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Acute-on-chronic liver failure (ACLF) is a rapidly progressive illness with high short-term mortality. Timely liver transplant (LT) may improve survival. We evaluated various indices for assessment of the severity of liver failure and their application for eligibility and timing of living donor LT (LDLT). Altogether 1021 patients were analyzed for the severity and organ failure at admission to determine transplant eligibility and 28 day survival with or without transplant. The ACLF cohort [mean age 44 ± 12.2 years, males 81%) was of sick patients; 55% willing for LT at admission, though 63% of them were ineligible due to sepsis or organ failure. On day 4, recovery in sepsis and/or organ failure led to an improvement in transplant eligibility from 37% at baseline to 63.7%. Delay in LT up to 7 days led to a higher incidence of multiorgan failure (p

Multiple predictive models of mortality exist for acute-on-chronic liver failure (ACLF) patients that often create confusion during decision-making. We studied the natural history and evaluated the performance of prognostic models in ACLF patients.Prospectively collected data of ACLF patients from APASL-ACLF Research Consortium (AARC) was analyzed for 30-day outcomes. The models evaluated at days 0, 4, and 7 of presentation for 30-day mortality were: AARC (model and score), CLIF-C (ACLF score, and OF score), NACSELD-ACLF (model and binary), SOFA, APACHE-II, MELD, MELD-Lactate, and CTP. Evaluation parameters were discrimination (c-indices), calibration [accuracy, sensitivity, specificity, and positive/negative predictive values (PPV/NPV)], Akaike/Bayesian Information Criteria (AIC/BIC), Nagelkerke-RThirty-day survival of the cohort (n = 2864) was 64.9% and was lowest for final-AARC-grade-III (32.8%) ACLF. Performance parameters of all models were best at day 7 than at day 4 or day 0 (p 0.05 for C-indices of all models except NACSELD-ACLF). On comparison, day-7 AARC model had the numerically highest c-index 0.872, best accuracy 84.0%, PPV 87.8%, RAPASL-ACLF is often a progressive disease, and models assessed up to day 7 of presentation reliably predict 30-day mortality. Day-7 AARC model is a statistically robust tool for classifying risk of death and accurately predicting 30-day outcomes with relatively lower prediction errors. Day-7 AARC score 12 may be used as a futility criterion in APASL-ACLF patients.

Background Globally, congenital toxoplasmosis remains a significant cause of morbidity and mortality, and outbreaks of T. gondii infection represent a major public health threat, especially in developing countries. Evidence in the literature indicates that only a few studies have been conducted on the incidence of maternal and congenital toxoplasmosis in Saudi Arabia. This prospective study aims to measure the overall incidence of congenital toxoplasmosis, both patent and ‘silent’ infection, among pregnant women in the Eastern Province of Saudi Arabia. The study would attempt to relate the cord blood results with the time of seroconversion in the mother, underlining the importance of early intervention in such cases. Methods Five hundred paired maternal/cord blood samples were tested for anti-Toxoplasma IgG or IgM antibodies. Samples were collected during delivery from mother and newborn (cord blood) from November 2011 to May 2012. Only positive for anti-Toxoplasma IgG or/and IgM cord blood was processed for real-time PCR for confirmation. The age of mothers ranged from 16 to 45 years. Results The sample subjects were tested during child delivery for specific IgG and IgM antibodies against Toxoplasmosis, of which 21.0% (n = 105) mother/baby pairs were found serologically positive for anti-Toxoplasma IgG antibodies. The rate of maternal seropositivity for anti-Toxoplasma IgM antibodies was found among 4 participants (0.8%), who were also seropositive for anti-Toxoplasma IgG antibodies. None of the children tested positive for anti-Toxoplasma IgM antibodies, even those born to mothers with IgM positive. All 105 cord blood tests in the study sample were confirmed negative by real-time PCR. The seroprevalence of Toxoplasma IgG antibodies increased with maternal age, parity, and was significantly higher in women who gave birth to children with congenital anomalies (p = 0.008). Conclusion The findings of the current study indicate a dire need to develop and implement preventive programs against Toxoplasma gondii infection, as well as a health education program on how to avoid toxoplasmosis for all seronegative women during pregnancy.

