Pattern of Glomerular Disease in a Tertiary Care Hospital of Bangladesh.

Glomerular disease is one of the most important causes of chronic kidney disease in developing countries like Bangladesh as well as the whole world. The pattern of glomerular disease varies in different countries and can have different clinical presentations. The aim of the study was to analyze the clinical profile and to determine the histological pattern of glomerular diseases in a large tertiary care hospital in Bangladesh. All kidney biopsies performed in Mymensingh Medical College Hospital, Bangladesh from October 2018 to March 2020 were prospectively analyzed in the study. A total of 101 patients with kidney biopsy were examined by clinical and laboratory findings and by light and immuno-fluorescence microscopy. The mean age was 30.0±14.6 years and 50(49.5%) were male and 51(50.5%) were female with a male to female ratio of 1:1. The clinical syndromes namely nephrotic syndrome, nephritic syndrome, nephrito-nephrotic presentation, RPGN like presentation, macroscopic haematuria and asymptomatic urine abnormality were present in 31.7%, 34.5%, 22.8%, 11.9%, 19.8% and 10.9% patients respectively. The most common histological varieties found in the study were mesangial proliferative glomerulonephritis (MesPGN) (18.8%) and focal segmental glomerulosclerosis (FSGS) (18.8%). Other histopathological pattern among the studied subjects revealed minimal change disease (MCD) in 5.9%, membranous nephropathy (MN) in 7.9%, membranoproliferative glomerulonephritis (MPGN) in 16.8%, IgA nephropathy in 5%, IgM nephropathy in 2%, IgG nephropathy in 2%, diffuse proliferative glomerulonephritis (DPGN) in 1%, focal proliferative glomerulo-nephritis (FPGN) in 3%, crescentic GN in 3%, lupus nephritis (LN) in 13.9%, amyloidosis in 1% and fibrillary glomerulopathy in 1% patient. The pattern of glomerular disease found in this study was similar to other studies performed in Bangladesh with a little variation. It may guide the future researchers to establish a national kidney biopsy registry in Bangladesh.

Correlation of eGFR By MDRD and CKD-EPI Formula with Creatinine Clearance Estimation in CKD Patients and Healthy Subjects.

This cross sectional comparative study was conducted in the Nephrology and Medicine outdoor and in-patients department of Mymensingh Medical College Hospital, Bangladesh from April 2014 to March 2015. A total of 100 patients with CKD and 100 healthy subjects were included in the study. Data were collected by interview of the patients, clinical examination and laboratory investigations using a semi-structured case record form. Among all subjects, 50.0% had no CKD and 50.0% patients had CKD: Stage 3 CKD were 8.5%, CKD Stage 4 CKD were 21.0%, CKD Stage 5 CKD were 20.5%. Serum creatinine was 4.32±3.08mg/dl in patients with CKD and 1.00±0.22mg/dl was in healthy subjects. Mean±SD of CCR/ml/min was found 17.67±11.63ml/min in patients with CKD and 79.31±13.31ml/min was found in healthy subjects. On the other hand, Mean±SD CCCR/ml/m/1.73m² was found 19.79±12.85 ml/m/1.73m² in patient with CKD and healthy subjects had 83.83±13.33 ml/m/1.73m². Urinary creatinine was 45.59±15.63 & 57.66±11.45mg/dl respectively. CKD-EPI eGFR was 22.10±15.02 & 90.61±23.27ml/m/1.73m²; MDRD eGFR was 22.15±14.18 & 89.35±26.19 ml/m/1.73m² respectively. Difference between all the variables between CKD group and healthy group was found statistically significant (p<0.001). CKD-EPIeGFR and MDRDeGFR were increased both in CKD patients and healthy subjects in respect to CCR and CCCR. There was a strong positive correlation between CCCR (ml/m/1.73m2) and CKD-EPI (ml/m/1.73m²) among all patients (r=0.934 and p<0.001) and also a positive correlation of CCCR with MDRD among all patients (r=0.913 and p<0.001). A positive correlation of CCCR was found with CKD-EPIeGFR among CKD patients (r=0.848 and p<0.001). A positive correlation of CCCR was also found with MDRDeGFR among CKD patients (r=0.841, p<0.001). There are positive correlations between CCCR and CKD/EPI among healthy subjects (r=0.616 and p<0.05) and between CCCR with MDRD among healthy subjects (r=0.568 and p<0.05). Various formulae were used to calculate GFR on the basis of serum creatinine levels. The Overall correlation of population (healthy and CKD patients) between CCCR and CKD EPI and MDRD formula was (r=0.93 and 0.91) respectively, among CKD patients it was (r=0.848 and r=0.841) in healthy subjects it was (r=0.616 and r=0.568) respectively. CKD EPI eGFR and MDRD eGFR formula had fairly good correlation with conventional 24 hours creatinine clearance in both CKD patient and healthy subjects, there was even more strong correlation especially in CKD patients. The performance of CKD-EPI equation is better than MDRD equation to estimate the eGFR in both CKD patients and healthy subjects.

