Finger nail creatinine and its role in confirming chronicity of renal failure.

It is often difficult to differentiate acute renal failure (ARF) from chronic renal failure (CRF) when the patient presents with advanced uremia for the first time. Assessments of kidney size, history of nocturia, and pallor are used as indirect indicators of CRF. Some investigators have proposed an estimation of finger nail creatinine concentrations to differentiate between ARF and CRF, as patients with CRF have higher nail creatinine concentrations. Measurement of creatinine in the nail can be performed easily in a biochemistry laboratory. The nail clippings are cleaned, dried, pulverized and creatinine extracted from the powdered nail to be assessed biochemically. By standardizing the methods, the biochemistry laboratory can provide the results within 48 hours. In this study, we analyzed the nail clippings of 49 normal subjects, 50 cases of known acute kidney injury (AKI), and 50 cases of known CRF on follow-up at the Nephrology Clinic, Medical College, Trivandrum between December 1999 to November 2000. Forty-nine normal individuals were selected from healthy bystanders of respective patients. On study, it was revealed that patients with ARF had a mean fingernail creatinine level of 30.9 mg/100 g of nail as against 30.1 mg/100 g of nail in normal controls. There was no difference between the controls and ARF patients.Patients with known CRF had a mean fingernail creatinine level of 69.2 mg/100 g. There was a significant increase in the level of nail creatinine in patients with known CRF versus ARF patients and normal controls. The measurement of nail creatinine is useful, easy and can be standardized and performed in a biochemistry laboratory. This simple investigation can help in solving the question of ARF versus CRF in a given case. From this study, it is concluded that the result of creatinine concentrations of nail clippings can indicate chronicity of renal failure.

Fulminant cerebral infarction in a patient with nephrotic syndrome.

Fulminant cerebral infarction secondary to arterial thrombosis in adults with nephrotic syndrome is rare. We report a 42 year old male with fulminant right anterior cerebral and middle cerebral artery infarction. Minimal change disease of the kidney was documented by renal biopsy. The possible pathogenesis is discussed and pertinent literature reviewed.

Evolving trends in the etiopathogenesis of acute renal failure.

Research during the last few years has uncovered the mechanisms responsible for acute renal failure. During the initiation phase of acute tubular necrosis sublethal injury, apoptosis or necrosis of the tubular epithelium, hemodynamic alterations, tubule obstruction and back leakage occur. Hypofiltration persists due to imbalance between endothelins and endothelium derived nitric oxide, medullary congestion and tubuloglomerular feedback. Recovery is characterised by tubular epithelium regeneration. A greater understanding of the pathogenesis of acute renal failure will allow better management of such cases.

Treatment considerations in acute renal failure.

Acute renal failure (ARF) is characterised by progressive azotaemia, and for therapeutic purposes consideration of prerenal, intrinsic renal and postrenal types still holds good. Prerenal azotaemia is generally caused by loss of body fluids or blood, whereas postrenal azotaemia is effected by acute or chronic urinary tract obstruction. Provided these conditions are recognised on time and treated, they are reversible. However, delay in recognition or treatment could result in renal parenchymal damage and sustained ARF. Therefore utmost attention should be focused on identifying reversible factor(s) in the setting of ARF. Once reversible factors have been excluded, and ARF becomes sustained, a diagnosis of acute intrinsic renal failure is almost certain. Lack of natriuretic and diuretic responses to fluid challenge or infusion of furosemide (frusemide) and dopamine are further indications of this possibility. Management of acute intrinsic renal failure essentially consists of dietary control and dialysis therapy. The latter facilitates fluid and electrolyte management, but does not reduce the overall mortality. The potential benefit of parenteral hyperalimentation to promote renal function recovery must be carefully weighed against the risk of severe infectious complications.

Erythrocyte morphology under phase contrast microscopy in haematuria.

Fresh urine samples from twenty patients with macroscopic haematuria were examined by phase contrast microscopy to study the erythrocyte morphology. Other appropriate investigation like - renal biopsy in suspected glomerulonephritis and appropriate urological investigations in other cases to prove the site of origin of erythrocyte were done in all cases. Changes in erythrocyte morphology were observed in all the 12 patients with histological evidence of proliferative glomerulonephritis. These changes included extrusion of cell cytoplasm (39.5%), 'Doughnut' cell (26.5%) budding cell (15%) and cell membrane rupture with loss of cytoplasm (15%). Overall 83.3% of the erythrocytes showed some morphologic change or the other. In 8 patients where bleeding was into the pelvicalyceal system, ureter or bladder, 95% of RBCs showed no discernible morphologic change. It is concluded that the morphological changes in the erythrocyte identified under the phase contrast microscope can help to differentiate between glomerular and non glomerular causes of bleeding.

Paraquat poisoning with acute renal failure--a case report.

Paraquat poisoning is relatively rare and is associated with mortality varying from 35 to 50%. A patient who consumed paraquat developed features of non-oliguric acute renal failure and recovered following haemodialysis. Renal biopsy done during the early recovery phase showed features of acute tubulo-interstitial nephritis with no disruption of tubular basement membrane. On recovery the patient had no evidence of proximal renal tubular dysfunction.

Conservative vs. surgical management of septic abortion with renal failure.

The role of surgery in the management of postabortum renal failure complicated with extensive uterine sepsis, perforation or peritonitis is controversial. This study compares the course and final outcome of 14 patients (66.6%) conservatively managed with appropriate antibiotics, fluid or blood replacement and dialysis, with seven patients (33.3%) for whom hysterectomy or laparotomy was undertaken in addition. Whereas all 14 patients treated conservatively died as the result of uncontrolled septicemia, three of the seven surgical patients recovered completely. Extensive necrosis with perforation of the uterine wall was confirmed either at laparotomy or at autopsy in all 21 women. To reduce mortality, the authors recommend early surgical intervention for patients suffering from postabortum renal failure complicated with uterine sepsis or perforation.