Raised Serum Creatinine Research Articles

Assessing the Utility of the Metabolic Score for Insulin Resistance (METS-IR) in Evaluating Metabolic Risk Among Individuals Undergoing Master Health Checkups in a Tertiary Care Hospital in South India: A Retrospective Cohort Study.

Background The metabolic score for insulin resistance (METS-IR) is a neoteric score for assessing insulin resistance that has been used as a non-insulin-based, objectively measured method. It is an easily accessible tool that can be used on a large scale to detect insulin resistance in a community. Methods We conducted a retrospective cohort study to explore the utility of this score in identifying metabolic risk in those individuals attending a master health checkup in a tertiary care setting. Data were collected from 254 individuals between October and December 2023. Results According to the univariate regression analysis, METS-IR had a strong correlation in predicting cardiovascular health risks, as evidenced by its positive linear association with an increase in age (β=0.186, p=0.003), weight (β=0.534, p<0.001), waist circumference (β=0.405, p<0.001), and body mass index (BMI; β=0.635, p<0.001). This explained the value of this score in depicting adiposity and insulin resistance. Lab parameters that showed a significant association were fasting blood sugar (β=0.176, p=0.005) and fasting triglycerides (β=0.175, p=0.005). According to the multivariate regression analysis, METS-IR had a significant positive association with fasting blood sugar (B=0.489, p<0.001) and fasting triglycerides (B=0.022, p=0.003), implicating its importance in cardiovascular health. High-density lipoprotein cholesterol (HDL-c; B=-0.168, p=0.005) confirmed its protective role with its negative association in higher quartile groups. An increase in serum albumin levels (B=-0.168, p=0.005) and raised gamma-glutamyl transpeptidase (GGT) (B=0.059, p=0.022) portrays its due diligence in liver health. METS-IR had a weak association with the estimated glomerular filtration rate (eGFR) with Pearson's correlation coefficient of 0.020 (p=0.756) and Spearman's rho of 0.021 (p=0.739). However, raised serum creatinine had a significant association in higher quartile groups, with a p-value of 0.018. Conclusions METS-IR is useful as a screening tool for predicting cardiovascular disease. However, the complex interplay of other confounding factors in identifying renal dysfunction has yet to be explored when considering this score in our study population.

P191 CO-EXISTING HYPERTENSION: AN INDEPENDENT RISK FACTOR FOR DIABETIC RETINOPATHY IN TYPE-2 DIABETES

Background and Objectives: Hypertension has plausible reason to be show the interaction due to its independent effect on retina. Epidemiological studies also provide clue that for hypertension as a possible effect modifier in the risk development of retinopathy in diabetic patients. It is worth exploring whether subgroup in diabetic population with Hypertension have different risk potential of developing retinopathy. The present study aimed to assess the association of hypertension as a risk factor for diabetic retinopathy (DR) in type 2 diabetes mellitus. Methods: A total of 977 type-2 diabetic patients recruited retrospectively in 2008 from Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorder (BIRDEM) based on hospital records for determining the incidence of diabetic retinopathy (DR), who were naı̈ve type-2 diabetes during 1993. At the end of 15 year follow-up 495 patients were diagnosed as DR by retinal colour photography. Data on diabetes and lipid profile with serum creatinine, blood pressure and biophysical measures were obtained at baseline, 5, 10 and 15 years follow-up. Binary logistic regression model was used to assess the associations of co-existing hypertension with retinopathy risk adjusting for clinical, biochemical and anthropometric variables. Results: In all three follow-up points, including at baseline, mean systolic and diastolic blood pressure were found to significantly higher among patients who developed DR (P&lt;.001). Binary logistic regression model confirmed coexisting hypertension (OR 3.2; 95% CI 2.2 -4.7) as a significant risk factor of DR adjusting for possible confounders; serum creatinine (OR 21.9; 95% CI 14.0 -35.4) and glycemic control status (OR 17.2; 95% CI 9.4 -31.4). Interaction between hypertension, glycemic control and raised serum creatinine did not appear to be statistically significant (P&gt;0.05). Conclusions: Co-existing hypertension is a significant risk factor of DR irrespective of nephropathy or glycolic control status among Type 2 diabetes mellitus.

