Establishment of dry chemistry based reference intervals of renal function test parameters for the adult population of Kaski District, Nepal.

BACKGROUND: Reference intervals (RIs) for clinical chemistry test parameters are specific to the method of measurement and population under service. However, there has been no locally available dry chemistry based RIs for the Nepalese population. Thus, the present study aimed to establish dry chemistry based RIs for sodium, potassium, urea, and creatinine specific to adult populations of Kaski districts, Nepal METHODS: This was a cross-sectional study conducted at the Manipal Teaching Hospital, Pokhara, Kaski, Nepal on 360 healthy adult participants aged 18-65 years. The test parameters under study were analyzed using a fully automated OCD Vitros 350 dry chemistry analyzer following the protocols provided by the reagent kit manufacturer. The RIs were estimated using reference limits at 2.5th and 97.5th percentiles. The normal distribution of the data was tested by Kolmogorov-Smirnov, and Shapiro-Wilk tests. The differences between males and females RIs were compared by the Mann-Whitney test while age-specific RIs for each sex was compared by One-Way-ANOVA and Dunnett's Multiple Comparisons Tests. All the data were managed and analyzed using MS Excel and SPSS version 20. RESULTS: The RIs of urea, creatinine, sodium, and potassium specific to the adult population of Kaski district, Nepal are as follows: urea: 4.20-13.70 mmol/L (males: 4.70-13.99; females: 4.20-13.23); creatinine: 44.20-106.10 µmol/L (males: 48.82-106.10; females: 35.40-83.78); sodium 135-146 mmol/L (males: 135-146; females: 135-146) and potassium 3.60-5.10 mmol/L (males: 3.54-5.0; females: 3.60-5.10). These RIs were found to be different from currently used RIs provided by the reagent manufacturer. RIs of all the test parameters were significantly influenced by the age of the study participants. However, only the RIs of urea, creatinine, and potassium were significantly influenced by sex. CONCLUSIONS: The present study has for the first time established dry chemistry based RIs for selected renal function test parameters specific to the adult population of Kaski district, Nepal. This result will aid the clinician in minimizing the errors in result interpretation and making a precise clinical decision.

Association of serum magnesium level with poor glycemic control and renal functions in Nepalese patients with type 2 diabetes mellitus.

BACKGROUND: Hypomagnesaemia has been shown to be associated with type 2 diabetes mellitus (T2DM) and its complications. The present study investigated the association of hypomagnesaemia with T2DM and its complications in patients hailed mostly from the western hilly region of Nepal. METHODS: This study was conducted among 150 type 2 diabetic patients and 150 of non-diabetic controls between May to September 2016. Relevant demographic, anthropometric, physiological and biochemical variables were measured using standard protocols. Statistical analyses were performed by SPSS version 17.0. RESULTS: Hypomagnesaemia (1.7±0.2mg/dl) was present in 50% of diabetic patients and none in the healthy controls (2.0±0.2mg/dl). It was inversely correlated with levels of glycated hemoglobin (HbA1c) (r=-0.299), total cholesterol (r=-0.219), low density lipoprotein-cholesterol (r=-0.168) and creatinine (r=-0.215) and directly correlated with serum creatinine based glomerular filtration rate (eGFRcr) (r=0.196). Subjects with hypomagnesaemia were significantly older (57.4±11.5years) and had higher levels of HbA1c (8.4±1.2%) and serum total cholesterol (248.3±72.0mg/dl). The methods of diabetes control did not have a significant influence on serum magnesium level. Patient's age (OR: 1.05 (95% CI-1.01-1.09)), poor glycemic control (OR: 6.78 (95% CI-2.56-17.95)) and low eGFRcr (OR: 4.89 (95% CI-1.78-13.40)) were the significant predictors of hypomagnesaemia. CONCLUSION: Half of type 2 diabetic population under study had hypomagnesaemia without regard to the method of diabetes control. Old age, poor glycemic control, and low eGFRcr were the significant predictors of low serum magnesium in these patients. Besides their regular anti-diabetic treatment, clinicians should also consider dietary supplementation of magnesium to prevent further complications of diabetes in these patients.

Prevalence and pattern of dyslipidemia in Nepalese individuals with type 2 diabetes.

BACKGROUND: Atherogenic dyslipidemia is an important modifiable risk factor for cardiovascular disease among patients of type 2 diabetes mellitus. Timely detection and characterization of this condition help clinicians estimate future risk of cardiovascular disease and take appropriate preventive measures. The aim of this study was to determine the prevalence, pattern and predictors of dyslipidemia in a cohort of Nepalese patients with type 2 diabetes. RESULTS: We found mixed dyslipidemia as the most prevalent (88.1%) and isolated dyslipidemia (10.1%) as the least prevalent forms of dyslipidemia in our patients. The most prevalent form of single dyslipidemia was high LDL-C (73.8%) and combined dyslipidemia was high TG, high LDL-C and low HDL-C (44.7%). Prevalence of all single and mixed dyslipidemia was higher in patients with poor glycemic control and hypertension. The glycemic status of patients correlated with their fasting serum lipid profile. Dyslipidemia was associated mainly with male gender, poor glycemic control and hypertension. CONCLUSIONS: Atherogenic dyslipidemia is associated mainly with male gender, poor glycemic control and hypertension. It is highly prevalent in Nepalese patients with type 2 diabetes. Urgent lifestyle modification, sustained glycemic control and aggressive lipid lowering treatment plans are necessary to minimize the future risk of cardiovascular disease in this population.

