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Therapeutic plasma exchange (PLEX) removes toxins and different mediators from plasma in patients with acute-on-chronic liver failure (ACLF).To observe the safety and outcome of PLEX in ACLF patients in Bangladesh.Twenty-eight patients with ACLF attending Bangabandhu Sheikh Mujib Medical University from September 2020 to May 2021 were enrolled in the study. The patients were given different treatment modalities and followed up for 3 months or up to death. The patients were divided into two groups, each containing 14 patients of ACLF. One group of 14 patients received standard medical therapy (SMT) for ACLF and the second group of 14 patients received SMT plus PLEX.At 90 days, a total of 13 patients (46.43%) survived, of them 8 (57.1%) belonged to PLEX group and 5 (35.7%) were from SMT group. Serum bilirubin and ALT declined significantly after 7 and 30 days but not after 90 days in PLEX group in comparison to SMT group (The study presented here has shown that PLEX is safe in Bangladeshi in ACLF patients, but its efficacy remains to be checked in large-scale randomized trial or in combination therapy with other procedures in ACLF patients.Al Mukit A, Al Mahtab M, Rahim MA

Introduction Patients with acute-on-chronic liver failure (ACLF) have low survival without liver transplantation. Granulocyte colony-stimulating factor (G-CSF) improves survival in ACLF and erythropoietin (EPO) promotes hepatic regeneration in animal studies. The aim of this study is to determine whether coadministration of G-CSF and EPO improves the outcome in ACLF. Methods The study was conducted in the Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka. Consecutive patients with ACLF were randomly assigned into group A and group B. Group A patients received subcutaneous G-CSF (5 mcg/kg/d) for 6 days and subcutaneous EPO (40 mcg/wk) for 4 weeks and group B patients received only standard medical care (control group). All patients were followed up for 3 months. The primary end point was to see survival at 3 months. Results Patients had comparable baseline characteristics; hepatitis B virus infection was the commonest etiology of ACLF as both acute and chronic events. A higher proportion of patients were male in both groups. The survival was higher in group A than in group B at the end of 3 months (36.4% vs 29.4%; p = 0.457), but this was not statistically significant. Regarding complications, hepatorenal syndrome was higher in group B than in group A (36.7% vs 41.7%). In both the groups, Child-Turcotte-Pugh score and model for end-stage liver disease scores were similar before treatment and improved during follow-up. Conclusion This is one of the early human studies that demonstrate potential hepatic regeneration using EPO in ACLF patients. Further study with a larger cohort will be needed to reproduce the results of the present work. How to cite this article Haque Md N, Al-Mahtab M, Das DC, et al. Effect of Granulocyte Colony-stimulating Factor and Erythropoietin on Patients with Acute-on-chronic Liver Failure. Euroasian J Hepato-Gastroenterol 2020;10(2):64-67.

Background: Chronic hepatitis is inflammation of the liver that lasts at least 6 months. Knowledge of aetiology and pattern of development of complications of chronic liver disease will help in designing optimal and cost effective control measures of the disease. Methods: The present study was performed to find out the aetiological factors in patients of chronic liver disease. This was a retrospective, cross-sectional study. Patients attending Hepatology Green Unit, Bangabandhu Sheikh Mujib Medical University, Dhaka in 2014 with chronic hepatitis were included. Results: Total 3250 patients were studied, 2310(71.08%) males and 940(28.92 %) females. Most of the patients 1547 (47.6%) belong to age group of 18 to 30 years followed by 922 (28.37%) who were between the age group of 31-40 years. Majority of patients 2012(61.91%) had HBV infection, 1095(33.69%) had nonalcoholic steatohepatitis ( NASH), 81(2.49%) had HCV infection, 7(0.22%) had alcohol abuse, 28(0.86%) had Wilson’s disease, 19(0.58%) had autoimmune hepatitis and no aetiological factors were recorded in 8(0.25%) patients. However in case of females 52.55 % (494/940) due to NASH, while 40.21 % (378/940) due to HBV. Conclusion: HBV infection is the major risk factor for chronic liver disease and NASH challenges HBV in our patients.Bangladesh J Medicine Jan 2017; 28(1) : 24-27