Acute-on-chronic liver failure (ACLF) is a progressive disease associated with rapid clinical worsening and high mortality. Early prediction of mortality and intervention can improve patient outcomes. We aimed to develop a dynamic prognostic model and compare it with the existing models. A total of 1402 ACLF patients, enrolled in the APASL-ACLF Research Consortium (AARC) with 90-day follow-up, were analyzed. An ACLF score was developed in a derivation cohort (n = 480) and was validated (n = 922). The overall survival of ACLF patients at 28 days was 51.7%, with a median of 26.3 days. Five baseline variables, total bilirubin, creatinine, serum lactate, INR and hepatic encephalopathy, were found to be independent predictors of mortality, with AUROC in derivation and validation cohorts being 0.80 and 0.78, respectively. AARC-ACLF score (range 5–15) was found to be superior to MELD and CLIF SOFA scores in predicting mortality with an AUROC of 0.80. The point scores were categorized into grades of liver failure (Gr I: 5–7; II: 8–10; and III: 11–15 points) with 28-day cumulative mortalities of 12.7, 44.5 and 85.9%, respectively. The mortality risk could be dynamically calculated as, with each unit increase in AARC-ACLF score above 10, the risk increased by 20%. A score of ≥11 at baseline or persisting in the first week was often seen among nonsurvivors (p = 0.001). The AARC-ACLF score is easy to use, dynamic and reliable, and superior to the existing prediction models. It can reliably predict the need for interventions, such as liver transplant, within the first week.

Background: Urinary Tract Infection (UTI) is a common infection in nephrotic syndrome and have a propensity for long term renal damage. It may be an important cause of poor steroid response. The objective is to study the frequency and etiological organisms of urinary tract infection in idiopathic nephrotic syndrome children.Methods: This Comparative cross-sectional study was conducted in the Pediatric ward of Chittagong Medical College Hospital, Chittagong from 01.01.2009 to 31.12.2009. 52 nephrotic syndrome children diagnosed by serum albumin, serum cholesterol and 24 hours total urinary protein or protein creatinin index were included. After elaborate clinical evaluation, urine for R/M/E and C/S was done in all patients. Data regarding pyuria, hematuria, etiological organisms were analyzed by statistical method.Results: UTI was found in 30.8% nephrotic children and in majority cases (68.8%) they were asymptomatic. Male female ratio among UTI patients was 1:1. Mean serum cholesterol in nephrotic syndrome with UTI was higher than that of children without UTI (418.94 mg/dl vs 352.03 mg/dl, p value < 0.05).Pyuria had poor association with definite UTI (p value > 0.05). E-coli was the commonest organism isolated in urine culture followed by klebsiella.Conclusion: UTI is one of the most common infections in nephrotic syndrome and may be asymptomatic. It should be screened in every nephrotic child routinely.Chatt Maa Shi Hosp Med Coll J; Vol.15 (2); Jul 2016; Page 41-44

Background: Hydatid disease is a zoonotic disease caused by Echinococcus granulosus. In humans, lungs are the second common organ involved after liver. Surgical treatment is considered gold standard. Different surgical techniques has developed. However, head to head comparison of these has not yet been done in our country. Methods: A prospective randomized study was done in the Department of Thoracic Surgery, National Institute of Diseases of the Chest and Hospital between July 2004 and June 2006. Patients with pulmonary hydatid disease were offered two surgical techniques, enucleation with or without capitonnage. Group I was offered enucleation of cyst with closure of bronchial opening. Group II was offered enucleation of cyst with capitonnage. Results: 43 patients (age range 7 – 45 years, mean 25 years) having hydatid disease of the lung were enrolled in the study. Group I involved 23 patients, Group II involved 20 patients. There were 15 males and 28 females. Presenting complaints were chest pain [76.7%], cough without sputum [46.5%], haemoptysis [30.2%], respiratory distress [27.9%], cough with sputum [11.6%] while 23.2% were asymptomatic. The right lung was affected more [65.11%] than left lung [23.3%] and bilateral disease was found in 11%. Postoperatively, in group I, 12.9% developed air-leakage, 4.3% wound infection. In group II, 20% developed air-leakage, 5% haemorrhage and 5% empyema. None of the patient in the former group had to stay in the hospital for >15 days, where as 10% of the latter group had to stay in hospital for >15 days. The hospital stay was found to be significantly higher in the latter group compared to the former group (p < 0.05). There was no significant difference between groups in the development of haemorrhage, empyema, wound infection and broncho-pleural fistula. There was also no significant difference in the rate of recurrence. No anaphylaxis or death occurred in either group. Conclusion: Capitonnage offered no added benefit rather increasing complications. So enucleation followed by closure of bronchial opening may be a reasonable approach. DOI: http://dx.doi.org/10.3329/jdmc.v23i1.22702 J Dhaka Medical College, Vol. 23, No.1, April, 2014, Page 94-101