Peak Serum Creatinine as a Biomarker of Pancreatic Necrosis in Acute Pancreatitis: A Cross-Sectional Study

Pancreatitis is the inflammation of the pancreas. Pancreatitis can result in pancreatic necrosis which may lead to significant morbidity and mortality. It is possible to predict pancreatic necrosis and organ dysfunction using many biochemical indicators and markers. Peak serum creatinine has been identified as one of such useful markers to predict pancreatic necrosis. Objective: To find the diagnostic accuracy of elevated peak serum creatinine as a predictor of pancreatic necrosis in patients with acute pancreatitis taking the contrast-enhanced computed tomogram scan (CECT) as the gold standard and to establish the degree of agreement between the two clinical tests. Methods: A cross-sectional, analytical study that was carried out at the Department of Surgery, Benazir Bhutto Hospital, Rawalpindi from January 2020 to January 2023. 150 patients diagnosed as having pancreatitis were enrolled in the study. Peak serum creatinine at 48 hours &gt; 1.8 mg/dl was labeled as a predictor of pancreatic necrosis. Contrast-enhanced computed tomogram scan was done within 96 hours of admission. The pancreatic necrosis suggested by raised serum creatinine was confirmed by CECT. The diagnostic accuracy of peak serum creatinine and the degree of agreement between the two modalities was calculated. The Kappa coefficient was used to calculate the strength of agreement. Results: The results show that Peak serum creatinine has a sensitivity of 45.5%, specificity of 97.35%, PPV of 85.0 %, NPV of 93.8 %, and accuracy of 84.6%. This study found that the degree of agreement between raised peak serum creatinine levels and CECT to predict pancreatic necrosis was 84.7% with a “Kappa coefficient” of 0.51. Consequently, the null hypothesis was rejected in light of these findings. Conclusions: It was concluded that elevated serum creatinine (SCr &gt;1.8 mg/dl) at 48 h of admission can be used as a predictor of pancreatic necrosis in patients with acute pancreatitis.

Acute ST elevation myocardial infarction (STEMI) in a patient with leptospirosis; a therapeutical dilemma – A case report

A 45-year-old previously healthy farmer was seen at the Emergency Department with ischemic type chest pain. He had a history of an acute febrile illness for four days. The ECG showed an acute anterior myocardial infarction. His laboratory investigations revealed thrombocytopenia, a raised serum creatinine level and significantly raised high-sensitive cardiac Troponin I. A provisional diagnosis of acute STEMI with co-existing leptospirosis was made. The patient was managed conservatively with antibiotics, statins, and aspirin. Neither thrombolysis nor primary coronary intervention was attempted due to high risk of bleeding. Diagnosis of leptospirosis was confirmed later by markedly elevated leptospira antibodies. After recovery, he underwent coronary angiogram which revealed a totally occluded left anterior descending artery and is awaiting myocardial viability assessment with dobutamine stress echocardiography before PCI. We report this uncommon presentation of acute myocardial infarction in a patient with leptospirosis, as it causes a considerable therapeutic dilemma especially in a resource-poor setting.

Impairment of Renal Function and Dyselectrolytemia in Perinatal Asphyxia

Background: Perinatal asphyxia is one of the major causes of neonatal death and disabilityworldwide. Asphyxiated newborns are vulnerable to develop impaired renal functions andderangement in electrolytes level.Objective: To determine the effects of perinatal asphyxia on renal functions and serumelectrolytes.Methods: This cross sectional observational study was conducted at inpatient department ofPaediatrics of Rangpur Medical College Hospital from May 2017to October 2017. After parentalpermission and clearance, total 200 eligible hospitalized term neonates fulfilling the inclusionand exclusion criteria were enrolled into the study. Estimation of serum creatinine, blood urea,serum sodium and potassium were done for every neonate after hospitalization. Data collectionand processing were done for each patient. Data were analyzed through SPSS software (version16.0). Level of significance was predetermined as p&lt;0.05.Results: Analysis revealed that out of 200 neonates 130(65%) patients were in Hypoxic IshchemicEncephalopathy stage-ll followed by 50(25%) and 20(10%) patients in stage-lll and stage-lrespectively. Of total subjects, 68(34%) neonates had raised serum creatinine (p&lt;0.001) andmajority (36 cases out of 50,18% of total) of them were in stage-lll. Blood urea wasraised(p&lt;0.001) in more than half (112 cases out of 200, 56% of total neonates) of the asphyxiatedneonates, higher level was observed in stage-ll and stage-lll. Majority of asphyxiated neonates139(69.5%) were hyponatremic which was significant in all stages of birth asphyxia (p=0.026).Hyperkalemia observed in 38(19%) asphyxiated neonates which was significant with increasedseverity of perinatal asphyxia (p=0.007).Conclusion: Renal function impairment and electrolyte abnormalities are common in asphyxiatednewborns. The degree of hyponatremia, hyperkalemia, raised serum creatinine and blood urea levelwere directly proportionate to severity of asphyxia. The early identification and time basedintervention to assess renal function and electrolyte abnormality in the early post asphyxiatedperiod will significantly reduce the morbidity and mortality.

Predictors of Frailty in Patients With Liver Cirrhosis.

