Palash Mitra

Community Acquired Acute Kidney Injury from Edible Agents: Report from a Developing Country, Bangladesh

Toxin is a common cause of community acquired acute kidney injury (AKI) which includes environmental toxins like plant toxins as well as various drugs and chemicals which are usually ingested for medicinal as well as recreational purposes. Averrhoa carambola (Star fruit/ Kamranga) and Avorrhoa bilimbi are two such commonly used traditional remedies. They belong to family Oxalidaecae and contain high-levels of oxalic acid. AKI may occur after consuming concentrated juice due to deposition of oxalate crystals in the renal tubules. Here we present two patients who developed AKI after ingestion of freshly made juice from A. bilimbi and star fruit. Both patients were diabetic and the juice was ingested on empty stomach with the belief of improving glycemic status. Initial presentation was GI upset in both scenarios. Patient with A. bilimbi toxicity had diabetic nephropathy and required hemodialysis. Renal biopsy revealed deposition of polarizable oxalate crystals in the patient who consumed A. bilimbi and acute tubular necrosis in the patient with star fruit toxicity. All cases regained normal renal function within three months. We also present a patient who ingested raw fish gallbladder as a remedy for asthma. The patient presented with AKI within five days of ingestion and required hemodialysis. His highest serum creatinine was 10.4mg/dl and fell to 1.7 mg/dl after four weeks. Cyprinol and related compounds in fish gallbladder are thought to be the cause of acute tubular necrosis in such cases. The fourth patient developed AKI with rhabdomyolysis after consuming a locally made energy drink. He also required dialysis and serum creatinine gradually improved from 7.2mg/dl to 1.4mg/dl at discharge. The possibility of toxicity of caffeine, adulteration with other chemicals or ascorbic acid toxicity causing oxalate nephropathy could not be excluded. All four patients developed AKI caused after ingesting easily available products and are presented here for public awareness. We believe proper knowledge and education can reduce toxin induced AKI in our society.

Haemophagocytic syndrome in an adult suffering from pyrexia of unknown origin: an uncommon presentation of tuberculosis: a case report

BackgroundTuberculosis is common, can involve various organs of the body and may have diverse presentations. Haemophagocytic syndrome is one of the rare presentations of tuberculosis carrying a very high mortality. Early detection and institution of anti-tuberculosis medications can be life-saving.Case presentationA 23-year-old Bengali man presented with prolonged fever, weight loss, hepatosplenomegaly, pancytopenia and altered liver function. He had high erythrocyte sedimentation rate, positive tuberculin test, granuloma in liver biopsy, and haemophagocytosis was evidenced by histopathological examination of bone marrow. He recovered with anti-tuberculosis therapy.ConclusionThis case demonstrates that consideration of tuberculosis as an underlying cause of haemophagocytic syndrome could be rewarding and life-saving in this rapidly fatal condition.

Serum Intact Parathyroid Hormone Level is Inversely Correlated with Glycated Haemoglobin in Diabetic Chronic Kidney Disease Stages 3-5 Predialysis Patients

Introduction: Diabetes mellitus (DM) is one of the leading causes of chronic kidney disease (CKD). Management of chronic kidney disease-mineral and bone disorder (CKD-MBD) is an integral component of CKD management; serum intact parathyroid hormone (iPTH) level is the key target. This study was designed to evaluate the relationship between glycated haemoglobin (HbAlc) and iPTH in diabetic CKD stages 3-5 patients not yet on dialysis. Methods: This cross-sectional study was conducted in BIRDEM General Hospital, Dhaka, Bangladesh from January 2013 to December 2014. Diabetic patients suffering from CKD stages 3-5, who were not on dialysis, were consecutively and purposively included in this study. Along with base-line characteristics, clinical and laboratory data including HbAlc and iPTH levels were recorded for all patients. Data were analyzed by using SPSS version 20.0 and Pearson’s correlation test was applied to evaluate the relationship between HbAlc and iPTH. Results: Total patients were 306, including 166 (54.2%) males. Mean age was 56.5±11.3 years. Mean duration of DM and CKD were 12.8±7.6 and 2.9±1.7 years respectively. Among the study population, 49 (16.0%) were in CKD stage 3, 90 (29.4%) in CKD stage 4 and rest 167 (54.6%) in CKD stage 5. Mean HbAlc (%), serum creatinine (mg/dl), urea (mg/dl), calcium (mg/dl), phosphate (mg/dl), alkaline phosphatase (U/L) and iPTH (pg/ml) were 7.77±2.14, 6.8±3.0, 141.1±75.7, 8.1±1.2, 5.2±1.9,164.1±135.3 and 229.7±151.2 respectively. Mean HbAlc (%) and iPTH (pg/ml) in CKD stages 3, 4 and 5 were 8.36±1.59 and 171.7±127.9, 7.99±1.92 and 179.5±131.4, and 7.77±2.14 and 273.8±119.2 respectively. On correlation analysis, HbAlc had a significant negative correlation with iPTH (r=-0.002). Conclusion: The results of current study showed that most diabetic CKD stages 3-5 predialysis patients had poor glycaemic control and HbAlc had negative correlation with iPTH. As iPTH level is influenced by presence and control of DM, the targets of iPTH in CKD stages 3-5 in general, as recommended in existing guidelines, may not be appropriate in diabetic CKD patients and this issue merits further investigation. Birdem Med J 2017; 7(2): 110-113