Background: Non-alcoholic fatty liver disease (NAFLD) is becoming a public health problem with increasing incidence and it has been shown to be associated with diabetes, dyslipidemia, obesity and metabolic syndrome and ultimately puts more than half the world’s population at risk of developing NAFLD/NASH/cirrhosis in the coming decades. The importance of detection of patients with NAFLD is to intervene the associated factors and avoid transformation to more severe forms of the disease.Methods: An observational case control study was carried out at Medicine Department, Dhaka Medical College Hospital (DMCH), Dhaka, during the period of August, 2011 to June, 2012. A total number of 100 consecutive patients and 100 healthy controls was approaches DMCH were enrolled in this study. Out of 100 NAFLD patients only 20 patients gave consent for liver biopsy to see the extent of liver damage.Result: Less physical activity, Obesity, mean blood pressure, Diabetes, TG, TC were significantly (P5) was found in 9(45%) of the NAFLD group.Conclusion: Significant proportion of NAFLD patient suffers from NASH which is alarming and they have potential for the development of advanced liver disease. So recognition of these risk factors in patients of NAFLD can help in early implementation of strategies that halt the progression of this disease. DOI: http://dx.doi.org/10.3329/jom.v14i2.19665 J Medicine 2013, 14(2): 143-148

Aims: Asian Pacific Association for the Study of Liver (APASL) acute-on-chronic liver failure (ACLF) Research Consortium (AARC) proposed new prognostic scoring system of ACLF in cluding lactate. However, lactate is not routinely checked in clinical practice of patient with ACLF in Korea. Therefore, we aimed to investigate the predictive accuracy of lactate-free AARC-ACLF score for predicting short-term mortality in patients with alcoholic liver disease. Methods: A total of 749 ALD patients who had liver failure (bilirubin≥5mg/dL and INR≥1.5) in AARC database were in vestigated. Diagnostic performances for short-term mortality were compared according to the area under receiver operating characteristic (AUROC) curve. Predictive accuracy of lactate-free AARC-ACLF score were compared with other prognostic scores in 143 ALD patients with liver failure and 60 ALD patients with ACLF according to AARC definition in Korean ACLF cohort. Results: Among 749 patients, 30-day and 90-day mortality were 40.3% and 51.5%. There were no significant differences in AUROC for predicting 30-day and 90-day mortality between AARC-ACLF score and lactate-free AARC-ACLF score (30-day mortality: 0.752 vs. 0.751, P=0.918, 90-day mortality: 0.728 vs. 0.736, P=0.346). In Korean ACLF cohort, the AUROCs of lactate-free AARC-ACLF score for predicting 28-day and 90- day mortality were 0.861 and 0.846 in ALD with liver failure, and 0.884 and 0.874 in ALD patients with ACLF according to AARC definition, respectively. In Korean ALD patients with liver failure and ACLF according to AARC definition, diagnostic per formance of lactate-free AARC-ACLF score for predicting 28- day and 90-day mortality was comparable to those of Model for End-stage Liver Disease (MELD), MELD-Na, Chronic Liver Failure-Sequential Organ Failure Assessment score. Conclusions: Lactate-free AARC-ACLF score is as excellent as AARC-ACLF score in predicting short-term mortality in ALD patients with liver failure of AARC database and Korean ACLF cohort.

There are paucity of information about prevalence and risk factor of hepatitis C virus (HCV) in Bangladesh.Blood was collected from 1018 randomly selected subjects from a semi-urban area of Bangladesh. Anti-HCVs were checked in the blood twice using a third-generation commercial kit. The data of the questionnaires were analyzed to find possible risk factors.Nine of the 1018 subjects (88%) were tested positive for anti-HCV. The HCV-positive subjects were28 years old. Major risk factors for HCV infection were treatment by unqualified and traditional practitioners, history of mass-vaccination against smallpox, hair cutting and shaving by barbers, and body piercing. However, known risk factors such as blood transfusion, surgery, invasive therapy, and intravenous drug use were not detected in any HCV-infected subjects.Control of HCV infection in Bangladesh may be difficult because the risk factors are related to normal tradition and culture of Bangladeshi people.