The Budd–Chiari syndrome (BCS) is a rare disorder due to chronic liver disease (CLD), which is caused by the obstruction of hepatic venous outflow that can be located at any place from the small hepatic venules up to the entrance of the inferior vena cava (IVC) into the right atrium. Among the causes of BCS, the rarer one is coagulation factor deficiencies. Here, we report a case of BCS associated with deficiency of protein C resulting in thrombus in IVC. The patient was a 50-year-old male, who had been suffering from recurrent abdominal and leg swelling for a long period of 7 years. He was evaluated thoroughly, and other causes of liver cirrhosis were excluded. How to cite this article Begum R, Al Mahtab M, Al Mamun A, Moben AL, Hossain SMS, Das DC, Malakar D, Rashid HO, Roy PP, Rahman S. Budd–Chiari Syndrome Due to Protein C Deficiency: A Rare Disorder to cause Chronic Liver Disease. Euroasian J Hepato-Gastroenterol 2016;6(2):194-197.

Mobilization of bone marrow-derived stem cells by granulocyte colony stimulating factor (G-CSF) supports hepatic regeneration and may augment clinical improvement in patients with acute-on-chronic liver failure (ACLF). The aim of this study is to assess the impact of G-CSF on complications and transplant-free survival in patients with ACLF. Thirty-two patients with ACLF defined by Asian Pacific Association for the Study of the Liver (APASL) criteria were openly randomized to control (group A) or intervention (group B) receiving G-CSF (5 μg/kg/day, for 6 consecutive days) in addition to standard medical therapy with antiviral drugs. The patients were followed for 90 days. Simultaneous use of G-CSF and antiviral drugs in hepatitis B virus (HBV) ACLF significantly improved survival over antiviral drugs alone. Incidence of hepatorenal syndrome and hyponatremia were reduced due to use of G-CSF. Baseline parameters of the two groups of patients were comparable. Child–Turcotte–Pugh (CTP) and Model for End-Stage Liver Disease (MELD), disease severity scores improved in patients treated with G-CSF, with significant difference only for the CTP score at 90 days follow-up. In addition, mean white blood cell (WBC) count at day 15 was significantly higher in G-CSF group in absence of infection compared with control group. G-CSF therapy improved survival and clinical recovery in HBV-ACLF. G-CSF therapy also prevented renal failure and hyponatremia. We strongly recommend use of G-CSF therapy in addition to standard medical therapy.

Objective To compare Knodell and HAI scores in patients with wild type and pre-core/core promoter mutant CHB to see if there is any difference in severity of liver injury between these two types of HBV. Methods We did percutaneous liver biopsies of 155 CHB patients. Of them 102 (65.8%) were infected wild type HBV and the rest 53 (34.2%) were infected with pre-core/core promoter mutant CHB. Results 11/53 (20.8%) patients with pre-core/core promoter mutant CHB had moderate to severe CH (HAI score 8-18). In contrast, moderate to severe CH was seen in 19/102 (18.6%) patients with wild type CHB. Fibrosis score was >2 in 15/53 (28.3%) pre-core/core promoter mutant CHB as opposed to 20/102 (19.6%) patients with wild type CHB. Conclusions The study shows that pre-core/core promoter mutant HBV produces more severe histological liver disease compared to wild type HBV.

This cross-sectional observational study was conducted to evaluate the implication of CA19-9 level in predicting the extent of hepatic fibrosis in patients with chronic hepatitis B (CHB). Fifty treatment-naive patients with CHB were divided into three groups: group I, patients with no fibrosis (F0; n = 3); group II, patients with mild fibrosis (F1; n = 25) and group III, patients with moderate fibrosis (F3; n = 22). There was no significant (p > 0.05) difference in levels of serum bilirubin, serum alanine aminotransferase, alkaline phosphatase, and alpha fetoprotein among groups I, II and III. Also, mean CA19-9 level did not differ among the three groups. It was observed that, for group II, AUC was 42.6%, sensitivity 52%, specificity 32%, considering cut-off value as 2.8 U/ml to predict F1 liver fibrosis. For group III, AUC was 57.7%, sensitivity 68%, specificity 50% considering cut-off value as 3.2 U/ml to predict F3 fibrosis. The levels of CA19-9 level do not seem to have significant predictive implication to assess hepatic fibrosis. How to cite this article Haque MS, Sultana S, Al-Mahtab M, Al-Mamun A, Rahman S. The Value of Serum CA19-9 Levels in predicting Extent of Hepatic Fibrosis in Patients with Chronic Hepatitis B. Euroasian J Hepato-Gastroenterol 2015;5(1):16-18.