Estimation of 10-Year Risk of Coronary Heart Disease in Nepalese Patients with Type 2 Diabetes: Framingham Versus United Kingdom Prospective Diabetes Study.

BACKGROUND: Predicting future coronary heart disease (CHD) risk with the help of a validated risk prediction function helps clinicians identify diabetic patients at high risk and provide them with appropriate preventive medicine. AIM: The aim of this study is to estimate and compare 10-year CHD risks of Nepalese diabetic patients using two most common risk prediction functions: The Framingham risk equation and United Kingdom Prospective Diabetes Study (UKPDS) risk engine that are yet to be validated for Nepalese population. PATIENTS AND METHODS: We conducted a hospital-based, cross-sectional study on 524 patients with type 2 diabetes. Baseline and biochemical variables of individual patients were recorded and CHD risks were estimated by the Framingham and UKPDS risk prediction functions. Estimated risks were categorized as low, medium, and high. The estimated CHD risks were compared using kappa statistics, Pearson's bivariate correlation, Bland-Altman plots, and multiple regression analysis. RESULTS: The mean 10-year CHD risks estimated by the Framingham and UKPDS risk functions were 17.7 ± 12.1 and 16.8 ± 15 (bias: 0.88, P > 0.05), respectively, and were always higher in males and older age groups (P < 0.001). The two risk functions showed moderate convergent validity in predicting CHD risks, but differed in stratifying them and explaining the patients' risk profile. The Framingham equation predicted higher risk for patients usually below 70 years and showed better association with their current risk profile than the UKPDS risk engine. CONCLUSIONS: Based on the predicted risk, Nepalese diabetic patients, particularly those associated with increased numbers of risk factors, bear higher risk of future CHDs. Since this study is a cross-sectional one and uses externally validated risk functions, Nepalese clinicians should use them with caution, and preferably in combination with other guidelines, while making important medical decisions in preventive therapy of CHD.

Prevalence of metabolic syndrome in Nepalese type 2 diabetic patients according to WHO, NCEP ATP III, IDF and Harmonized criteria.

BACKGROUND: Metabolic syndrome (MetS) present in type 2 diabetic patients greatly increases the risk of strokes and cardiovascular diseases. Timely detection and mapping of MetS facilitates appropriate preventive and therapeutic approaches to minimize these risks. Our study aimed to determine the prevalence of MetS among Nepalese type 2 diabetic patients using WHO (1999), NCEP ATP III (2001), IDF (2005) and Harmonized (2009) definitions and identify the diagnostic concordance and disparity resulting from these four definitions. METHODS: Clinical and biochemical data were collected for 1061 type 2 diabetic patients at Manipal Teaching Hospital, Pokhara, Nepal. The data was analyzed in order to identify prevalence of MetS in these patients. Statistical analysis included usage of Student's t- and Chi-square tests, kappa statistics and 95% confidence intervals. RESULTS: The total age adjusted prevalence rates of MetS were 80.3%, 73.9%, 69.9% and 66.8% according to Harmonized, NCEP ATP III, WHO and IDF definitions, respectively. Prevalence increased with the age and was higher in females (p <0.001) according to WHO, NCEP ATP III and Harmonized definitions. Patients of Dalit community had the highest prevalence (p<0.05) according to NCEP ATP III and Harmonized definitions while Mongoloid and Newar patients had the highest prevalence (p <0.05) according to WHO and IDF definitions, respectively. Prevalence was also highest among patient engaged in agriculture occupation. Central obesity and hypertension were respectively the most and the least prevalent components of MetS. The highest overall agreement was between Harmonized and NCEP ATP III definitions (κ =0.62, substantial) and the lowest between WHO & IDF definitions (κ=0.26, slight). The Harmonized definition had the highest sensitivity (99.9%) and negative predictive value (98.9%) while NCEP ATP III definition had the highest specificity (98.9%) and positive predictive values (99.9%) in identifying the cases of MetS. CONCLUSIONS: The prevalence of MetS among Nepalese type 2 diabetic patients was very high suggesting that these patients were at increased risk of strokes, cardiovascular diseases and premature death. The Harmonized definition was the most sensitive while NCEP ATP III and IDF definitions were the most specific in detecting the presence of MetS in Nepalese type 2 diabetic patients.

Influence of alcohol consumption on oxidative stress and antioxidant status in cancer patients--case-control study from Western Nepal.

