Abstract
Background and Aims
Emphysematous pyelonephritis (EPN) is an uncommon, severe, necrotizing infection of the renoureteral unit and is recognized by accumulation of gas within the collecting ...system, renal parenchyma and/or perinephric tissue. Common risk factors for EPN are diabetes mellitus, renal stone, obstructive uropathy and immunosuppression. Principles of treatment include resuscitative measures, antibiotics, strict glycaemic control and interventions in selected cases. This study aimed to describe clinical, laboratory and imaging characteristics of EPN patients with special emphasis on in-hospital outcome.
Method
This cross-sectional study included consecutive 22 EPN patients, managed in the Department of Internal Medicine and the Department of Nephrology of a tertiary care hospital in Dhaka, Bangladesh from January 2013 to December 2019. Patients’ selected socio-demographic, clinical and laboratory parameters and in-hospital treatment-outcome were recorded in case record forms at the time of discharge or death, if were any.
Results
Total patients were 22 (mean age 46.8±12.5, range 34.0–55.0 years) including 16 (72.7%) females. All (22, 100%) were diabetic one (4.5%) patient was newly detected as diabetic during EPN diagnosis. Three (13.6%) patients had renal stones (bilateral in one), two (9.1%) had obstructive uropathy, six (27.3%) had chronic kidney disease, 12 (54.5%) had hyponatreamia and 16 (72.7%) were complicated by acute kidney injury (AKI). Patients presented with fever (22, 100%), loin pain/renal angle tenderness (19, 86.4%), vomiting (19, 86.4%) and dehydration (8, 36.4%). One (4.5%) patient had pneumaturia. One (4.5%) patient presented with uraemic encephalopathy and none had shock. One (4.5%) patient had tender ectopic (pelvic) right kidney. Patients had leukocytosis (mean total white cells 19917±7549, range 10250–37630/cmm of blood) and four (18.2%) patients had thrombocytopaenia. All patients had high erythrocyte sedimentation rate (mean 65.7±20.8, range 35–120 mm in 1st h) and C-reactive protein (mean 68.9±60.3, range 18–209 mg/L). Glycaemic status was poor mean random blood glucose at admission 17.4±6.0, range 10.6–35.5 mmol/L and mean glycated haemoglobin (HbA1c) 9.8±2.1, range 6.9–15.5%. Diagnosis of EPN was confirmed by abdominal ultrasonography and computed tomography scan. One patient had EPN in ectopic right kidney, one patient had EPN along with air in ureter, two patients had associated emphysematous cystitis and one had psoas abscess. Ten (45.5%) patients had EPN in right kidney (including pelvic kidney), 11 (50%) had EPN in left kidney, one (4.5%) had bilateral EPN and three (13.6%) patients had concomitant contralateral pyelonephritis. According to Huang and Tseng classification, one (4.5%) patient had class 4 EPN, three (13.6%) patients had class 3B, five (22.7%) patients had class 3A and thirteen (59.1%) patients had class 2 EPN. Escherichia coli was the most common (13, 59.1%) organism identified on urine culture including four (4/13, 30.8%) cases with extended-spectrum beta-lactamase positive E. coli and four (18.2%) patients were complicated by bacteraemia. Five (22.7%) patients required surgical interventions nephrectomy in three (13.6%) and open drainage in two (9.1%). All patients were treated with intravenous antibiotics and other supportive measures. One patient required three sessions of haemodialysis. Mean hospital stay was 16.1±6.4 (range 7–31) days. AKI resolved in 3 (3/16, 18.8%) patients and in others renal function was improving at the time of discharge and there was no death.
Conclusion
Most EPN patients were successfully managed by conservative approach in this study, two-thirds had AKI, one-fourth required surgical interventions and there was no death. Though conservative approaches for managing EPN is becoming popular, we emphasize interventions should not be delayed, as and when indicated, and may appear life-saving.
