What is the management of rhabdomyolysis (muscle breakdown) and Acute Kidney Injury (AKI) secondary to a bee sting?

Management of Rhabdomyolysis and AKI Secondary to Bee Sting

Immediate aggressive fluid resuscitation with volumes >6L is essential for severe rhabdomyolysis (CPK >15,000 IU/L) from bee stings to prevent acute kidney injury and need for dialysis, while simultaneously removing any retained stingers and monitoring for anaphylaxis. 1

Immediate First Aid and Anaphylaxis Management

• Remove any retained stingers immediately by plucking or scraping, as venom delivery continues for up to 30-60 seconds while embedded in skin 1
• Activate emergency medical services immediately if any signs of anaphylaxis develop (difficulty breathing, tongue/throat swelling, lightheadedness, vomiting, disseminated hives) 1
• Administer epinephrine autoinjector if available and anaphylaxis is present, as this is the primary treatment regardless of triggering agent 1
• Wash the sting area with soap and water 1

Fluid Resuscitation Strategy

For severe rhabdomyolysis (CPK >15,000 IU/L):

• Administer >6L of intravenous fluids to prevent AKI and need for renal replacement therapy 1
• Initiate volume resuscitation as early as possible, as delayed initiation is associated with higher rates of AKI development 1

For moderate rhabdomyolysis:

• Administer 3-6L per day of intravenous fluids 1

Critical timing consideration: Patients who develop AKI consistently had longer delays to fluid resuscitation initiation compared to those who did not develop kidney injury 1

Monitoring and Detection Protocol

Perform repeated laboratory assessments combining: 1

• Plasma myoglobin levels
• Plasma creatine phosphokinase (CPK) measurements
• Potassium (kalemia) measurements
• Serum creatinine to assess kidney function 2, 3
• Indirect bilirubin (to detect hemolysis) 2, 3

Urinary monitoring: 1

• Place bladder catheter to monitor hourly urine output
• Monitor urine pH and maintain at ≥6.5 through alkaline diuresis 4
• Assess for myoglobinuria 3

Monitoring frequency: Repeat assessments every 30 minutes to 1 hour during the first 24 hours 1

Nephrotoxin Avoidance

Immediately discontinue all potentially nephrotoxic medications: 1

• NSAIDs - avoid entirely, especially the "triple whammy" combination with diuretics and ACE inhibitors/ARBs
• Statins - particularly important as drug interactions can worsen rhabdomyolysis-induced AKI 1
• Review all medications for nephrotoxic potential, as each nephrotoxin presents 53% greater odds of developing AKI 1

Critical pitfall: Combining three or more nephrotoxins more than doubles AKI risk, with 25% of patients receiving three or more nephrotoxins developing AKI 1

Renal Replacement Therapy Indications

• Initiate hemodialysis for severe AKI that does not respond to aggressive fluid resuscitation 5
• Mean number of hemodialysis sessions required is approximately 8-9 sessions 5
• Timely dialysis improves renal survival 5

Pathophysiology-Specific Considerations

Multiple mechanisms contribute to AKI from bee stings: 2, 3

• Intravascular hemolysis (monitor indirect bilirubin)
• Rhabdomyolysis with myoglobinuria (pigment nephropathy)
• Arterial hypotension causing ischemic renal injury
• Direct nephrotoxicity from venom components (melitin, phospholipase A2) to renal tubules
• Acute tubular necrosis is the most common biopsy finding 2, 5

Severity correlates with number of stings: Creatinine levels are typically higher with >1,000 stings, though severe cases can occur with fewer stings 2

Role of Renal Biopsy

• Consider early renal biopsy in patients who do not respond to supportive measures within expected timeframe 5
• Biopsy findings may reveal acute interstitial nephritis (AIN), acute tubular necrosis (ATN), or both 5
• Administer corticosteroids if AIN is identified on biopsy, as this improves renal survival 5

Supportive Care

• Antihistamines for local reactions (though systemic manifestations take priority) 1
• Corticosteroids may be considered for systemic inflammation 3
• Monitor for and treat hypotension aggressively, as it plays a major role in ischemic renal injury 2, 3

Prognosis

• Complete renal function recovery is possible with early recognition and aggressive management 3, 5
• At 24-month follow-up, approximately 90% of survivors have normal renal function 5
• Mortality occurs primarily from delayed treatment, severe shock, or massive envenomation 3, 5

Key clinical pearl: Early alkaline diuresis and aggressive fluid management are vital in protecting renal function and preventing morbidity and mortality from bee sting-induced rhabdomyolysis 4