Relationship between Renal Function and Bone Mineral Density in Postmenopausal Women.

Renal insufficiency is a risk factor for osteoporosis and can increase risk of fracture. It may be a result of an age-related decline in renal function or chronic kidney disease. In patients with CKD, accurate diagnosis of osteoporosis or CKD-MBD is important for determining the most appropriate treatment. This was a cross sectional study was done at Institute of nuclear medicine and Allied Sciences, BSMMU, Dhaka from 1st January 2014 to 31st December 2014. Study population was total 69 postmenopausal women age over 50 years. Women with Bilateral hip replacement or bilateral hip pins or screws, metallic rods in spine, Carrying out BMD scan within the week after other radiological investigation using contrast media e.g. Barium meals or enema, IVPs were excluded from study. Clinical variables were- age (years), height (cm), weight (kg), BMI. Laboratory variables were- serum creatinine and BMD (Dexa). Estimated GFR was determined by using the serum Creatinine by MDRD formula. Renal function test and Bone mineral density (BMD) were done in all of these patients. Majority (43.4%) of the patients were in 6th decade. The mean weight was found 57.4±11.2kg. Majority 41(59.4%) patients belonged to T score at hip (-1 to -2.5) and their mean T score at hip was found (-1.1±1.1). Osteopenia and osteoporosis were found in 59.4% and 4.3% respectively according to BMD. High serum creatinine level was found in 10.1% cases. Renal function impairment was found in 79.6% of patient. Majority (50.7%) patients had mild decrease of eGFR (60-89 ml/min/1.73m²), There was Pearson's correlation (r=0.156; p=0.200) but not significant was found between age with T score at hip of the patients. Positive Pearson's correlation (r=0.112; p=0.361) was found but not significant between age and serum creatinine level. A significant negative Pearson's correlation (r= -0.274; p=0.023) was found between T score at hip and serum creatinine level of the patients. A significant negative Spearman correlation (r=-0.278; p=0.021) was found between BMD and serum creatinine of the patients. A significant positive Spearman correlation (r=0.580; p=0.001) was found between BMD and estimated GFR of the patients. This study was undertaken to evaluate the relationship between renal function and bone mineral density in postmenopausal women. Majority of the postmenopausal women were in 6th decade and most of them were overweight and obese. Renal function impairment was found in 79.6% of patient. Osteoporosis was found in 04.3% and 20.3% cases according to T score at hip and T score at lumber spine respectively. Significant negative Pearson's correlation was found between T score at hip and serum creatinine level of the patients. Significant negative Spearman correlation was found between BMD and serum creatinine of the patients. Significant positive Spearman correlation was found between BMD and estimated GFR of the patients.

A Deadly Herbicide 'Paraquat Poisoning' and Miserable Death of a 19 Years Boy.

Poisoning by paraquat herbicide now a days is a major medical problem in many parts of Asia as well as in Bangladesh. Already it has been banned in the European Union and some other countries for several years. Paraquat is highly toxic if ingested, with clinical features including oral burns, sore throat, vomiting and diarrhoea, progressing to pneumonitis, pulmonary fibrosis and multi-organ failure. Recently we dealt with many cases of paraquat poisoning in Mymensingh Medical College Hospital and here we report one case. A 19 years old student intentionally ingested 10 ml of paraquat herbicide and presented with multi organ failure. His renal function was supported with 4 session's hemodialysis and regain normal renal function. But he also developed Acute Lung Injury (ALI) and liver dysfunction, was supported with ionotropic and invasive ventilation and couldn't save. On 14th day of poisoning he died.

Status of Serum Calcium, Phosphate and Intact Parathyroid Hormone in Predialysis Chronic Kidney Disease Patients of Stage-3 to Stage-5 Compared To KDOQI Guideline.

