Acute kidney injury (AKI) has become increasingly prevalent in both developed and developing countries, and is associated with severe morbidity and mortality, especially in children. Uncertainty regarding the true incidence of AKI limits awareness of the problem, thereby reducing political visibility of the disorder and hampering efforts to prevent its occurrence. In developed countries, AKI occurs predominantly in urban intensive care units and is associated with multiorgan failure and sepsis, high mortality, and occurrence in older populations. While cases of AKI in urban areas of the developing world have similar characteristics to those in the developed world, AKI in rural regions commonly develops in response to a single disease and specific conditions (e.g. gastroenteritis) or infections (e.g. severe malaria, leptospirosis, or hemolytic-uremic syndrome) and in younger otherwise healthy individuals. Many causes of AKI in rural settings, such as diarrhea, poisoning, malaria, or septic abortion, can be prevented by interventions at the individual, community, and regional levels. Treatment with dialysis is often unavailable or too costly in developing regions, so there must be community-wide efforts to eradicate causes of AKI, expedite diagnosis, and aggressively manage prerenal conditions and specific infections. We have reviewed recent literature on AKI, identified differences and similarities in the condition between developed and developing areas, analyzed the practical implications of the identified differences, and made evidence-based recommendations for study and management.

The contrasting characteristics of acute kidney injury in developed and developing countries

Brown spiders and loxoscelism

Although much has been published about the pathophysiology and treatment of necrotic spider bites, therapeutic interventions continue without evidence-based justification.

Bites of brown recluse spiders and suspected necrotic arachnidism.

Loxoscelism: Old obstacles, new directions

Enzymatic characterization, antigenic cross-reactivity and neutralization of dermonecrotic activity of five Loxosceles spider venoms of medical importance in the Americas.

A clinical and epidemiological study of 267 cases of envenomation by Loxosceles spp. (loxoscelism), notified to Centro de Informacoes Toxicologicas de Florianopolis (Santa Catarina State, Brazil), was conducted between January 1985 and December 1995. Most of the incidents occurred along the coast of the mid-southern region of the state, during the warmest months. L. laeta and L. intermedia were identified as the causative agents. Cutaneous loxoscelism was clinically diagnosed in 232 (86·9%) patients with local pain (86·5%), oedema (80·5%), hyperaemia (79·8%) and necrosis (56·9%). Cutaneous-visceral loxoscelism was detected in 35 patients (13·1%) with intravascular haemolysis, manifested by jaundice (68·6%), oliguria (45·7%), dark urine (28·6%), haemorrhage (25·7%), anuria (8·6%) and shock (2·9%), besides the cutaneous effects. Specific antivenom was given to 125 patients (46·8%) and only 8(6·5%) had mild reactions. Acute renal failure was observed in 17 cases (6·4%); 4 patients (1·5%) died, all of whom were children under 14 years old.

Vera Regina von Eickstedt

Papers

A clinical and epidemiological study of Loxosceles spider envenoming in Santa Catarina, Brazil