Prevalence of Subclinical Hypothyroidism in Hospitalized Pre-dialysis Patients with Chronic Kidney Disease.

Among general population sub-clinical primary hypothyroidism is common. The cross sectional descriptive type of observational study was conducted in medicine and allied wards in Mymensingh Medical College Hospital, Mymensingh, Bangladesh from January 2010 to December 2010; among 230 purposively selected hospitalized pre-dialysis patients with chronic kidney disease. The purpose of the study was to find out the prevalence of sub-clinical hypothyroidism in hospitalized pre-dialysis patients with chronic kidney disease. Data were collected from the patients using a case record form by face to face interview, clinical examination and laboratory investigations. The collected data were entered into SPSS version 20.0 and analyzed accordingly. Mean age of the patients was 47.2 years with a SD of ±2.05 years. Maximum patients were male with a male female ratio of 5:1. A significant number of patients were smoker- 11.8% of sub-clinical hypothyroidism group and 13.6% of euthyroid group. Among the patients 40 (17.40%) had sub-clinical hypothyroidism while the majority 190 (82.60%) did not have it. Estimated prevalence of sub-clinical hypothyroidism in hospitalized pre-dialysis patients with chronic kidney disease was 17.40%. Co-morbidities found in the patients were hypertension, diabetes mellitus, chronic glomerulonephritis and obstructive uropathy. All the patients (40, 100.0%) with sub-clinical hypothyroidism were hypertensive. On the other hand, 184 (97.1%) patients without sub-clinical hypothyroidism were hypertensive. Presence of co-morbidities in patients with sub-clinical hypothyroidism did not differ significantly (p>0.05) from patients without sub-clinical hypothyroidism. Patients in group with sub-clinical hypothyroidism were more over weight in comparison to patients without sub-clinical hypothyroidism (p<0.05). Biochemical parameters of patients with sub-clinical hypothyroidism differed significantly (p<0.05) from those of patients without sub-clinical hypothyroidism. There was no significant difference between urinary albumin of two groups of patients (p>0.05). Stage 4 CKD patients were more in sub-clinical hypothyroidism group in comparison to euthyroid group. As this study may not reflect the actual picture, further large scale multi-centric study is recommended to explore the real situation of sub-clinical hypothyroidism in patients with chronic kidney disease.

Comparison of Serum Amylase and Lipase Levels between Predialysis and Maintenance Haemodialysis CKD Patients.

This cross sectional study was done to compare serum levels of amylase and lipase between predialysis and maintenance haemodialysis chronic kidney disease (CKD) patients and also to find out their relationship between degrees of renal impairment in Mymensingh Medical College Hospital and National Institute of Kidney Diseases and Urology, Dhaka, Bangladesh from May 2016 to April 2017. A total of 80 patients were included purposively as study subjects and made into two groups namely predialysis CKD group comprising 50 patients and other as maintenance haemodialysis group comprising of 30 patients. Among the predialysis group majority of the CKD was caused by glomerulonephritis (48%) followed by diabetes (26%), HTN (2%) and large portion undiagnosed (24%) whereas in the haemodialysis group ESRD was caused by diabetes (46%) followed by glomerulonephritis (16%), HTN (13%) and undiagnosed (23%). This study showed that mean serum amylase (158±718U/L vs. 111±41U/L) did not significantly differ between study groups except being above reference level but serum lipase (739±888U/L vs. 434±214U/L) was significantly higher in the predialysis group. There was a correlation between rising serum creatinine with serum amylase and lipase.

