Serum creatinine and cystatin C provide conflicting evidence of acute kidney injury following acute ingestion of potassium permanganate and oxalic acid

Abstract

Aim: Acute kidney injury (AKI) is common following deliberate self-poisoning with a combination washing powder containing oxalic acid (H₂C₂O₄) and potassium permanganate (KMnO₄). Early and rapid increases in serum creatinine (sCr) follow severe poisoning. We investigated the relationship of these increases with direct nephrotoxicity in an ongoing multicenter prospective cohort study in Sri Lanka exploring AKI following poisoning.

Methods: Multiple measures of change in kidney function were evaluated in 48 consenting patients who had serial sCr and serum cystatin C (sCysC) data available.

Results: Thirty-eight (38/48, 79%) patients developed AKI (AKIN criteria). Twenty-eight (58%) had AKIN stage 2 or 3. Initial increases in urine creatinine (uCr) excretion were followed by a substantial loss of renal function. The AKIN stage 2 and 3 (AKIN2/3) group had very rapid rises in sCr (a median of 118% at 24 h and by 400% at 72 h post ingestion). We excluded the possibility that the rapid rise resulted from the assay used or muscle damage. In contrast, the average sCysC increase was 65% by 72 h.

Conclusions: In most AKI, sCysC increases to the same extent but more rapidly than sCr, as sCysC has a shorter half-life. This suggests either a reduction in Cystatin C production or, conversely, that the rapid early rise of sCr results from increased production of creatine and creatinine to meet energy demands following severe oxidative stress mediated by H₂C₂O₄ and KMnO₄. Increased early creatinine excretion supports the latter explanation, since creatinine excretion usually decreases transiently in AKIN2/3 from other causes.

Keywords:

• Acute kidney injury
• oxidative stress
• creatinine
• cystatin C dimers
• potassium permanganate/oxalic acid

Acknowledgments

We would like to thank the physicians, directors, medical staff of the study hospitals and SACTRC staff for their support. Specially acknowledge the support provided by late Dr. Philip Peake. We also thank patients who participated in the study.

Disclosure statement

We declare that none of the authors have a conflict of interest.

Additional information

Funding

This work was supported by the National Health and Medical Research Council (NHMRC), [grant number 1011772].