Outcome of Acute Kidney Injury in Patients with Type 2 Diabetes Mellitus

Background: Diabetic patients are more vulnerable to develop acute kidney injury (AKI) when compared to non diabetic counterpart. However, it is not known whether outcome of AKI is variable according to etiology in diabetic subjects. This study was aimed to observe the causes of AKI in diabetic population and to evaluate the outcome. Methods: This cross-sectional study was done in Department of Nephrology, BIRDEM General Hospital, from May 2009 to April 2010. During the study period a total of 50 subjects were included. All cases of AKI and AKI on chronic kidney disease (CKD) were included except AKI due to trauma. Results: AKI due to acute gastroenteritis, non-steroidal anti-inflammatory drugs (NSAIDs),septicemia, gentamicin, obstructive uropathy, rapidly progressive glomerulonephritis (RPGN) comprised 46%, 42%, 4%, 2%,2%, and 4% cases respectively. All cases of AKI due to acute gastroenteritis improved. Among NSAID induced AKI, 26% improved, 6% improved with residual renal damage, 8% did not improve and 1% patient expired. All cases of septicemia induced AKI improved. Patient with gentamicin induced AKI improved with residual renal damage. Patient with obstructive uropathy improved. None of AKI cases due to RPGN improved. Conclusion: It may be suggested that outcome of AKI is variable according to etiology. Outcome is better in AKI due to pre-renal and post-renal causes than AKI due to intrinsic causes. Further study can be done to compare the outcome of AKI according to etiology between diabetic and non-diabetic populations. Birdem Med J 2016; 6(2): 95-99

Glycemic Status of Type 2 Diabetic Subjects On Different Anti-Diabetic Management

Background: Diabetes mellitus (DM) is a complex multi-system disorder that may lead to diabetes specific complications and target organ damage which can be prevented or delayed by good or strict glycemic control. Our aims were to evaluate the glycemic status of adult type 2 DM (T2DM) patients on different anti-diabetic management, to evaluate role of education and economic status on glycemic control and to correlate glycemic status with complications. Methods: This cross-sectional study was conducted in BIRDEM General Hospital from November 2013 to April 2015. Data were collected in a pre-formed data collection form, purposively and consecutively from 300 T2DM patients who were diagnosed as diabetic for 3 months or more and were compliant, after face to face interview and undergoing the required physical examinations. Then data were compiled and analyzed accordingly. Result: Neither the educational level nor the monthly income had any influence on glycemic control. Only 17% of the patients had good glycemic control (HbA1c <7) in spite of different anti-DM managements. The overall mean HbA1C was 8.9±1.9%, among which the group of patients with medical nutrition therapy had the lowest mean HbA1c level (8.5±1.3%). Chronic kidney disease and polyneuropathy are the two commonest (45% and 40% respectively) complications with a significant (r=1, p=0.000) positive correlation between both macro and microvascular complications of DM with uncontrolled glycemic status. Conclusion: From the current study it can be concluded that glycemic control is rarely achieved and no treatment regimen is superior to other in achieving glycemic control. Patients educational or income level did not have any influence in glycemic control and there is a strong positive correlation between uncontrolled T2DM and it’s complications. Birdem Med J 2017; 7(2): 121-126

Basiliximab as Induction in Kidney Transplantation: Are There any Real-Life Advantages?

Background: Basiliximab is an interleukin-2 receptor antagonist used as induction therapy in kidney transplantation and is believed to reduce acute rejection episode (ARE). Our aims were to compare the impact of basiliximab induction therapy with no induction therapy on incidence of ARE, time requirement for serum creatinine (S.Cr) to normalize after transplantation, initial post-transplant hospital stay, infection in immediate post-transplant period, chronic allograft injury and graft survival at 1 and 3 years. Methods: We retrospectively reviewed the medical records of patients who had undergone living related donor kidney transplantation in a tertiary care hospital of a developing country between July 2004 and June 2014. We selected patients who received calcineurin inhibitors, mycophenolate and prednisolone to classify as no induction therapy (n=50; group 1, receiving prednisolone, mycophenolate and cyclosporine as maintenance therapy) and induction therapy with basiliximab (n=61; group 2, receiving prednisolone, mycophenolate and tacrolimus as maintenance therapy). Results: Among the 111 study subjects, only two had experienced ARE (one from each group, p=0.889). Patients who received basiliximab had a shorter mean hospital stay (11.4±3.3 versus 13.7±5.0 days, p=0.005) and shorter mean duration for normalization of S.Cr (4.7±2.3 versus 7.3±5.6 days, p=0.002) after transplantation. There was no significant difference in incidence of infection in immediate post-transplant period (p=0.134). One year graft survival rate was better in those who received basiliximab (98.2% versus 89.4%, p=0.010) but there was no significant difference at 3 years (79% versus 74%, p=0.549). Overall incidence of chronic allograft injury was less with basiliximab (11.5% versus 36%, p=0.002) induction. Conclusions: Induction therapy with basiliximab was associated with shorter mean hospital stay, early renal function recovery, better 1 year graft survival and less overall incidence of chronic allograft injury. We have encountered minimum ARE to comment on benefit of basiliximab on ARE. Birdem Med J 2017; 7(2): 90-94