Autoimmune hepatitis is often unrecognized and under-diagnosed, especially in our part. Acute on chronic liver failure (ACLF) on the other hand is a newly recognized disease entity describing patients who develop acute liver failure on the background of pre-existing chronic liver disease. Methods: We present an elderly lady who presented to us with history of episodic fever and jaundice over a period of two years. Results: Although initially diagnosed as a case of idiopathic thrombocytopenic pupura (ITP), on further investigation she was finally diagnosed as ACLF (hepatitis B virus induced acute liver failure on autoimmune hepatitis induced cirrhosis of liver).DOI: http://dx.doi.org/10.3329/jom.v14i2.19674 J Medicine 2013, 14(2): 192-194

Introduction: The aim of this study is to compare Knodell and HAI scores in patients with wild type and precore/core promoter mutant CHB to see if there is any difference in severity of liver injury between these two types of HBV. Methods: We did percutaneous liver biopsies of 155 CHB patients. 102 (65.8%) of them were infected wild type HBV and the rest 53 (34.2%) were infected with precore/core promoter mutant CHB. Results: 11/53 (20.8%) patients with precore/core promoter mutant CHB had moderate to severe CH (HAI score 8–18). In contrast, moderate to severe CH was seen in 19/102 (18.6%) patients with wild type CHB. Fibrosis score was >2 in 15/53 (28.3%) precore/core promoter mutant CHB as opposed to 20/102 (19.6%) patients with wild type CHB. Conclusion: The study shows that precore/core promoter mutant HBV produces more severe histologic liver disease compared to wild type HBV.

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.

Background In industrialized countries, the audit has become an integral part of medical care. The experience from developing countries like Bangladesh is still inadequate. This study had been carried out to find out relation among some factors like age, sex, causes, diurenal variation, duration of hospital stay with death and errors in certification process. Materials and methods It was a cross-sectional study conducted at the Department of Medicine, Sir Salimullah Medical College (SSMC) and Mitford Hospital from March 2010 to August 2010. Information of consecutive 100 deaths was collected in a predesigned clinical data sheet within half an hour of every occurrence. Necessary data were collected from hospital case records (admission registrar, case files and death certificates) using structured checklist. Patients who were brought dead were excluded from the study. Results Among 100 deaths, 48% were males (n = 48) and 52% were females (n = 52). Within this group, 66.7% were males and 33.3% were females. First day (within 24 hours of admission) death accounted for 46% (n = 46) of all death and by the second day 23% (n = 23) of all deaths occurred. The highest underlying cause of death was cerebrovascular diseases (29% of total death), infectious disease contributed 20%, chronic liver disease 13%, malignancy 7%, poisoning 6%, cor pulmonale 5%, while others were 20%. Conclusion In this studychronic liver disease was found to be one of the leading causes of death in our hospital and most of them occurred due to hepatic encephalopathy. So, early detection of hepatic encephalopathy and treatment is necessary to reduce hospital mortality. How to cite this article: Abedin MF, Hoque MM, Islam ASMS, Chowdhury MFI, Das DC, Begum SA, Mamun AA, Mahtab MA, Rahman S, Saha AK. Chronic Liver Disease is One of the Leading Causes of Death in Bangladesh: Experience by Death Audit from a Tertiary Hospital. Euroasian J Hepato-Gastroenterol 2014;4(1):14-17.

Percutaneous liver biopsy is a commonly used procedure for management of patients with liver diseases. We studied 107 patients of liver diseases with percutaneous liver biopsy to assess the need and usefulness of post procedure abdominal binder, analgesics, antibiotics or blood transfusion, and safety of the procedure.We selected 107 consecutive patients having clear indication for liver biopsy. Each and every patient underwent percutaneous liver biopsy under uniform technique. The study was performed at the Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh during the period from July 2006 to December 2007.Mean age of the patients was 27.35 years with +/- 7.62 (SD) years. Eighty five of them were male and 22 were female. No abdominal binder or antibiotic was used after the procedure. No analgesic or blood transfusion was required after the procedure.Routine post procedure use of abdominal binder and antibiotic are needless. Analgesics and blood transfusion are not always needed after the procedure. Percutaneous liver biopsy is a safe procedure in expert hands.