The chronic kidney disease (CKD) is associated with a variety of bone disorders and disorders of calcium and phosphorus metabolism. Bone disease associated with chronic kidney disease having higher rate of CKD progression and increased risk of death. To see the status of serum calcium, phosphate and intact parathyroid hormone in pre-dialysis CKD (stage- 3 to 5) patients. This was a across sectional study done in outpatient department of Nephrology of National Institute of Kidney Diseases and Urology, Dhaka, between 1st June 2012 to 31st May 2013. The patients of CKD stage 3, 4 and 5 yet not on dialysis attending out patients department of Nephrology, NIKDU by using MDRD-4 equation according to K/DOQI guidelines and reviewing previous medical records and investigation reports were enrolled in this study. There after serum calcium (corrected for serum albumin), phosphate and iPTH levels were measured and compared with the recommended target ranges in K/DOQI guideline. The number of patients with serum levels according to K/DOQI guidelines for different stages CKD(3,4,5) were as follows: serum calcium: 56.6, 58.5 and 76.7; serum phosphate: 55.2, 58.5 and 56.7; iPTH 37.9, 12.2 and 36.7 and Ca x P product 100.0, 97.6 and 86.7, respectively. The percentages of patients (who received drug) with serum calcium levels within according to K/DOQI guidelines for stages 3, 4 and 5 were as follows: serum calcium: 63.2%, 64.7% and 83.3%; respectively, serum phosphate: 63.2%, 61.8% and 66.7%; respectively, iPTH 42.1%, 14.7% and 4.7% and Ca x P product 100.0%, 100.0% and 87.5%, respectively. On the other hand patients who didn't receive drug the percentages of patients with serum calcium levels according to K/DOQI guidelines for CKD stages 3, 4 and 5 were as follows: serum calcium: 50.0%, 28.6% and 50.0%; respectively, serum phosphate: 40.0%, 42.9% and 16.7%; respectively, iPTH 30.0%, 14.7% and 16.7% and Ca x P product 100.0%, 85.7% and 83.3%, respectively. The patients achieving the four recommendations of K/DOQI guidelines was 4(13.8%) in stage-3, 3(7.3%) in stage-4 and 5(16.7%) in stage-5. More than half of the pre-dialysis patients of CKD were within target range of serum calcium and phosphate recommended in K/DOQI guideline and this proportion was more in those who were taking both phosphate binder and Vit-D. Ca x P was within target range in almost all patients so it may not be an important parameter for therapeutic decision making. However majority of the patients were out of target range of iPTH even though having normal serum calcium and phosphate level. So emphasis should be given in monitoring of iPTH level in early stages of CKD.

Brachial Plexus Schwannoma: A Case Report with Emphasis on Imaging.

Brachial plexus tumors are rare. Schwannomas are benign nerve sheath tumors and only about 5% arise from brachial plexus. Diagnosis of these tumors are challenging for radiologists as well as clinicians as they are rare and the anatomy of the neck is complex. We report a case of a middle aged woman who was admitted in Mymensingh Medical College in Neurosurgery Department on 15th December 2017 with right supraclavicular swelling; based on the clinical findings was provisionally diagnosed as supraclavicular lymphadenopathy; Ultrasonography and Magnetic Resonance Imaging suggested schwannoma. Complete excision of the mass through supraclavicular approach showed the origin of it from the brachial plexus, which subsequently was confirmed to be a schwannoma with histopathology.

Pattern of Anaemia in Chronic Kidney Disease.

The prevalence of chronic kidney disease (CKD) in Bangladesh is increasing. Chronic kidney disease refers to an irreversible deterioration in renal function which classically develops over a period of years. Initially, it manifest's only as a biochemical abnormality. Eventually loss of excretory, metabolic and endocrine functions of the kidneys leads to clinical symptoms and signs of renal failure, which are referred to as uraemia. In our country the number of CKD patient is increasing day by day, probably due to having uncontrolled DM, GN(Glumerulonephritis), uncontrolled hypertension, interstitial nephritis in addition to indiscriminate drugs & using of chemicals in fruits and foods. Objective of the study was to find out the morphological pattern of anaemia in patient with chronic kidney disease. This was a cross sectional observational study. This study was carried out at the Department of Medicine, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from January 2011 to June 2011. Patients admitted in medicine ward male or female who satisfied the inclusion and exclusion criteria of the study were taken as study subjects. The socio demographic characteristics, presenting symptoms, risk factors, investigations and findings of diagnostic modalities and outcome were recorded. Mean age was 55.8 years of the patients who were included in this study, youngest patient is of 19 years old & older one is of 85 years. In this study 33 patients were male & 17 patients were female. Thirty three (33) patients were suffering from normocytic normochromic anaemia, 11 were suffering from microcytic hypochromic anaemia & rest 6 were suffering from combined deficiency. Female patient were suffering mainly from microcytic hypochromic anaemia (58.8%) & male patient suffered from normocytic normochromic anaemia (69.7%). CKD patients also suffered from microcytic hypochromic anaemia & also from combined deficiency.