AIM: The present study assess the effect of consumption of alcohol on oxidative stress and antioxidant status in patients suffering from different types of cancer. METHODS: This hospital based case control study conducted in the Western part of Nepal covered a total of 93 cancer patients with or without alcohol intake and smoking habits, along with 94 age, sex and habit-matched individuals serving as controls. Plasma thiobarbituric acid reacting substances (TBARS), total antioxidant activity (TAA), vitamin C, α-tocopherol and erythrocyte reduced glutathione (GSH) were estimated and compared. RESULTS: The TBARS level was found to be significantly higher (p≤0.001) in all types of cancer patients when compared to controls, being aggravated in alcoholics with a smoking habit. No statistical significance (p≥0.05) was observed in the level of vitamin C and α-tocopherol. GSH and TAA level were significantly decreased (p≤0.001) in all the groups except those who consumed both branded as well as homemade alcohol and non-alcoholics without smoking habit. CONCLUSION: Alcohol, irrespective of its commercial brand, increases oxidative stress in all types of cancer patients. This is even higher when alcohol intake is combined with a smoking habit. Decreased TAA and GSH are major risk factors for cancer development.

Screening of different classes of proteases in microfilarial and adult stages of Setaria cervi.

Many of the filarial proteases involved in critical physiological functions are expressed in stage-specific manner and belong to various mechanistic classes. Setaria cervi, a bovine filarial parasite express different classes of proteases. This parasite shows strong antigenic cross-reactivity with human filarial parasites Wuchereria bancrofti and Brugia malayi. Somatic extracts of S. cervi microfilariae (mf) and adult stages as well as their excretory-secretory (ES) products were screened for the presence of different classes of proteases using general (casein, bovine hemoglobin) and class specific substrates. Detergent-soluble extracts of male and female worms were also screened. Significant enzyme activity was detected in ES products both at pH 5.0 and 7.0 with casein. Cathepsin B-like activity was found to be much higher in membrane-bound extract than in the crude-soluble extract. However, it was also found to be actively secreted by both mf and adult worms. Cathepsin D-like activity assayed at pH 3.0 was very low both in somatic extract as well as in ES products. Collagenase activity at neutral pH showed higher levels, both in somatic extract and ES products. Cathepsin L-like activity was detected only in crude-soluble extract but was below detectable limit in ES products. Leucine aminopeptidase activity was significant both in crude-soluble extract and ES products. This study, thus, might be helpful for a better understanding of host-parasite interaction and identification of appropriate virulence factors that may be targeted as vaccine and/or drug targets against lymphatic filariasis.

Purification and characterization of a leucine aminopeptidase from the bovine filarial parasite Setaria cervi.

Using synthetic peptide substrate Leu-p-NA, leucine aminopeptidase (LAP) activity was detected in both microfilarial and adult stages of a bovine filarial parasite Setaria cervi. A single protein fraction containing LAP activity was purified from the adult female S. cervi using three different chromatographic techniques. This purified enzyme was shown to be a 321 kDa zinc dependent metalloexopeptidase having maximum activity at pH 9.0 and 37 degrees C. Its activity was significantly inhibited by aminopeptidase specific inhibitors such as 1,10-phenanthroline, ethylene diaminetetraacetic acid (EDTA), amastatin and bestatin; and activated by Co2+, Mn2+ and Mg2+ ions. Puromycin and l-amino acids (e.g., glutamine, leucine and glycine) also showed some moderate inhibitory effects on the purified enzyme. Among various synthetic substrates tested, the purified enzyme hydrolysed Leu-p-NA at very high rate suggesting it to be a LAP. Both ELISA and western blotting analyses of S. cervi LAP revealed the presence of homologous protein in human filarial parasite Wuchereria bancrofti. The higher sensitivity of S. cervi LAP with microfilariaemic sera compared to other categories of W. bancrofti infected human sera implied its potential as a serodiagnostic marker against active filarial infection. The antigenic similarity between S. cervi LAP and W. bancrofti makes this molecule ideal for the discovery of new diagnostic marker, drugs and/or vaccine candidate for human lymphatic filariasis.

Vaccination with Setaria cervi 175 kDa collagenase induces high level of protection against Brugia malayi infection in jirds.

A zinc containing metalloprotease, 175 kDa collagenase, purified from adult female Setaria cervi showed strong cross-reactivity with sera from putatively immune (PI) individuals (unpublished observation) and induced cytotoxicity to B. malayi L3 larvae and microfilariae by ADCC mechanism [Srivastava Y, Bhandari YP, Reddy MVR, Harinath BC, Rathaur S. An adult 175 kDa collagenase antigen of Setaria cervi in immunoprophylaxis against Brugia malayi. J Helminth 2004;78:347-52]. These preliminary observations suggested the immunoprotective nature of collagenase. To confirm the vaccine potential of this protease, a vaccine trial was conducted in jirds (Meriones unguiculatus) against human filarial parasite B. malayi. The vaccination resulted into a mean protection level of 75.86% and produced high level of protease neutralizing antibodies. Cytokine analysis in immune jirds sera suggested a mixed Th1/Th2 type cellular immune response whereas ELISA, immunoblotting and enzyme antibody inhibition assay revealed the presence of specific anti-collagenase antibodies. Taken together, all these results suggest that S. cervi 175 kDa collagenase could form the basis of an effective molecular vaccine against human lymphatic filariasis.