Introduction Frailty is noticed in a large number of cirrhotic patients with advanced liver disease. Frailty not only disposes cirrhotic patients to increased rates of decompensation and hospitalization but also leads to prolonged hospital stay and increased psychological and social impact, resulting in the delisting of these patients from the transplant list. Therefore, our aim was to identify the factors that are independent predictors of frailty in patients with liver cirrhosis. Methods This cross-sectional study was carried out at the Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan, from March 1, 2022, to August 31, 2022. All the patients diagnosed with livercirrhosis and aged 18-70 years were included in the study. The excluded patients comprised those with disorders that over-estimate frailty such as cardiopulmonary disease and hepatocellular carcinoma. The measurement of the Liver Frailty Index (LFI) was done using the hand grip strength method, timed chair stands, and balance testing. Patients with LFI >4.5 were considered frail. All data was entered and analyzed using IBM SPSS Statistics for Windows, Version 22.0 (Released 2013; IBM Corp., Armonk, New York, United States). Continuous variables were analyzed using the student-t test while categorical variables were analyzed using the chi-square test. Variables with significance on univariate analysis then underwent multivariate analysis to identify the independent predictors of frailty in cirrhotic patients. A p-value < 0.05 was considered statistically significant. Results A total of 132 patients were included in the study. Out of them, 89 (67.4%) were males. On assessment, 51 (38.6%) patients were frail on presentation. On univariate analysis, female gender, advanced age, raised total leucocyte count, increased percentage of neutrophils on peripheral smear, raised serum creatinine, raised total bilirubin, raised prothrombin time, high Child Turcotte Pugh (CTP) score, and high model for end-stage liver disease along with low hemoglobin and low serum albuminlevels werestatistically significantlyassociated with frailty in cirrhosis. On multivariate analysis, female gender, age >40 years, CTP>B7, Hemoglobin <10g/dl, and neutrophils >60% on peripheral smear were independent predictors of liver frailty in cirrhotic patients. Conclusion Female gender, advanced age, increased neutrophils on peripheral smear, decreased hemoglobin along with increased degree of liver dysfunction were independent predictors of increased frailty in patients with chronic liver disease.

#2108 Secondary amyloidosis in a cancer patient on pembrolizumab—an unusual finding

Abstract Background and Aims With the widening horizon of ICPIs in the management of oncological disorders, we require to remain vigilant of the possible iRAEs. We present a case report of secondary amyloidosis in at metastatic non-small cell lung carcinoma (NSCLC) patient treated with Pembrolizumab. We aim to describe the clinic-biological &amp; histopathological characteristics of ICPI-related kidney injury which may be beyond interstitial nephritis &amp; its response to treatment &amp; the role of kidney biopsy to define ICPI-related kidney injury. Treatment is challenging due to a paucity of relevant data, implicating further studies. Treatment with colchicine and steroids, tocilizumab in the setting of elevated interleukin-6 (IL6) levels have been reported in case series; unfortunately no appreciable renal benefit were noted. Method 77 year male, diabetic &amp; hypertensive on regular medication for &amp;gt;15 yr, reformed smoker (≈50 pack-years of cigarette) diagnosed with NSCLC (EGFR–wild type, PDL1–70%), received Pembrolizumab (13 cycles) &amp; Paclitaxel + Carboplatin &amp; was in remission. Follow up PET showed partial response—new lesions in brain. Gemcitabine added to the treatment &amp; had received 2 cycles, till hospitalization with febrile episode, decreased oral intake &amp; progressive edema. Clinical evaluation was non-contributory. Hematology &amp; biochemical evaluation (Table 1) showed raised serum creatinine 1.1 mg/dL (baseline 1 mg/dL), urinalysis—2+ protein, quantification showed 2.9295 g/24 h → 6.38 g/24 h (baseline uPCR-0.19 g/g). Abdominal ultrasound &amp; ECHO finding were not conclusive. Fundoscopy showed no evidence of proliferative diabetic or hypertensive retinopathy. Results Kidney Biopsy (Figure) was done. LM showed, few of 8 gloms with mild segmental mesangial expansion due to amorphous extracellular deposits which was PAS &amp; silver negative but showed congophilia (Fig. A,B,C,D). If negative for albumin, IgG, IgA, C3, C1q &amp; had 1+ granularity in the mesangium on IgM staining &amp; showed no light chain restriction in glomeruli &amp; tubular cast for kappa &amp; lambda. IHC (Fig. E) was positive for serum amyloid associated proteins. EM revealed minimal subendothelial &amp; mesangial expansion due to extracellular material organized into randomly arranged fine fibrils, &amp; no significant foot process effacement, electron dense deposits along the capillary basement membrane or within mesangium, glomerular basement membrane, thereby excluding possibility of light chain deposition disease. Conclusion Secondary amyloidosis with ICPI use has uncommonly &amp; with Pembrolizumab rarely been reported. Treatment is challenging due to paucity of literature. Hassan Izzedine et al. in their case series, on Pembrolizumab treated cancer patient [N = 676], showed 12 patients (7 men) (Incidence 1.77%) developed AKI (n = 10) &amp;/or Proteinuria (n = 2), median duration of use 9 months. All (n = 12) underwent renal biopsy, which showed AIN in 4, ATI in 5, MCD in 2. Recovery happened with withdrawal of drug coupled with corticosteroid. Reintroduction resulted in more severe recurrence of AIN in 1 patient only. Lapman et al. reported 1 case of secondary amyloidosis in cancer patients treated with Pembrolizumab. 42yr male Caucasian, had no reported chronic illness, except Asthma. Similarly developed significant proteinuria (Urine Pro 3+) &amp; AKI (Sr. Creat 1.58 mg/dl; Baseline 1.0 mg/dl) after 90 days of Pembrolizumab therapy. Under went 2 Kidney Biopsy–1st Biopsy revealed AA amyloid. AA amyloidosis was attributed to Pembrolizumab as repeat Bx revealed progressive deposits despite remission of malignancy, but his kidney disease progressed, and had to be initiation on maintenance hemodialysis. Stopping Pembrolizumab &amp; corticosteroids led to resolution of proteinuria in our patient too.

