Place: Bellary

Place: Bellary Date:

From, Dr. HARSHAVARDHAN.L Post Graduate Student in M.D. Dept. of Medicine, VIMS, Bellary. To, The Principal, Vijayanagar Institute of Medical Sciences, Bellary.

THROUGH PROPER CHANNEL

Respected sir, Subject: Acceptance of registration and forwarding of dissertation topic,

In accordance with the above cited subject, I undersigned studying Post Graduate Course in M.D. General Medicine have been alloted the dissertation topic “A STUDY OF CLINICAL PROFILE AND OUTCOME OF PATIENTS WITH SNAKE BITE INDUCED RENAL FAILURE IN VIMS”,under the guidance of PROFESSOR, DR.AJIT KUMAR.B.K Department of Medicine, VIMS, Bellary.

I request you to kindly forward the dissertation topic in the prescribed form to the university for approval.

Thanking you, Yours faithfully,

Dr. HARSHAVARDHAN.L

Signature of the guide DR.AJIT KUMAR.B.K. Professor in Medicine, Department of Medicine VIMS,BELLARY.

Place: Bellary Date: From, The Professor & Head of the Department, Department of Medicine, VIMS, Bellary.

To, The Registrar, Rajiv Gandhi University of Health Sciences, Bangalore.

THROUGH PROPER CHANNEL

Respected sir, As per the regulations of the University of registration of Dissertation topic, the following Post Graduate in M.D. General Medicine has been allotted the dissertation topic as by the Official Registration Committee of all qualified and eligible guides of the Department of Medicine.

NAME TOPIC GUIDE Dr. HARSHA “A STUDY OF CLINICAL DR.AIJT VARDHAN.L PROFILE AND OUTCOME KUMAR.B.K Post Graduate OF PATIENTS WITH Professor Student in M.D. SNAKE BITE INDUCED Dept.of Medicine, Dept. of Medicine, RENAL FAILURE IN VIMS,Bellary. VIMS, Bellary. VIMS”

Therefore, I kindly request you to communicate the acceptance of the dissertation topic allotted to the PG student at an early date.

Thanking you, Yours faithfully,

Signature of the guide DR. NAGABUSHANA M.V. DR.AJIT KUMAR.B.K. Professor & Head Professor, Department of medicine Department of Medicine VIMS,BELLARY. VIMS,BELLARY. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

ANNEXURE—II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE Dr. HARSHAVARDHAN.L CANDIDATE AND Post Graduate Student in ADDRESS (in block letters) M.D.General Medicine. VIMS,BELLARY-583 104 2. NAME OF THE VIJAYANAGAR INTITUTE OF INSTITUTION MEDICAL SCIENCES, BELLARY 3. COURSE OF STUDY AND MD GENERAL MEDICINE SUBJECT

4. DATE OF ADMISSION TO 31-05-2007 THE COURSE 5. TITLE OF THE TOPIC: “ A STUDY OF CLINICAL PROFILE AND OUTCOME OF PATIENTS WITH SNAKE BITE INDUCED RENAL FAILURE IN VIMS.” 6. BRIEF RESUME OF THE INTENDED WORK: 6.1 NEED FOR THE STUDY: Snake Bites are a worldwide problem. It is estimated that 2,000 species of snakes exist, and 400 of them are poisonous. Snakebites are blamed for 40,000 deaths per year in the world; the vast majority occur in the tropical countries of Africa, South and Southeast Asia, and Latin America. In India alone, 15,000 patients die of snakebites per year 1. The principal systemic effects of the envenomation are on the nervous system, kidneys, heart and blood coagulation and locally at the site of bite. Renal failure complicates 5.5% to 26.0% of all poisoning from snakes.