Complement 3 is an important component of ascitic fluid total protein, which offers local defence against infection of the ascitic fluid. Hepatic synthesis of complement 3 as well as other proteins and their concentrations in ascitic fluid is significantly reduced in patients with advanced cirrhosis. The level of protein in ascitic fluid in cirrhotic patients with spontaneous bacterial peritonitis was compared with that in patients without spontaneous bacterial peritonitis. Ascitic fluid protein level in spontaneous bacterial peritonitis (n=15) was 1.1 ± 0.3 g/dL whereas it was 1.5 ± 0.5 g/dL in patients without spontaneous bacterial peritonitis (n=15). In conclusion, this study suggests that, ascitic fluid protein level is significantly (p=0.008) reduced in cirrhotic patients who develop spontaneous bacterial peritonitis.Keywords: Ascitic fluid; Bacteria; Cirrhosis; PeritonitisOnline: 11 August 2009DOI: 10.3329/bmrcb.v35i2.3023Bangladesh Med Res Counc Bull 2009; 35: 41-43

Bangladesh is situated in the intermediate prevalence region of hepatitis B virus (HBV). The lifetime risk of acquiring HBV infection in Bangladesh is greater than 40%. It has been estimated that this virus is responsible for 10%-35% cases of acute viral hepatitis, 35.7% cases of fulminant hepatic failure, 33.3%-40.5% cases of chronic hepatitis and 46.8% cases of hepatocellular carcinoma in Bangladesh. The aim of this study is to compare the correlation between HBV DNA load and grade and stage of liver disease in patients with chronic hepatitis B (CHB).Percutaneous liver biopsies done in 159 CHB patients revealed 62.9% (100 patients) had wild type HBV infection and the rest 37.1% (59) had pre-core/core promoter mutant HBV infection. HBV DNA load was measured using PCR in all patients.In the wild type CHB group, 97% (97 patients) had moderate to high HBV DNA load and 3% (3) had low to moderate HBV DNA. In the pre-core/core promoter mutant group, 74.6% (44 patients) had moderate to high HBV DNA and the rest 25.4% (15) had low to moderate HBV DNA. The patients with moderate to high HBV DNA of the patients with wild type CHB, 78.4% (76 patients) had minimal to mild chronic hepatitis (HAI-NI 0-8) and 21.6% (21) had moderate to severe chronic hepatitis (HAI-NI 9-18). 66.6% (2 patients) and 33.3% (1) patients with low to moderate HBV DNA load had minimal to mild and moderate to severe chronic hepatitis respectively. In the moderate to high HBV DNA group, 77.3% (75 patients) patients had minimal to moderate fibrosis (HAI-F 0-2) and 22.7% (22) (HAI-F 3-4) had severe fibrosis to cirrhosis. These figures were 33.3% (1 patient) and 66.6% (2) respectively in the patients with low to moderate HBV DNA load. On the other hand in case of patients with pre-core/core promoter mutant type CHB, in the moderate to high HBV DNA group, 79.5% (35 patients) had minimal to mild chronic hepatitis (HAI-NI 0-8) and 20.5% (9) had moderate to severe chronic hepatitis (HAI-NI 9-18). 93.3% (14) and 6.7% (1) patients with low to moderate HBV DNA load had minimal to mild and moderate to severe chronic hepatitis respectively. In the moderate to high HBV DNA group, 68.2% (30 patients) had minimal to moderate fibrosis (HAI-F 0-2) and 31.8% (14) (HAI-F 3-4) had severe fibrosis to cirrhosis. These figures were 86.7% (13) and 13.3% (2) respectively in patients with low to moderate HBV DNA load.The study shows that high HBV DNA load does not correlate with necro-inflammatory activity or extent of fibrosis in the liver in patients with either wild type or pre-core mutant type CHB.

A cross-sectional study was carried out in the Department of Cardiology, Bangabandhu Sheikh Mujib Medical University, Dhaka in collaboration with Department of Cardiology, CMH, Dhaka Cantonment from June 1999 to May 2000. The patients clinically diagnosed or documented to have coronary artery disease (CAD) requiring coronary angiography (CAG) were included in the study, and were grouped into patients with Cardiovascular Dysmetabalic Syndrome (CDS Group) and without CDS (non-CDS group). The CDS was diagnosed by using the diagnostic criteria defined by Western Working Group, Hawaii, in 1997, Patients with hypertrophic and dilated cardiomyopathies, valvular and congenital heart diseases, and other systemic diseases were excluded frarn the study. OtherCAD risk factors, i,e. Smoking, family history of CAD and physical inactivity were also analyzed. The CAG findings were analyzed in terms of severity and pattern of coronary lesions and were compared between the groups.