Background: Diabetic retinopathy is the commonest cause of blindness in the working age group of both developed and developing countries. It is the indicator of all micro-vascular complications of ...diabetes mellitus. This study was aimed to find out the frequency and pattern of diabetic retinopathy among hospitalized adult type 2 diabetic patients.Methodology: This cross-sectional study was carried out in the Department of Medicine and Endocrinology of BIRDEM General Hospital, Dhaka over a period of six months. Retinopathy was determined by fundoscopic examination in dilated pupil. Data were collected in preformed questionnaire including demographic characteristics, fundoscopic findings, and laboratory investigation reports with prior informed consent of the patients.Results: Total patients were 94, male were 52 and female were 42. Mean age of the patients was 52.2 ± 11.12 years. Hypertension was the most common (42.8%) co-morbid condition followed by dyslipidemia (33%), nephropathy (34%), neuropathy (21.3%), ischemic heart disease (9.6%) and stroke (5.3%). Study showed 37.23% Patient had good glycemic control (HbA1C <7%) and 62.77% had poor glycemic control. The frequency of retinopathy of any form was present in 36.2% patients. Among them, non-proliferative diabetic retinopathy (NPDR) was present in 78.79%, proliferative diabetic retinopathy (PDR) 6.06%, maculopathy 6.06%, both maculopathy and PDR in 9.09% diabetic patients. Among NPDR, 46.15 % was mild, 26.92% was moderate and 26.92% was severe NPDR. This study also revealed retinopathy was more with increase in duration of diabetes (66.6% vs. 17.3% p=0.01), in poorly controlled diabetic than good control (52.54% vs. 8.5%, p=0.01), those with hypertension (55% vs. 22%, p=0.02), and those having diabetic nephropathy (78.12% vs. 14.51%, p=0.01).Conclusion: This study showed frequency of diabetic retinopathy was 36.2% and among retinopathy NPDR was predominate. Poor glycemic control, increase duration of diabetes, presence of other microvascular complication i.e. nephropathy found to be significant risk factors for developing retinopathy.J MEDICINE January 2016; 17 (1) : 17-20
Introduction: Chronic kidney disease (CKD) amongst diabetic patients is a worldwide public health problem. It is associated with cardiovascular disease and CKD mineral bone disorder (CKD-MBD). ...Cardiovascular and MBD are important contributors of morbidity and mortality in CKD patients. Serum intact parathyroid hormone (iPTH) and alkaline phosphatase (ALP) are two important markers to identify and mange CKD-MBD. This study was designed to evaluate the relationship between serum iPTH and alkaline phosphatase in diabetic CKD stages 3-5 patients with MBD.
Methods: This cross-sectional study was conducted in BIRDEM General Hospital, Dhaka, Bangladesh from January 2013 to December 2014. Diabetic patients suffering from stage 3-5 CKD with MBD and not on dialysis, were consecutively and purposively included in this study. Along with base-line characteristics, clinical and laboratory data including serum alkaline phosphatase 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 iPTH and serum ALP.
Results: Total patients were 306, of which 166 (54.2%) were males and 140 females (45.8%). Mean age of the study population was 56.5±11.3 years. Mean duration of diabetes mellitus (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 stage 4 and rest 167 (54.6%) in stage 5. The mean HbA1c level did not differ significantly (p>0.05 by ANOVA) amongst CKD-MBD stage 3, 4 and 5 cases. Mean±SE values of glycated haemoglobin (HbAlc %), serum creatinine (mg/dl), urea (mg/dl), calcium (mg/dl), phosphate (mg/dl), ALP (U/L) and iPTH (pg/ml) of total study population were 7.77±0.12, 6.8±0.17, 141.1±4.33, 8.1±0.07, 5.2±0.11, 164.1±7.74 and 229.7±8.64 respectively. Out of total cases, serum ALP was raised in only 53.9% CKD-MBD cases compared to 76.8% for iPTH. Serum iPTH level was found elevated in 79.6%, 83.3% and 72.5% CKD-MBD stage 3, 4 and 5 cases respectively while in comparison, serum ALP was found raised in 44.8%, 54.4% and 56.2% cases respectively. On correlation analysis between serum iPTH and ALP, the r values observed were 0.074, 0.231 and 0.046 for stage 3, 4 and 5 CKD-MBD cases respectively.
Conclusion: The results of current study showed that most diabetic stage 3-5 pre-dialysis CKD-MBD patients had raised serum iPTH. In comparison, significantly low number of cases had raised serum ALP.