Most cases are due to the Viperidae family of snakes, which includes pit viper, rattlesnake, Russell's viper.1 The complications related to kidneys are observed in majority of patients with snake bite admitted to a hospital and is an important cause morbidity and mortality. The onset of renal failure in these patients is signaled by the development of oliguria or anuria. This acute renal failure is largely a preventable complication. So the patients with snake bites should be hospitalized and monitored for early detection of renal complications. Early treatment improves survival in snake bite victims. Hence the present study. 6.2 REVIEW OF LITERATURE: Snake bite poisoning is known to man since antiquity. References to snake bite are found even in the oldest medical writings. It constitutes a significant cause of mortality in tropical countries2. The problems resulting from snake venoms include neurotoxicity, myotoxicity, renal failure, edema, bleeding due to activation of clotting proteins, and intravascular hemolysis3. The effects of a snake bites depend on the characteristics of both victim and snake. Approximately one-third of Snake bite involve the upper extremity and cause a higher long-term functional morbidity than do lower-extremity wounds4. Acute renal failure is mainly observed following bites by the viperidae group, sea snakes and the colubridae group.The exact pathogenesis of ARF following snake bite in not well established. However, a number of factors may contribute viz. bleeding, hypotension, circulatory collapse, intravascular hemolysis, disseminated intravascular coagulation, microangiopathic hemolytic anemia and also direct nephrotoxicity of the venom.

ARF develops in 5-30% of the victims of sever viper poisoning and is the cause between 2-3% of cases of acute renal failure, but a very much higher proportion in some centers at some times of the year5. It develops from a few hours to 72 hours following snake bite, is more oliguric in 50% of the cases. Hyperkalemia may be prominent in bites associated with myonecrosis such as those of sea snakes5. Acute tubular necrosis is the predominant lesion seen in 70-80% of patients with ARF, but acute cortical necrosis can occur6. Renal management is supportive. Acute renal failure is a syndrome charecterised by rapid decline in glomerular filtration rate(GFR) and retention of nitrogenous waste products such as Blood Urea Nitrogen and Creatinine7. GFR may fall by approximately 50% before the serum creatinine level rises because the initial decrement in creatinine filtration by glomeruli is matched by enhanced creatinine secretion by proximal tubules8 . Merchant MR et al noted that oliguria (100%), local swelling (48%) and bleeding tendencies (42%) to be the predominant clinical features encountered in viperine snake bite. Development of oliguria within 24 hours of snake bite and cortical necrosis were associated with higher mortality.9 6.3 OBJECTIVES OF THE STUDY: a) To study the renal involvement in patients with snake bite with reference to clinical features and the time of onset of renal failure. b) To aid in the prompt diagnosis and effective management of ARF cases in snake bite .

7. MATERIALS AND METHODS 7.1 SOURCE OF DATA: The study will be conducted in patients admitted in the Department of General Medicine of VIMS hospital and also patients referred from other departments of combined hospitals of VIMS, BELLARY. 7.2 METHOD OF COLLECTION OF DATA Our study is a clinical, prospective, observational and open study. All the patients confirmed of snake bite will be selected and subjected to detailed history, physical examination and biochemical tests with special reference to renal involvement. Special tests like bleeding time, clotting time, prothrombin time, USG abdomen and liver function tests will be done where ever necessary. Patients will be followed up till the discharge or death of the patient. The complete data is collected in a specially designed Case Recording Form . The data collected will be transferred in to a Master Chart, which is then subjected for statistical analysis. Patients are selected with the following inclusion/exclusion criteria. 1)INCLUSION CRITERIA: All the patients with history of snake bite with at least one of the following criteria 1. Features suggestive of snake bite with or without local and systemic envenomation . 2.Definite fang marks are noted. 3. Patient or attenders have seen the offending snake. 2) EXCLUSION CRITERIA: patients with history of suspected snake bite, where in 1. Paediatric cases age less then 14 years excluded. 2. No features of envenomation. All the patients included in the study will be explained about the procedure in detail and issused Patient Information Sheet. Informed/written consent will be taken in each case . All investigations and interventions will be done under direct supervision and guidance of our guide. 3) SAMPLE SIZE AND DESIGN: A total of 100 cases of snake bite will be studied prospectively. 7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO DESCRIBE BRIEFLY YES, our study requires investigations like 1) Random Blood Sugar 2) Blood urea 3) Serum creatinine 4) Serum electrolytes 5) Urine examination for - Albumin - Sugar - Microscpy 6) Complete Haemogram Which are relevant to the individual patient , to make and confirm diagnosis, to asses severity of disease process, to asses prognosis and management of patients. Important parametes like BLOOD UREA, CREATININE AND SERUM ELECTROLYTES are considerd as efficacy parameters in our study. 7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3-YES 8. LIST OF REFERENCES: 1) Schrier, Robert W Tropical Nephrology, Toxic Nephropathies in the Tropics, Animal toxins. Disease of Kidney and Urinary Tract 8th Edition Lippincott Williams And wilkins ,2007 page-2035.