Clinical Significance of Hepatobiliary Localization of Tc-99m EC in Diuretic Renography

Abstract Objective Technetium-99m ethylene dicysteine (Tc-99m EC) is a well-established, tubular tracer for diuretic renography. Few occasional cases have been reported in literature regarding visualization of liver, gallbladder (GB), or bowel due to increased hepatobiliary route of excretion of Tc-99m EC on diuretic renography. This study aimed to retrospectively review the incidence of visualization of liver, GB, or bowel and its clinical significance in Tc-99m EC diuretic renography. Materials and Methods Data of all patients who underwent diuretic renography in the department from January 24, 2022 to March 31, 2023 was included in the study. The data was analyzed to assess the incidence of visualization of GB or bowel loops, correlation of the hepatobiliary localization with factors like age of the patient, concentration of 99m TcO4 solution, quality control parameters, presence of renal stone disease, serum creatinine, relative renal function, and effective renal plasma flow. Effect of hepatobiliary localization on scan interpretation and reporting was assessed. Results The retrospective analysis of 437 diuretic renograms revealed the hepatobiliary localization of tracer in 34 patients. Out of these 34 patients, 14 patients had only faint visualization of tracer at 4 hours delayed image. Twenty scans had visualization of both GB and bowel. Out of these 20 scans, GB and bowel were visualized during dynamic imaging in one scan, after initial 20 minutes in two scans and in 2 to 4 hours delayed images in rest of the 17 scans. Two out of 20 patients had increased serum creatinine, 16 patients had either single kidney or relative renal function less than 26%, and 12 patients had renal stone disease. Out of the four patients in whom relative renal function was more than 25%, one patient had raised serum creatinine and three patients had renal stone disease. Interpretation of images was affected only in three patients, in which reporting of the scans required single-photon emission computed tomography imaging and correlation with other imaging modalities. Conclusion Hepatobiliary excretion of Tc-99m EC usually does not usually affect the scan interpretation and quantitative renogram analysis, but reader should be cognizant of the potential pitfalls during scan interpretation. In this study, we reviewed the possible causes of this hepatobiliary clearance and importance of additional views and correlation with other imaging modalities to clarify the suspicion arises for accurate reporting.

Population-wide long-term study of incidence, renal failure, and mortality rates for lupus nephritis.

Given limited regional data, we investigate the state-wide epidemiology, renal and patient outcomes for lupus nephritis (LN) in Western Australia (WA). Patients hospitalized with incident SLE (≥2 diagnostic codes in the state-wide WA Health Hospital Morbidity Data Collection) in the period 1985-2015 were included (n = 1480). LN was defined by the presence of glomerulonephritis and/or raised serum creatinine. Trends over three study decades for annual incidence rate (AIR)/100.000 population, mortality (MR), and end-stage renal disease (ESRD) rates/100 person years were analyzed by least square regression and compared with a matched control group (n = 12 840). Clinical evidence of LN developed in 366 SLE patients (25.9%) after a median disease duration of 10 months (IQR 0-101) with renal biopsy performed in 308 (84.2%). The AIR for LN (0.63/100.000) did not change significantly over time (R2 = .11, p = .85), while point prevalence reached 11.9/100.000 in 2015. ESRD developed in 14.1% (n = 54) of LN patients vs. 0.2% in non-LN SLE patients and 0.05% in controls (all p ≤ 0.01). ESRD rates increased over time in LN patients (0.4 to 0.7, R2 = .52, p = .26). The odds ratio for death was 8.81 (CI 3.78-22.9) for LN and 6.62 (CI 2.76-17.9) for non-LN SLE patients compared to controls and MR for LN patients increased over time (1.3 to 2.2, R2 = .84, p = .26). The incidence rate of LN in WA remained unchanged over 30 years. A lack of improvement in renal failure and mortality rates illustrates the pressing need for better long-term treatment options and/or strategies in LN.

