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Journal of Postgraduate Medicine, Vol. 54, No. 1, January-March, 2008, pp. 60-61 Letter Paraphenylene diamine-induced acute renal failure: Prevention is the key Bhargava P Department of Medicine 1, Christian Medical College and Hospital, Vellore Code Number: jp08023 Sir, I read with interest the case series of paraphenylene diamine (PPD) ingestion by Ram et al . [1] It was distressing to note that, despite the fact that patients arrived almost immediately after consumption, renal failure could not be pre-empted. The authors completely neglect this key fact in their review. The quantity of PPD ingested has not been mentioned, hence making it impossible for us to know whether these patients had consumed toxic doses of PPD. Also, the other components of the hair dye have not been mentioned. Some dyes contain resorcinol in addition to PPD and this may also lead to nephrotoxicity, thus a toxicological analysis would enable one to be certain that the manifestations in these patients were solely due to PPD. In experience at our center we have found that, in patients with an early presentation, aggressive treatment of rhabdomyolysis can prevent renal failure and the need for dialysis. This is of paramount importance in resource poor settings that exist in our country. Rhabdomyolysis should be treated with rehydration to maintain a urine output of 250-300 mL/h until the myoglobinuria ceases. [2] This requires the infusion of large quantities of crystalloids, starting at 1.5 L/h. This should be continued till the CPK level reaches below 1000 units/L. It may be necessary to insert a central venous catheter to guide fluid therapy. Other strategies which have been advocated, include mannitol and sodium bicarbonate. Literature is, however, conflicting on the usefulness of these measures over and above adequate hydration. [3] The objectives are to alkalinize urine to a pH of greater than 6.5 (thereby decreasing the toxicity of myoglobin to the tubules) and to enhance the flushing of myoglobin casts from renal tubules by means of osmotic diuresis. This strategy may prevent renal failure in most patients, infact, investigators in one study found that forced diuresis within the first 6 h of admission prevented all episodes of acute renal failure in patients with rhabdomyolysis. [4] In patients with PPD ingestion early recognition of rhabdomyolysis and its appropriate treatment may prevent the development of renal failure and thus obviate the necessity for dialysis. References
Copyright 2008 - Journal of Postgraduate Medicine |
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