Introduction: Hepatitis C virus (HCV) is a leading cause of chronic liver disease worldwide including Bangladesh. Approximately 0.84% of our population is infected with HCV. Genotypes of HCV are important in the determination of treatment duration and in predicting the response to treatment in HCV infection. Methodology: 61 consecutive patients who presented to us with chronic hepatitis C (CHC) and who could afford treatment and having no features of decompensation were included in the study. Results: Of the 61 study subjects, 46 were males and 15 females. They were between 12 and 70 years of age. Of them 41% had genotype 3, 31% had mixed genotypes 3 + 4 and 21% had genotype 1. Patients also had genotypes 2, 4, 5 and mixed genotypes 5 + 6, the figure being 1.6% in each case. Conclusion: Genotype 3 is the commonest HCV genotype in Bangladesh, while we also have a high prevalence of mixed HCV genotypes.

Autoimmune hepatitis is defined as chronic liver disease of unknown aetiology with aberrant autoreactivity and genetic predisposition. It is characterized by female predominance, circulating auto-antibodies, hypergammaglobulinaemia and association with HLA DR3 and HLA DR4 [1]. Differential diagnosis includes chronic viral hepatitis, drug induced hepatitis and alcohol. We present two patients with autoimmune hepatitis representing the two extremes of hepatic involvement in this condition. The first patient is a young lady who was diagnosed with autoimmune chronic hepatitis. The second patient, on the other hand, is an elderly gentleman who presented to us with autoimmune hepatitis-related decompensated cirrhosis of liver.

Background/Aims: Preferential production of immunoregulatory cytokines may play an important role in the pathogenesis of chronic hepatitis B. Patients with chronic hepatitis B infection were evaluated to determine whether serum interleukin-10 (IL-10) levels were changed and whether the degree of these changes in serum levels correlated with HBV DNA levels, histologic activity index (HAI) or serum aminotransferase levels (ALT). Methodology: 15 patients diagnosed of chronic hepatitis B (wild type) with raised ALT, 15 inactive HBsAg carriers, 15 healthy people with resolved acute hepatitis B, and 15 healthy controls without any hepatitis marker positivity were included in the study. Serum IL-10 levels were measured. The associations between liver pathology, HBV DNA and ALT levels were assessed. Result: IL-10 is elevated more in chronic hepatitis B with positive HBeAg and raised ALT in comparison to asymptomatic carrier, resolved acute hepatitis B and control. Conclusions: IL-10 production is increased in chronic hepatitis B patients with HBeAg positivity and raised ALT as compared to other groups (p < 0.01). No correlation between HBV DNA, HAI or ALT could be established through this study. However, as IL-10 is increased in chronic hepatitis B infection with HBeAg positivity, the HBe antigen may be responsible for the raised IL-10 levels.

152 © 2011, INASL Recent studies indicate that HEV has replaced hepatitis A as the dominant etiological agent of acute hepatitis in Bangladesh. This study has shown that patients of chronic liver diseases in Bangladesh and other developing countries should be cautious about contaminating food and water that may contain HEV. Also, the patients should consult with physicians as soon as they feel anomaly in their physical conditions for containment of ACLF.

Introduction: Liver cirrhosis and renal failure are two diseases that may occur in conjunction due to mutually related pathological processes. Liver cirrhosis causes portal hypertension that ultimately causes splanchnic vasodilatation leading to hepatorenal syndrome. Hypovolemia is another cause of renal failure in liver cirrhosis. The study presented here was done to assess the renal functions in patients with liver cirrhosis with ascites. Materials and methods: Sixty patients with uncomplicated cirrhosis of liver with ascites with normal renal function were included in this study. All patients were examined physically and biochemical. Main biochemical variables were serum bilirubin, serum albumin, serum creatinine and prothrombin time. Enrolled patients were categorized according to Child-Pugh class B and C. Serum creatinine levels were measured in all cases. Results: Mean level of serum albumin, serum creatinine and prothrombin time among Child B and C classes of liver cirrhosis patients were 27.36 vs 26.84 gm/dl, 0.79 vs 0.93 mg/dl, 15.97 vs 19.26 seconds respectively. No statistically significant change in the serum creatinine level among Child B and C were noticed. Conclusion: This study showed that the effect of liver cirrhosis on renal dysfunction would be minimal, if any.