The Prevalence and Outcomes of Hepatorenal Syndrome in Chronic Liver Disease Patients in a Tertiary Care Hospital

Hepatorenal syndrome (HRS) leads to a severe kidney injury leading to its eventual failure in the background of chronic liver disease. Objective: This research’s objective was to define the frequency of hepatorenal syndrome (HRS) in the background of cirrhosis and to find out the outcomes of the patients with HRS. Methods:This is a detailed prospective clinical series research. It was conducted in the Department of Medicine, Jinnah Postgraduate Medical Center (JPMC), Pakistan, from February 2020 to December 2020 after approval by the authorized review board. Jinnah Postgraduate Medical Center (JPMC). A sample size of 101 was calculated. The lab values including prothrombin time (PT), serum albumin, and chronic liver disease variations were established for confirmative diagnosis. Frequency tables were created for parameters to be determined (sex and Child-Pugh classification). The means and their SD of parameters of interest (age and weight) were calculated. Results:The demographic variables were the mean age of the patients was 62.5±10.2 and the mean bilirubin was 2.32 ± 2.3mg/dL. 68 (67.3%) of the patients had normal creatinine and 33 (32.7%) of the patients had raised serum creatinine. 2(10.5%) of the patients had a numerical score of 5-6, 13 (68.4%) of the patients had a total score of 7-9 and 4(21.1%) of the patients had 10-15 scores. Hepatorenal syndrome was detected in 11.9% of patients with cirrhosis, among whom 4 (33.3%) died. Conclusions:The hepatorenal syndrome is quite common in liver diseases and it needs to be assessed.

Myoglobin Cast Nephropathy, A Series of Five Cases

Acute kidney injury is a potential complication of severe rhabdomyolysis, which occur mostly due to excessive release of myoglobin from necrosed muscle cells. The major causes of rhabdomyolysis in Indian subcontinent include wasp sting, snake envenomation, strenuous exercise and seizures, etc. The main pathophysiology of AKI due to tubular obstruction, renal vasoconstriction and tubular damage due to myoglobin casts in the tubular lumen. With raised serum creatinine level these patients also show remarkably high serum creatine phosphokinase (CPK). On light microscopy myoglobin casts present as granular eosinophilic pigment casts, sometimes may mimic haemoglobin casts or bile casts. To differentiate the myoglobin casts from other, immunohistochemistry for myoglobin is used in most of the centers worldwide now days. A good number of patients need haemodialysis and most of them recover well, however early diagnosis and timely intervention is warranted. Here we report five cases of myoglobin cast nephropathy in a year at department of histopathology, Armed Forces Institute of Pathology (AFIP), Dhaka, following different non traumatic causes, diagnosed by immunohistochemistry for myoglobin.

Diagnostic validity of peptic ulcer perforation scoring system in predicting mortality in patients with perforated peptic ulcer at a tertiary care hospital in India

Background: One of the prevalent ailments impacting the population of India is peptic ulcer. Although generally benign in its course, it can cause dangerous complications such as perforation and bleeding. Perforation is a life-threatening complication of the peptic ulcer. The status of patients may suddenly deteriorate if they wait too long to seek hospital care or if a diagnosis is delayed due to an unusual presentation. For triage and risk classification, it is critical to accurately and promptly identify high-risk surgical perforated peptic ulcer patients. Aims and Objectives: Perforations in peptic ulcer disease are known to cause considerable morbidity and mortality. The objective of this study was to verify the reliability of the peptic ulcer perforation (PULP) score in predicting patient death after surgery for PULP. Materials and Methods: This was a retrospective cross-sectional study included 50 PULP patients who underwent surgery and analyzed the data until discharge or death at tertiary care university hospital in India. Results: The mortality rate observed was 24%. Elderly population, raised serum creatinine, liver cirrhosis, steroid abuse, pre-operative shock, and American Society of Anesthesiologists (ASAs) grade were identified as risk factors for poor post-operative prognosis. The area under curve for mortality prediction was 0.947 for PULP score. Conclusion: Poor outcome was significantly higher in the elderly, patients with raised serum creatinine, pre-operative shock, and ASA. PULP score proved to be a more precise indicator of mortality. A larger study inclusive of other mortality risk prediction models would help formulate a more accurate and population specific scoring system.

Emphysematous pyelonephritis: An assessment of prognostic factors and the role of early pigtail drainage