Response of Proliferative Lupus Nephritis with Pulse Cyclophosphamide Therapy during Induction Period: A Single Centre Study in Bangladesh.

This prospective study was conducted to assess the response of proliferative lupus nephritis with pulse cyclophosphamide therapy during induction period in the department of Nephrology of Dhaka Medical College, Dhaka, Bangladesh from December 2012 to November 2013. A total of 35 clinically diagnosed SLE patients of class III/IV lupus nephritis were included. But 3 patients were dropped out during follow-up, therefore finally 32 patients (class III = 4, class IV = 28) were studied. The patients were evaluated for response on the basis of proteinuria, serum creatinine & active sediment in urine after 6th cycle of cyclophosphamide and 62.5% patients achieved complete response, 25% patients achieved partial response & 12.5% patients achieved no response. The factors favored complete response was early clinical presentation (7 months duration), proteinuria ≤3gm/day& normal renal function during their initial presentation. And higher anti ds DNA titre was an independent predictor for partial response/no response.

Prevalence of Microalbuminuria and Overt Proteinuria in Diabetes Mellitus and their Association with Renal Function.

This cross sectional observational study was conducted in the Department of Nephrology, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from April 2009 to March 2010. Samples were collectedfrom rural area of Khalishaur union of Purbadhala upazilla in Netrakona District, 30km away from Mymensingh Town. The main objective of the study was to find out the prevalence of microalbuminuria as well as overt proteinuria in diabetes mellitus in a rural population and to observe their association with renal function. In this study 1048 adult participants of 18 to 65 years in a rural area of Netrakona were included purposively as study subjects. Among them 54% were male and 46% were female. Mean age of study subjects was 42.4±13.4 years. Prevalence of microalbuminuria among diabetic participants was 29.72% where as in non diabetic non hypertensive participants it was 6.62%. Diabetic persons 9.45% and 3.9% of non diabetic participants showed overt proteinuria by dipstick test. Prevalence of hypertension in diabetic and non diabetic participants was 45.94% and 16.52% respectively. The mean eCCr of the diabetic patients and non-microalbuminuric healthy persons was 78.4±25.4 ml/min/1.73m² and 94.67±24.8 ml/min/l.73m² respectively according to Cock Croft-Gault equation. The mean eCCr of diabetic participants with overt proteinuria was 57.44±28.33 ml/min/l.73m² but diabetic patients with microalbuminuria had better mean eCCr 80.62±21.17 ml/min/1.73m² which justifies the importance of detection of microalbuminuria for early intervention. By regression analysis it was found that degree of microalbuminuria had linear relation with renal function and random blood sugar level. Neither BMI nor duration of diabetes showed any correlation with urine microalbumin. There was no effect of sex on the prevalence of microalbuminuria in diabetes mellitus. Microalbuminuria is the first sign of renal involvement in diabetic patients which is a risk factor for overt nephropathy. Monitoring of this condition is important because early treatment of microalbuminuria can prevent or postpone overt nephropathy.

Acute Kidney Injury in Patients with Acute Viral Hepatitis: A Study in a Tertiary Care Hospital.

This cross sectional observational study was done in the Department of Medicine, Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from May 2013 to April 2014 to find out the proportion of acute kidney injury among patients with acute viral hepatitis and to identify risk factors associated with development of acute kidney injury (AKI). A total of 100 patients with acute viral hepatitis were included purposively as study subjects. Among them 61 were male and 39 were female. They were divided into AKI group (n=6) and non-AKI group (n=94) on the basis of development of AKI. There was no significant difference in mean age (39.0±13.1 years vs. 32.2±10.8 years, p=0.335) and sex (67% vs. 61% & 33.0% vs. 39.0%) p=0.769) between AKI group and non-AKI group. There were 27% acute viral hepatitis A, 21% acute viral hepatitis B and 52% acute viral hepatitis E but no case of acute viral hepatitis C was found in this study. Acute kidney injury (AKI) developed in 6 of 27 patients with acute viral hepatitis A. This study showed that 22.2% patients with acute viral hepatitis A developed acute kidney injury but patients with acute viral hepatitis B (HBV) and hepatitis E (HEV) did not develop acute kidney injury. Majority of the patients with acute kidney injury were smokers and hypertensive with elevated mean arterial pressure (p=0.0001) at presentation and had higher total bilirubin (p=0.0001), alanine aminotranseferase values (p=0.040), prolonged prothrombin time (INR) {p=0.0001}, lower albumin (p=0.0001), lower haematocrit level (p=0.0001), high CRP concentration (p=0.0001), leucocytosis (p=0.0001) and thrombocytopenia (p=0.0001) at presentation than patients without acute kidney injury. It is evident from the study that acute kidney injury is not a rare complication in patients with acute viral hepatitis.