Introduction ‘Hepatology’, as an independent discipline of medical science, has recently been established in Bangladesh. The aim of this study was to formulate the distribution of pattern of liver diseases in this country. Materials and methods In this retrospective study, data regarding patients of liver diseases from the seven different administrative divisions of Bangladesh between January 2012 and 2013 were compiled. Results The study included 59,227 patients (age ranged 15-95 years). Majority of the patients were males (67.9%). Although all patients appeared at the department of hepatology, 13.2% were diagnosed with liver diseases, but a vast majority of patients (77.35%) were suffering from nonulcer dyspepsia or irritable bowel syndrome. Patients with liver diseases were mostly suffering from chronic liver diseases (CLDs) (37 -69%). Complication of CLD, like hepatic encephalopathy, was less frequent in regions with better healthcare system. Nonviral infections, like liver abscess and biliary ascarisis, were not uncommon. Acute hepatitis was another very common entity and contributed to approximately 20% cases. Conclusion This study provides insight about heterogeneous distribution pattern of liver diseases in different regions of Bangladesh. How to cite this article: Rahman S, Ahmed MF, Alam MJ, Debnath CR, Hoque MI, Hussain MM, Shamsul Kabir AKM, Karim MF, Khondokar FA, Mahtab MA, Masud MG, Mollick MKU, Moben AL, Noor-E-Alam SM, Podder PK, Raha AK, Rahim MA, Rashid MHO, Zaki KMJ, Akbar SMF. Distribution of Liver Disease in Bangladesh: A Cross-country Study. Euroasian J Hepato-Gastroenterol 2014;4(1):25-30.

Alveolar hydatid disease (AHD) in mice, caused by Echinococcus multilocularis, is characterized by restrictive and metastasizing progressive growth phases. In experimentally induced infections, neither inoculum size (5, 50 or 250 viable cysts) nor the route (intraperitoneal/subcutaneous) of infection altered the course of disease as measured by the size of the larval cyst mass (LCM) produced. Spleen weight and amyloid deposition were also shown to be independent of the route or size of inoculum. Inoculation of a soluble parasite protein extract (AHC-EXT) induced amyloid deposition, with a dose-dependent threshold. These results support our postulate that soluble component(s) of the LCM are the major factor in the pathogenesis of AHD.

Asymptomatic chronic hepatitis B virus (HBV) carriers are at risk of developing complications of liver disease, but these patients are not recommended for treatment with antiviral drugs. In fact, antiviral drugs are ineffective in these patients in the immune tolerance phase, when they have inadequate levels of host immunity. We postulated that combination therapy of an immune modulator and antiviral drugs may have potential to help these patients. Twenty-five patients with incidentally-detected asymptomatic chronic HBV were immunized with hepatitis B vaccine (10 microg of hepatitis B surface antigen) intramuscularly five times (at 0, 1, 2, 6, and 12 mo) to induce HBV-specific immunity. The patients were also treated with lamivudine (100 mg) daily for 12 mo. The combination therapy was safe for all patients with asymptomatic chronic HBV, and no increases in alanine aminotransferase or liver damage were detected in any patient. Although all of the patients were expressing HBV DNA in their serum before treatment, HBV DNA became undetectable in 16 of 25 patients, and was reduced in 9 of 25 patients at the end of the combination therapy. Combination therapy with the antiviral agent lamivudine and an immune modulator (hepatitis B vaccine) represents a potential therapeutic option for the control of HBV without liver damage in asymptomatic chronic HBV carriers.

