory function3. The severity of AKI and associated mortality rates escalate with the number of stings, particularly beyond ten stings, underlining the venom's dose-dependent toxicity4,18. The Wasp Sting Severity Score (WSS), which includes sting count and biochemical markers, categorizing sting severity and its impact on patient outcomes12. Our research confirms the critical role of sting count in determining the risk and severity of AKI, emphasizing the importance of sting number in patient prognosis.
Wasp venom-induced AKI is primarily attributed to acute tubular necrosis (ATN) resulting from hemolysis and rhabdomyolysis, with venom components disrupting skeletal muscle and red blood cell membranes10. This leads to the release of myoglobin and hemoglobin, which, upon reaching the renal parenchyma, cause intratubular obstruction and direct toxicity leading to renal failure10,19,26. Gross hematuria, identified by brown to tea-colored urine, indicates significant hemoglobin or myoglobin presence16,18,22. Xie et al. reported that 79.5% of patients with rhabdomyolysis following multiple wasp stings developed AKI, while in our cohort, 64.9% of patients exhibited gross hematuria18.
Wasp venom initiates allergic and toxic reactions, activating immune and inflammatory pathways that increase inflammatory cytokines (IL-6, IL-8) and coagulation factors27–29,leading to hemoglobin breakdown and enhancing inflammation through hemolysis products (heme, ferrous heme, oxygen free radicals)30.This process mediated by the STING-TBK1-p65/IRF3 signaling pathway and involves dysregulated lipid metabolism (HDL-C, Apo-A1)31,32. Our study demonstrates that elevated levels of the Systemic Inflammatory Response Index (SIRI), which reflects systemic inflammation and immune status correlate with MODS and AKI in patients stung by wasps8 .SIRI, easily assessed in emergency settings, offers a timely evaluation of the inflammatory response, proving more immediate than C-Reactive Protein (CRP) and Procalcitonin (PCT) in identifying high-risk patients. Moreover, in individuals affected by wasp stings, decreased platelet counts can lead to coagulation problems, exacerbate hemolysis, intensify bleeding-induced hypovolemia, and diminish perfusion, collectively facilitating AKI onset.
Although our study is based on real-world data and provides a comprehensive overview of patient information, there are still some limitations. Firstly, the retrospective nature of our study, being confined to a single institution, introduces the possibility of selection bias. As a result, additional prospective and longitudinal studies are essential to further validate the reliability of the nomogram. Secondly, the number of patients included in the analysis in this study is still limited, so further validation with a multiple center cohort study is necessary. Thirdly, in critical situations, SIRI may be influenced by comorbidities, significant hemolysis, or simultaneous trauma, potentially not reflecting accurately the severity of wasp sting reactions.