Hepatic Hydatid Cyst: A Case Report.

Hepatic hydatid disease is a goonotic disease caused by Echinococcus granulosus and it is endemic in different parts of the world. This infection is an important public health problem. Although it is distributed throughout the world but common in the livestock grazing regions of the world such as in Central Europe, Africa, South America, Central Asia and China. Here we present the case "30 years old female" with the complaints of right upper abdominal pain for 3 months, nausea & occasional vomiting for 1 month and was admitted under general surgery ward at Mymensingh Medical College Hospital, Mymensingh, Bangladesh on 12th March 2018. Considering history, physical examination, serological investigations, imaging studies and exploratory laparotomy the diagnosis is hepatic hydatid cyst. Echinococcus granulosus produces cysts in almost every organs of the body most commonly in the liver. Man is the incidental intermediate host where definitive host is carnivores such as dogs. Hydatid cyst always starts as a fluid filled, cyst like structure (stage I), which may proceed to a stage II lesion if daughter cysts and/or matrix develop. In some instances, the stage II lesion becomes hypermature and due to starvation, dies to become a mummified, inert, calcified, stage III lesion. Ultrsound is the preferred firstline imaging but CECT give more precise information regarding the morphology of the cyst. Magnetic Resonance Imaging is particularly useful because of its multiplaner capabilities and more detail anatomical resolution.

A 52 Years Old Male Presented With Acute Kidney Injury with Hepatitis after Taking Fish Gallbladder.

A 52 years old male was admitted at National Institute of Kidney Diseases & Urology, Dhaka, Bangladesh on 16th September 2016 with the history of oliguria, nausea, vomiting & swelling of both legs following consumption of rohu fish gall bladder for the permanent remedy of recurrent abdominal discomfort. He was admitted and received antiemetic, proton pump inhibitor. He had azotemia & underwent urgent haemodialysis (HD). Renal function improved over a period of 5 weeks. Fish gallbladder poisoning is quite frequent in several developing country of Southeast Asia. Rohu fish is commonly consumed in our country but cases of fish bile poisoning are not very common.

Magnetic Resonance Imaging of Cerebral Palsy in the Assessment of Time of Brain Insult.

The aim of this cross-sectional study was to find out the role of Magnetic resonance imaging (MRI) in the assessment of time of brain insult in cerebral palsy (CP). The study was conducted in the Department of Radiology & Imaging, Mymensingh Medical College Hospital, Mymensingh and a total number of 35 patients with were enrolled from January 2015 to December 2016. Maximum patients (57.2%) were under five years followed by 34.3% were of 5 to <8 years and 8.7% were of 8 to <12 years of age and mean age was 4.7 years. Majority of the patients were male 28(80%) and female were 7(20%). Among the patients 23(65.7%) came from poor, whereas 11(31.4%) came from middle class and only one (2.9%) from rich socioeconomic group. According to gestational age of the patients, 26(74.3%) were term (≥37weeks) at delivery and rest (25.7%) were preterm (<37 weeks). Delayed cry after birth were present in 32 (80%) patients. Regarding types of cerebral palsy spastic diplegia, spastic quadriplegia, hemiplegia and extrapyramidal were found 3(8.6%), 25(71.4%), 4(11.4%) and 3(8.6%) respectively. Abnormal MRI was reported in 94.2% patients and gave clues to time of insult in 79.9% (excluding the 14.3% miscellaneous findings). The findings were mal-developments (5.7%), periventricular white matter lesions (25.7%), cortical or deep grey matter lesions (48.6%), miscellaneous (14.3%) and normal (5.7%). Brain mal-developments were more seen in term than in preterm born children (5% vs. 0%). Periventricular white matter lesions were seen significantly more in preterm than in term born children (77.8% vs. 3.9%). Cortical or deep grey matter lesions occurred significantly more in term than in preterm born children (60% vs. 20%). Based on the study it can be concluded that Magnetic Resonance Imaging (MRI) can help in the assessment of time of insult to the developing brain in cerebral palsy (CP).