2) Chugh KS, Aikat BK, Sharma BK, Dash SC, Mathew MT, Das KC Acute Renal Failure following poisonous snake bite Am J Trop Med Hyg 1975 Jul;24(4):692-7.

3) Greer, John P., Foerster, John, Lukens, John N.,et.al., Volume 1 - Part IV - Disorders of Red Cells, Section 3 - Hemolytic Anemia , 38 - Acquired Nonimmune Hemolytic Disorders , HEMOLYSIS DUE TO VENOMOUS SNAKE BITES.Wintrobe's Clinical Hematology (11th Edition), Lippincott Williams & Wilkins, 2004page-1231.

4) Rudolph, Colin D., Rudolph, Abraham M., et.al; Chapter 4 - The Acutely Ill Infant and Child, 4.3 INJURIES AND UNTOWARD EVENTS, 4.3.8 Poisonous Bites and Stings, TERRESTRIAL BITES AND STINGS, Phylum Chordata, Pit Viper - Signs and Symptoms: Rudolph's Pediatrics (21st Edition) McGraw-Hill, 2003page-396.

5) Warrel, David A, Cox, Timothy M, Firth, John.D., Benz, Edward J OXFORD TEXT BOOK OF MEDICINE 4th Edition :Oxford University Press,2003 Page261.

6) Kohli HS, Sakhuja V. Snake Bites and Acute Renal Failure. Saudi J Kidney Dis Transpl 2003;14:165-76.

7) Brady HR, Barry M.B,et al. Acute renal failure. In:BM Brenner (ed). Brenner and Rector,s-The Kidney 6 th ed Philadelphia; Saunders 2000:1201-1246.

8) Brenner WM,Porter GA: Endogeneous creatinine clearance as a clinical measure of glomerular filtration rate . Br Med J 4:84, 1971.

9) Merchant MR, Khanna UB, Almeida AF, Acharya VN, Mittal BV Clinicopathological study of acute renal failure following viperine snake bite J Assoc Physicians India 1989 Jul;(37)7:440-3.

9. SIGNATURE OF THE CANDIDATE: (Dr. HARSHAVARDHAN.L.) 10. REMARKS OF THE Recommended and forwarded for GUIDE: needful

11. NAME AND DESIGNATION OF (in block letters)

11.1 GUIDE DR.AJIT KUMAR.B.K MD,DNB PROFESSOR Department of Medicine VIMS,Bellary.

11.2 SIGNATURE

11.3 CO.GUIDE (if any) NONE

11.4 SIGNATURE

11.5 HEAD OF THE DR. NAGABUSHANA M.V. MD DEPARTMENT: Prof. & Head Of The Department, Department of Medicine, VIMS, Bellary.

11.6 SIGNATURE

12. 12.1 REMARKS OF THE Recommended and Forwarded for CHAIRMAN & needful. PRINCIPAL Dr.A.SRINIVASAMURTHY MD,DA Principal VIMS,Bellary 12.2 SIGNATURE