Outcome of Pregnancy Related Acute Kidney Injury Observed in a Tertiary Care Hospital.

This prospective case control study was carried out in Mymensingh Medical College Hospital (MMCH) from April 2011 to March 2012. The main objective of the study was to determine the short term maternal outcome of pregnancy related Acute Kidney Injury and to identify aetiological factors and to observe clinical features of pregnancy related Acute Kidney Injury. Total 60 pregnant women with AKI were included in the study as sample and equal (60) number of pregnant women with normal renal function was taken as control. Mean ages (±SD) of study and control group were observed 31.6±6.9 years and 25.5±4.7 years respectively. It was observed that most patients were from rural area with low income group. Most women were multiparous and presented in third trimester and postpartum period. Majority of the study subjects did not receive antenatal care at any stage of pregnancy. Fifty (86.7%) of the study subjects were oligo-anuric, forty-nine (81.7%) were edematous and fifty one (85%) were anaemic. Twenty-five (41.7%) patients presented with abnormal vaginal bleeding. Sepsis (including septic abortion and puerperal sepsis) was responsible for of Pregnancy Related AKI (PR-AKI) in more than two fifths of cases. Haemorrhage (APH & PPH combined) was the next common cause of Pregnancy Related AKI (PR-AKI). Toxemia of Pregnancy was responsible in one fourth of cases. Dialysis (HD & IPD combined) was required for two fifths of the patients. Rest patients were treated conservatively with antibiotics, blood transfusion, maintenance of fluid and electrolytes balance etc. Maternal outcome of Pregnancy related acute kidney injury was considered for the period of patient's hospital staying. 56.6% patients recovered completely, 15.0% patients recovered partially, 6.7% did not recover at the time of hospital discharge; while 21.7% died. So it can be concluded that, pregnancy related acute kidney injury is a critical condition, associated with worse prognosis.

Antidiarrheal, Antioxidant and Antimicrobial Activities of the Musa sapientum Seed.

Musa sapientum (M.sapientum) commonly known as 'banana' is widely used in Bangladeshi folk medicine for the treatment of various ailments including diarrhea. Hence, the present study was designed to investigate antidiarrheal, antioxidant and antibacterial potential of the methanolic extract of M.sapientum seed (MMSS). The extract was studied for antidiarrheal property using castor oil and magnesium sulfate induced diarrheal model and charcoal induced gastrointestinal motility test in mice. Total phenolic and flavonoids content, total antioxidant activity, scavenging of 1,1-diphenyl-2-picrylhydrazyl (DPPH) radical, as well as nitric oxide (NO) and assessment of reducing power were used to evaluate antioxidant potential of MMSS. In addition, disc diffusion methods were used for antibacterial assay using various diarrheal induced bacterial strains. At the doses of 100 and 200 mg/kg body weight, the extract reduced the frequency and severity of diarrhea in test animals throughout the study period. At the same doses, the extracts significantly (p<0.001) delayed the intestinal transit of charcoal meal in test animals as compared to the control. In DPPH and NO scavenging method, MMSS showed good antioxidant potentiality in a dose dependent manner with the IC(50) value of 12.32±0.33 µg/ml and 18.96±1.01 µg/ml, respectively with a significant (p<0.001) good reducing power. The extract also displayed strong anti-bacterial effect against when tested against Escherichia coli, Shigella dysenteriae, and Pseudomonas aeruginosa. Altogether, these results suggest that the MMSS could be used as a potential antidiarrheal agent along with its antioxidant and antibacterial potentiality.