Acute Oxalate Nephropathy due to "Averrhoa Bilimbi": A Case Report.

Averrhoa bilimbi found in bilimbi tree is a well known fruits of warm climates, found throughout Bangladesh, India, Myanmar and South East Asian countries. This fruit contents high level of oxalate. Acute renal failure due to tubular necrosis caused by oxalate crystal has been reported. We present a patient who developed acute kidney injury following ingestion of bilimbi fruit juice and had complete recovery with conservative management and concluded that star fruit and bilimbi fruit juice should be avoided in CKD and on dialysis patients.

Plasma Neutrophil Gelatinase Associated Lipocalin (pNGAL) Level to Identify AKI Early in Patients Undergoing Cardiac Valve Surgery.

Cardiac valve surgery is considered one of the most frequent surgical procedures in which AKI is a common & serious complication. Although serum creatinine is routinely used as a marker of renal function, it poorly reflects the immediate post operative period renal function. Within minutes to few hours after a renal insult, plasma neutrophil gelatinase associated lipocalin (pNGAL) is released. The aim of this study was to assess the superiority of pNGAL over serum creatinine in detecting AKI in early post operative period. This prospective observational study was carried out in the Department of Nephrology of National Institute of Kidney Diseases & Urology in collaboration with National Institute of Cardiovascular Diseases (NICVD) & Dhaka Shisu Hospital (DSH) from January 2015 to December 2016. Total 120 patients were selected from inpatient ward of cardiovascular surgery department. According to inclusion & exclusion criteria total 80 patients were included who was undergone cardiac valve surgery. Serum samples for pNGAL were collected from study population 6 hours after completion of surgery & stored at -80°C, serum samples were also collected for serum creatinine day before surgery, in 1st post operative day (POD1) & 2nd post operative day (POD2). Total 79 patients undergoing cardiac surgery, who met the inclusion & exclusion criteria, were consecutively included. There were 44 male (55.69%) and 35 female (40.31%) ranged from 15-60 years, with mean age of 36 years. pNGAL level in the blood of AKI patients (244.19±59.61ng/ml) 6 hours after completion of surgery was significantly higher from the non AKI patients (171.73±68.63ng/ml). A positive significant correlation was found between pNGAL 6 hours after completion of surgery & serum creatinine at POD1, POD2. This study demonstrated that level of pNGAL concentration 6 hours after completion of cardiac valve surgery increased before the rise of serum creatinine level & can thus AKI can be detected earlier by pNGAL.

NGAL (Neutrophil Gelatinase-associated Lipocalin) is an Early Predictor of Acute Kidney Injury after Cardiac Surgery and Variation of NGAL Values in Homogenous Study Subject.

Isolated CABG (coronary artery bypass grafting) has the lowest incidence of AKI (Acute Kidney Injury), followed by valvular surgery and then, combined CABG with valvular surgery. Due to the difference in baseline characteristics and in surgery type, the range of incidence is between 8.9 and 39% based on RIFLE (Risk Injury failure loss end stage kidney disease) or AKIN (Acute Kidney Injury Network) criteria. The advent of novel biomarkers of kidney injury has opened a new era of early detection and prognosis prediction for AKI. NGAL is a small molecule of 178 amino acids that belongs to the super family of lipocalins, which are proteins specialized in binding and transporting small hydrophobic molecules. The expression of NGAL raises 1000 fold in humans and rodents in response to renal tubular injury and it appears so rapidly in the urine and serum that it is useful as an early biomarker of renal failure. The role of plasma NGAL to classify AKI severity and predict the need for RRT (renal replacement therapy) after cardiac surgery has been suggested. Although study subjects were more or less from same cohort (All undergone cardiac surgery), previous studies showed that NGAL raised differently in different proportion. NGAL as an early AKI marker has successfully passed through the pre-clinical, assay development and initial clinical testing stages. It is badly need to enter in a consensus about the cutoff value of NGAL which should help the physician about leveling a case as AKI or non AKI and their consequence management.