Abstract Introduction: The management of emphysematous pyelonephritis (EPN), a necrotizing renal infection, has shifted from more invasive to less invasive approach in due course of time with decrease or reduction in mortality rate. Aim: To analyze the clinical spectrum, prognostic factors, different management strategies, and the outcome of the patients of EPN with the role of early pigtail drainage. Materials and Methods: The study was carried out at a tertiary care hospital from January 2016 to December 2021 and included patients who were diagnosed with EPN. The data on the demographic profile, clinical features, biochemical parameters, imaging studies, management, and outcome of patients of EPN were recorded. Results: A total of 51 patients of EPN were studied and were divided into two groups, responders (40 patients) and nonresponders (11 patients), based on their clinical progression and outcome. Among responders and nonresponders, a significant difference was seen in terms of age, presentation of altered consciousness and shock, average hemoglobin, average serum creatinine, and presence of thrombocytopenia. Out of total 51 patients, 13 (25.49%) showed a response with antibiotics only, DJ stenting was done in five (9.8%) patients, and pigtail catheterization in 33(64.7%) patients. There was a significant difference seen in the response with early pigtail drainage. Nephrectomy was needed in eight (15.68%) patients, and the mortality rate was 9.8%, with the death of five patients. Conclusion: Advanced age, lower hemoglobin levels, thrombocytopenia, raised serum creatinine levels, altered mental status, and presence of shock can be used as a score for poor prognosis. With the use of broad-spectrum antibiotics and early pigtail drainage, a large number of patients with EPN can be managed effectively. Nephrectomy should be reserved for patients who fail to respond to conservative management or those with advanced disease with the presence of multiple risk factors.

CLINICO-BIOCHEMICAL PROFILE AND HOSPITAL BASED OUTCOME OF PATIENTS WITH DIABETIC KETOACIDOSIS ADMITTED IN A TERTIARY CARE INSTITUTE IN ASSAM

BACKGROUND Diabetes mellitus is a metabolic disorder which is characterized by chronic hyperglycaemia resulting from defects in insulin secretion, insulin action, or both. Globally, the prevalence of diabetes among adults is estimated to be 537 million in 2021 and is expected to be 783 million by 2045. Most patients with DKA recover when treated appropriately but if remained untreated, may lead to complications and rise in mortality and morbidity. Hence, early identication of ketoacidosis and aggressive management with insulin, intra-venous uids and electrolytes replacement may change the outcome of the disease. A hospital based METHODOLOGY observational study recruited 60 patients of age more than 12 years admitted under the Department of Medicine, GMCH with Diabetic Ketoacidosis from 1stJuly 2020 to 31st June 2021. DKA was seen in all the age RESULTS groups but predominantly in middle-aged patients in 41-50 years age group (28%) with male predominance (Male:Female ratio =1.7:1). The incidenceof DKA was more among Type 2 Diabetes (76.7%) than with Type 1 Diabetes (23.3%) . Mortality of patients in the study was found to be 18.3%, which was higher in comparison to standard literature. Most of the patients in the study presented with nausea, vomiting and pain abdomen (28.30%). Sepsis and inadequate therapy (31.6% and 20.0%) were the leading precipitating cause of DKA Among the patients, 33.33% presented with severe DKA at the time of presentation and it was also observed that there is signicant correlation between severity of the disease and mortality (P &lt;0.05). Patients with Poor GCS, raised serum creatinine, blood urea, serum calcium, alanine transaminase, aspartate transaminase and total serum bilirubin has signicant correlation with mortality (P value &lt;0.05). However, the body mass index, blood sugar, pH, serum bicarbonate, sodium, potassium, magnesium, albumin, triglyceride, glycosylated haemoglobin, total leucocyte count and haemoglobin levels at the time of presentation do not have a signicant correlation with mortality (P value &gt;0.05). It was observed from CONCLUSION our study that contrary to standard literature, the incidence of DKA is more common in adults than children. DKA was signicant in patients with type 2 diabetes in our series of patients and hence further studies are necessary to re-evaluatethis observation. CONFLICT OF INTEREST None

Clinicoradiological and Biochemical Predictors of Mortality in Hospitalized Patients of Spontaneous Intracerebral Hemorrhage

Abstract Background Intracerebral hemorrhage (ICH) is a cerebrovascular insult leading to bleeding within the brain parenchyma. It is associated with high rate of mortality and morbidity. The main objective of our study was to study in-hospital predictors of mortality in patients with spontaneous ICH managed medically. Methods This was a single-center prospective study and patients of ICH meeting the inclusion criteria were recruited from March 2019 to December 2020. Demographic data were collected and brain imaging was done. Each patient was observed for outcome with either discharge or death. Results Total 202 patients of ICH were included in the study. Mean age of the patients was 58.46 ± 11.6 years (26–95 years), which included 75.25% males. Most common location of ICH was gangliocapsular (42.08%) followed by thalamus (37.13%). Overall mortality was 35.60% (n = 72). On univariate analysis, predictors of mortality were higher age, low Glasgow coma scale (GCS) score, intraventricular extension, volume of hematoma, raised ICH score, leucocytosis, raised creatinine, hypernatremia, and ventilatory support. Need for ventilatory support, raised serum creatinine, and low GCS was found to be independent predictor of mortality on multivariate analysis. Conclusion Our study showed that about one-third of ICH patient died during in-hospital management. Mechanical ventilation requirement, low GCS, and raised creatinine were found to be independent predictors of mortality in our study.