Background: Hepatitis C virus is encountered sporadically in Bangladesh. It results in a wide range liver diseases, with asymptomatic acute hepatitis rarely at one end to HCC at the other end of the spectrum. Methods: 1018 individuals of different age groups and sex with varied religious, educational and social backgrounds were tested for anti-HCV by ELISA. Before testing, blood samples were preserved at -20°C. The study was conducted in a semi-urban location on the outskirts of Dhaka. Results: 0.88% tested positive for anti HCV. None of them tested positive for HBsAg. There was a male predominance and those who tested positive were mostly between 17 and 50 years of age. Major risk factors for exposure to HBV appeared to be injudicious use of injectable medications, treatment by unqualified, traditional practitioners, mass-vaccination against cholera and smallpox, barbers and body piercing. Conclusion: HCV remains an important cause of morbidity and mortality in Bangladesh. Key words: HCV; prevalence; general population; Bangladesh. DOI: 10.3329/bsmmuj.v2i1.3705 BSMMU J 2009; 2(1): 14-17

A case of severe acute hepatitis E was treated with antiviraldrugs. The clinical course and prognosis would be reported.Abbreviations: HEV: Hepatitis E virus; ALT: Alanineaminotransferase.

Patient initials or identifier number KS ### Relevant clinical history and physical exam Patient KS, 73 years male CABG 10 years back Angina on exertion NYHA class III ### Relevant test results prior to catheterization Echo: Hypokinesia LAD/RCA territory, LVEF 40% ### Relevant

Background: In general, it is assumed that patients with chronic hepatitis B virus (HBV) infection with high viral load exhibit increased liver damages. Accordingly, the treatment guidelines emphasize on reducing viral load in chronic HBV carriers. The ethical and scientific basis of these observations was mainly accumulated from investigations from developed countries of the world. More than 80% chronic HBV carriers live in the developing nations of the world, but little is known about relationship between HBV viral load and extent of liver damages in these countries. In this study, we addressed this issue to provide insights about this. Methods: In this retrospective study we reviewed the records of 210 chronic hepatitis B (CHB) patients from our pool of 561 Bangladeshi CHB patients. All of these 210 patients had low HBV DNA (5 copies/ml by PCR). Of them 16 were HBeAg +ve and rest 194 HBeAg -ve. They have also been tested for other serologic markers of HBV (i.e. HBsAg, anti-HBe), HCV (i.e. anti-HCV) and serum alaninetransaminase (ALT) level. All patients also underwent per-cutaneous liver biopsy. Results: 37.5% (6/16) HBeAg +ve patients with low HBV DNA had significant hepatic necro-inflammation (HAI-NI ≥7), whereas this figure was 31.44% (61/194) in case of HBeAg -ve patients. On the other hand significant hepatic fibrosis (HAI-F ≥3) was observed in 31.25% (5/16) and 14.4% (28/194) in HBeAg +ve and -ve patients respectively. Conclusion: This study shows that a correlation could not be established between viral load and liver damage in patients with CHB in Bangladesh. A significant percentage of patients with low HBV DNA may have marked hepatic necro-inflammation and fibrosis, more so in case of HBeAg +ve CHB. Further study may be needed to find out the influence of other factors on liver damages in CHB patients in developing nations like Bangladesh, where about 8 million chronic HBV carriers are living. Most of these patients have not been characterized and treatment modalities have not been defined for them. Our study may suggest the research direction for management of these cases. Key Words: Low HBV DNA; Chronic hepatitis B; Hepatic necro-inflammation; Hepatic fibrosis.DOI: 10.3329/bsmmuj.v1i1.3693 BSMMU J 2008; 1(1): 19-21

Over 350 million people worldwide are infected with Hepatitis B virus (HBV) and globally around 1 million die due to consequences of this infection annually. Bangladesh belongs to the intermediate prevalence region for HBV infection. Here the lifetime risk of acquiring HBV is between 20-60%. Studies from our as well as other groups have shown that HBV is responsible for 31.25% cases of acute hepatitis, 76.3% cases of chronic hepatitis, 61.15% cases of cirrhosis of liver and 33.3% cases of hepatocellular carcinoma (HCC) in Bangladesh. doi: 10.3329/blj.v1i1.2619 Bangladesh Liver Journal Vol.1(1) 2009 p.6-12

Left atrial ball valve thrombus is an unusual condition, especially in patients with normal mitral valve. In the present case, we describe a 61-year-old female with restrictive cardiomyopathy who presented with a large left atrial ball valve thrombus, which subsequently embolized to right carotid artery and was treated with intravenous thrombolysis. This case provides useful insight into the genesis of such thrombi and highlights management dilemmas of a rare clinical problem.