IMC J Med Sci 2018; 12(2): 80-85
Introduction: Chronic kidney disease (CKD) amongst diabetic patients is a worldwide public health problem. It is associated with cardiovascular disease and CKD mineral bone disorder (CKD-MBD). ...Cardiovascular and MBD are important contributors of morbidity and mortality in CKD patients. Serum intact parathyroid hormone (iPTH) and alkaline phosphatase (ALP) are two important markers to identify and mange CKD-MBD. This study was designed to evaluate the relationship between serum iPTH and alkaline phosphatase in diabetic CKD stages 3-5 patients with MBD. Methods: This cross-sectional study was conducted in BIRDEM General Hospital, Dhaka, Bangladesh from January 2013 to December 2014. Diabetic patients suffering from stage 3-5 CKD with MBD and not on dialysis, were consecutively and purposively included in this study. Along with base-line characteristics, clinical and laboratory data including serum alkaline phosphatase 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 iPTH and serum ALP. Results: Total patients were 306, of which 166 (54.2%) were males and 140 females (45.8%). Mean age of the study population was 56.5±11.3 years. Mean duration of diabetes mellitus (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 stage 4 and rest 167 (54.6%) in stage 5. The mean HbA1c level did not differ significantly (p>0.05 by ANOVA) amongst CKD-MBD stage 3, 4 and 5 cases. Mean±SE values of glycated haemoglobin (HbAlc %), serum creatinine (mg/dl), urea (mg/dl), calcium (mg/dl), phosphate (mg/dl), ALP (U/L) and iPTH (pg/ml) of total study population were 7.77±0.12, 6.8±0.17, 141.1±4.33, 8.1±0.07, 5.2±0.11, 164.1±7.74 and 229.7±8.64 respectively. Out of total cases, serum ALP was raised in only 53.9% CKD-MBD cases compared to 76.8% for iPTH. Serum iPTH level was found elevated in 79.6%, 83.3% and 72.5% CKD-MBD stage 3, 4 and 5 cases respectively while in comparison, serum ALP was found raised in 44.8%, 54.4% and 56.2% cases respectively. On correlation analysis between serum iPTH and ALP, the r values observed were 0.074, 0.231 and 0.046 for stage 3, 4 and 5 CKD-MBD cases respectively. Conclusion: The results of current study showed that most diabetic stage 3-5 pre-dialysis CKD-MBD patients had raised serum iPTH. In comparison, significantly low number of cases had raised serum ALP. IMC J Med Sci 2018; 12(2): 80-85. EPub date: 31 December 2018 Address for Correspondence: Dr. Mehruba Alam Ananna, Assistant Professor, Department of Nephrology, Ibrahim Medical College and BIRDEM General Hospital, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka, Bangladesh. Email: ananna0701@gmail.com
Background: A well-functioning vascular access (VA) is essential to provide efficient hemodialysis (HD) therapy. There are 3 main types of access: arterio-venous fistula (AVF), arterio-venous graft ...(AVG) and central venous catheter (temporary or permanent). The aim of our study was to find vascular access profile of ESRD patients on maintenance hemodialysis in a tertiary care hospital.
Methods: This cross-sectional study was carried out in the Department of Nephrology and Dialysis of BIRDEM General Hospital, Dhaka, Bangladesh from November to December, 2015. After taking informed consent from the patients, data were collected from face to face interview and record books of the patients.
Results: Total patients were 107, male were 78 (72.9 %) and female were 29 (27.1%). The mean age was 57.3 ± 11.4 (range 32-80) years. Mean duration of CKD was found 5.7 ± 4.2 (range 1-20) years. Maximum dialysis duration was 6.5 years with mean of 1.7 ± 1.3 years. Near two-thirds (68.2%) of the patients were on thrice-weekly dialysis and one-third (31.8%) were on twice-weekly dialysis. The vascular access at initiation of dialysis was temporary catheter in majority (91.6%) of study participant and AV fistula in 8.4% cases. Of temporary catheter one-third (33.7%) were temporary jugular catheter and two-third (66.3%) were temporary femoral catheter. Among jugular catheter 9.1% were left sided catheter and rest (90.9%) were right sided catheter. Among the femoral catheter 70.8% and 29.2% were right and left side respectively. The current vascular access was AV fistula in 90.7%, temporary catheters 4.7%, permanent catheter 3.7% and AVG 0.9% in study patients. Of AVF near one third (29.9%) were radio-cephalic and 70.1% were brachial (62.6% brachio-cephalic, 7.5% brachio-basilic) fistulas. About seventeen percent (16.8%) patients had AVF failure.