Clinical features and outcomes of renal disease in children with COVID-19: A single-center retrospective study

Abstract Background: The clinical spectrum of coronavirus disease 2019 (COVID-19) ranges from asymptomatic course to severe illness. Children have accounted 1%–5% of diagnosed cases so far. This study aimed to observe the clinical features and outcomes of renal disease in children with COVID-19. Materials and Methods: This retrospective study was conducted in the Department of Pediatric Nephrology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, from November 2021 to April 2022. The data were collected from 24 COVID-19-positive children under 18 years old with preexisting renal disease admitted in BSMMU from March 2020 to September 2021. Results: The mean age of the participants was 8.7 (±4.4) years. Among them, preexisting renal diseases were mainly nephrotic syndrome (50%), chronic kidney diseases (29%), and lupus nephritis (8%). Among the participants, 58% of patients became reverse transcription- polymerase chain reaction negative within 14 days, and the mean duration of hospital stay was 14.5 (±5.9) days. Most frequently presented clinical features were fever (75%), cough (71%), respiratory distress (54%), proteinuria (71%), hematuria (21%), diarrhea and acute kidney injury (17%), rapidly progressive glomerulonephritis (4%), heart failure (33%), and decreased saturation of peripheral oxygen ≤90% in 58% of cases. Mean white blood cell count was 8773.9 (±5178.1)/mm3, raised serum creatinine 62.5%. Pneumonia in chest X-ray was present in 50% of cases. Children getting more immunosuppressive drugs, especially those who got rituximab, had milder symptoms. Overall case-fatality rate was 25% with the highest rate in chronic kidney disease (CKD) patients. Conclusion: Children with preexisting renal disease got affected slightly at a higher percentage than the normal child, and those who got immunosuppressive therapy, especially rituximab, had milder symptoms. Children with CKD had fatal outcomes.

Serum Creatinine Levels Have Been Shown to Accurately Predict in-Hospital Mortality in Individuals who have Been Effectively Treated with PPCI

Objective: The purpose of this study was to assess the predictive value of serum creatinine for in-hospital mortality among patients who had acute coronary syndromes. Study Design: An observational study Place and Duration: This observational study was conducted at Department of Cardiology, Rashid Latif Medical College, Lahore and Nowshera Medical College, Nowshera, KPK in the duration from 1st May, 2022 to 31 October, 2022. Methods: Total 198 patients had acute coronary syndromes who underwent successful primary percutaneous coronary intervention (PCI) were included. Patients were aged between 25-80 years. After receiving written consent, we recorded the subjects' ages, sexes, BMIs, and diagnoses in detail. Within 12 hours of an AMI diagnosis, serum creatinine levels were taken. Patients were split into two groups based on their serum creatinine levels upon admission. There are two categories, those with high levels of serum creatinine (over 1.3 mg/dL) and those with normal levels (below 1.3 mg/dL). Life expectancy at death was measured at one year. All of the information was analyzed with SPSS 22.0. Results: There were majority 140 (70.7%) males and 58 (29.3%) females in this study. Mean age of the patients was 55.18±11.24 years and had mean BMI was 24.6±14.52 kg/m2. Mean serum urea level was 37.3±0.22 mg/dL. Diabetes found in 40 (20.2%) cases and frequency of hypertension was 82 (41.4%). Anterior myocardial infarction was found in 79 (39.9%) cases followed by Inferior MI in 73 (36.9%) cases and non-ST MI in 46 (23.2%) cases. Mean left ventricular ejection fraction (LVEF) was 45±7.17 %. We found elevated serum creatinine in 37 (18.7%) cases and normal creatinine in 161 (81.3%) cases. Mortality in elevated group was higher found in 10 (27.02%) cases and as compared to normal group 8 (4.96%). Conclusion: The results of this study indicate that patients with AMI who had even slightly raised serum creatinine levels at admission have a significantly higher risk of dying within a year. Keywords: Myocardial Infarction, Comorbidities, Primary percutaneous coronary intervention, Mortality, Serum Creatinine

Evaluation Effect of Tenofovir Alafenamide (TAF) in Long-Term Therapy for Chronic Hepatitis B: A Systematic Review

Background: Tenofovir alafenamide (TAF) is phosphonamidate prodrug of tenofir that inhibits hepatitis B virus and HIV type-1 reverse transcription. TAF more stable form in plasma than tenofovir disoproxil fumarate (TDF) as choice treatment before. TAF in long-term treatment also significantly reduced bone mineral density (BMD) and raised serum creatinine, as well as improved markers of renal tubular function. This study aims to review the long-term therapy of TAF effect in body weight gain, BMD, renal function, lipids profile, ALT normalization, and HBeAg loss.Method: The data was taken from Pubmed, ScienceDirect, and Cochrane Library. We found 363 articles from databases. The articles related to long-term therapy in chronic hepatitis-B and adjusted according to restriction criteria. Articles selection using PRISMA flowchart and quality test using GRADE method into eligible articles.Results: We selected articles that eligible for systematic review with different GRADE recommendation which were 4 high-grade articles, 1 low-grade, and 1 very low-grade article. TAF in long-term therapy showed an increase in BMD (p 0.001), body weight gain (p 0.001), decreased renal dysfunction (CrCl; p 0.0001 and GFR; p = 0.027), and normalized ALT (p = 0.016). However, lipids profile level increase that could increase risk of atherosclerosis and dyslipidemia. There was no significant in HBeAg loss.Conclusion: TAF therapy is favourable therapy in long-term therapy of chronic hepatitis B patients by smaller reduce of BMD, and significant body weight gain, reduce renal dysfunction, good improvement in lipid profile and improving ALT enzymes.