Conclusion: Temporary dialysis catheters were the most common initial vascular access. Less than one-tenth patients started dialysis with AV fistula. More than two-thirds patients were on thrice weekly dialysis. AV fistula was the most common current vascular access with very small number of permanent catheter and AV graft.
Bangladesh Crit Care J March 2019; 7(1): 26-28
Introduction: Urinary tract infection (UTI) is common among patients with diabetes mellitus and the aetiological agents are often extended-spectrum beta-lactamase (ESBL) producing bacteria. Diabetic ...patients with UTI are sometimes complicated by bacteraemia. This study was designed to evaluate whether UTI due to ESBL-positive organisms is a risk factor for bacteraemia among patients with type 2 diabetes mellitus.
Methods: This was a cross-sectional analytical study, done in BIRDEM General Hospital, Dhaka, Bangladesh from January to April 2016. Adult (e”18 years) type 2 diabetic subjects of either sex with culture proven UTI were included in this study. All study participants were subjected to undergo blood cultures as well. ESBL-positivity of the infective organisms for UTI was evaluated as possible risk factor for bacteraemia.
Results: Total patients were 145 including 119 (82%) females. Eshcerichia coli (112, 77.2%) was the most common aetiological agents followed by Klebsiella pneumoniae (28, 19.3%). In 54 (37.2%) patients UTI was due to ESBL-positive organisms. Ten (6.9%) patients were complicated by bacteraemia 7 (7/ 54, 13%) among patients with UTI due to ESBL-positive organisms and 3 (3/91, 3.3%) among patients with UTI due to non-ESBL organisms. UTI due to ESBL-positive organisms appeared as a significant risk factor for bacteraemia (OR 4.37, 95% CI 1.08-17.38, p 0.03).
Conclusion: Nearly two-fifths of UTI cases were due to ESBL-positive organisms in this study. ESBLpositivity of the causative organisms was a significant risk factor for bacteraemia among type 2 diabetic subjects.
Bangladesh J Medicine Jan 2020; 31(1) : 9-12
Background and Aims : Microalbuminuria is claimed to be an early marker of nephropathy in type 2 diabetes.The raised arterial pressure is an important factor in the progression of diabetic ...nephropathy. There is a significant correlation between blood pressure and the progression of albuminuria in both type 1 and type 2 diabetes. This study in Bangladeshi type 2 diabetic patients was to evaluate whether microalbuminuria and raised arterial pressure are influenced by familial predisposition to hypertension.Methods : Sixty three newly diagnosed Bangladeshi type 2 diabetic patients were investigated. The diabetic subjects were divided into two groups as diabetes with family history of hypertension (n=37) and diabetes without family history of hypertension (n=26). Diabetic subjects were further divided into normotensive (n= 46) and hypertensive (n= 17); diabetic normoalbuminuric (n 44) and diabetic microalbuminuric (n 19) subgroups. Serum glucose was measured by glucose-oxidase; blood urea, serum creatinine and urinary creatinine by enzymatic-colorimetric method and urinary albumin by immunoturbidimetry method.Results : systolic blood pressure (SBP), diastolic blood pressure (DBP) and microalbuminuria were significantly elevated in diabetic subjects with familial predisposition to hypertension when compared to diabetic subjects without familial predisposition to hypertension SBP (127±16 vs 110±14) mmHg P= 0.001; DBP (81±9 vs 72±11) mmHg P= 0.001; Microalbuminuria 2.23(0.28-9.43) vs 1.52(.29-3.91) mg/mmol p<0.03. When diabetic normotensive subjects were compared with diabetic hypertensive subjects for microalbuminuria, no significant difference was found among themselves median (range) 1.67(0.17-8.62) vs 1.70(.28-9.43) mg/mmol p = NS. Comparison of blood pressure was found no significant difference between diabetic normoalbuminuric and diabetic microalbuminuric subjects systolic blood pressure (117±17 vs 125±17) mmHg p= NS ; diastolic blood pressure (76±11 vs 82±10) mmHg p= NS .Conclusion : Microalbuminuria, a marker of early diabetic nephropathy and raised arterial pressure, a progression factor of nephropathy are more influenced by familial predisposition to hypertension in diabetic population irrespective of presence or absence of microalbuminuria and hypertension.Bangladesh Crit Care J March 2016; 4 (1): 14-18
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