Neuroleptic malignant syndrome secondary to olanzapine, a presentation with severe acute kidney injury requiring hemodialysis: a case report

BackgroundWe present this case to draw attention to the importance of early diagnosis in terms of life-saving, noting that greater awareness is important among healthcare professionals. Our patient developed neuroleptic malignant syndrome (NMS) after his neuroleptic drug dosage was increased. His condition was complicated by acute kidney injury (AKI) which required hemodialysis. The uniqueness of this case is that the causative agent of NMS is an atypical antipsychotic, and atypical antipsychotics are generally considered to be safer than typical antipsychotics.Case presentationA 31-year-old Chinese man with underlying schizophrenia presented to our hospital with aggressive behavior. He was admitted to the psychiatric hospital and started on his regular medications, with an increase in the dose of olanzapine tablet from 5 to 10 mg daily. After 5 days in the ward, the patient was noted to have high fever, restlessness, confusion, increased muscle rigidity, tachycardia and tachypnoea. Antipsychotic therapy was stopped in view of suspected NMS. The first laboratory test for serum creatine kinase (CK) showed a markedly high level of this molecule. His renal profile showed raised serum creatinine in comparison to 2 months prior when the baseline serum creatinine was within the normal range. A diagnosis of NMS with AKI was made. Although the patient was given adequate intravenous fluid hydration with close monitoring of urine output, his renal function did not show improvement but continued to show a worsening trend. In view of this, he was started on urgent hemodialysis. The patient was dependent on intermittent hemodialysis before his AKI showed complete recovery. After 2 weeks, his blood test results returned to normal. He was discharged well.ConclusionNeuroleptic malignant syndrome is a life-threatening iatrogenic medical emergency in which high index of clinical suspicion is required for diagnosis and prompt treatment.

Congenital anterior urethral valves and diverticulum: A case series and association with posterior urethral valves

There is limited data regarding long-term results and associated complications in patients with anterior urethral valve (AUV) and diverticulum (AUD). We retrospectively reviewed AUV/AUD cases managed by us between the year 2002-2020. Presentation, investigations, management, concomitant posterior urethral valves (PUV) and pre-operative characteristics predisposing to long-term poor renal outcome were assessed. There were 27 patients [AUV (n=11); AUD (n=16)] with 5 having concomitant PUV. All presented with poor urinary stream and dribbling at a median age of 1-year (5 days-12 years). More patients with AUD (9 of 16, 56.3%) especially with concomitant PUV presented at ≤1-year-age as compared to those with AUV (4 of 11, 36.4%). Concomitant PUV and AUD cases (n=3) had characteristic micturating cystourethrography (MCUG) features. (Fig. 1A) Retrograde urethrography delineated the valve and distal urethra dimensions better (Fig.1B, C). Urethral hypoplasia distal to the valve (n=4) urethral duplication (n=1) were associated (Fig.1D). Syringocele was ruled out in proximal AUD by absence of filling defect on MCUG and appearance of urethral walls on urethrocystoscopy. Serum creatinine > 1mg/dL (n=5), trabeculated bladder (n=12), and vesicoureteral reflux (VUR) (n=12) was noted at presentation. Diverticulum/valve excision (n=13, 48.2%), fulguration alone (n=12, 44.4%) and primary urinary diversion (n=2, 7.4%) were performed. Follow up (range:3 mo-19 years), showed deranged renal function tests (n=6), VUR (n=4), impaired renal function on scans (n=8), and lower urinary tract dysfunction (n=7). Outcome with and without associated PUV was similar. Long term results were better in AUV compared to AUD. Pre-operative raised serum creatinine (>1mg/dL), trabeculated bladder, non-dilated posterior urethra on MCUG and bilateral impaired renal function on scans had significant association with follow up eGFR less than 60ml/kg/min. Co-existing PUV and AUD present earlier and have specific imaging findings. In proximal AUD, possibility of syringocele should be kept in mind, as they have similar presentation and imaging. Concomitant PUV did not alter prognosis. Secondary effects on bladder and renal function were more with AUD. Follow up eGFR less than 60ml/kg/min was associated with pre-operative elevated serum creatinine, trabeculated bladder, non-dilated posterior urethra, and bilateral impaired renal function on scans.