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Opportunistic infections, especially invasive fungal infections have emerged as an added health issue in this COVID-era. The dysregulated immune mechanisms in the pathophysiology of COVID-19, its treatment with corticosteroids and other immunomodulatory agents, invasive mechanical ventilation and other forms of ventilatory and oxygen delivery systems, prolonged hospital stay, injudicious use of antimicrobials – all have set the required stages for such infections. Aspergillus spp. and Mucorales are ubiquitous, environmental fungus; may colonize in airways and chronically damaged human lungs, without significant health effects and cause disease, especially in immunocompromized patients. We report case history of a middle aged Bangladeshi man with multiple comorbidities, who presented with fever and respiratory symptoms, four-months after recovery from COVID-19. He had Aspergillus and Mucors on sputum microscopy and cultures; but his response to antibiotics suggested these were colonozations in previously injured lungs by tuberculosis in the form of fibrosis and bronchiectasis. He is well and free of symptoms, two-months since discharge. BIRDEM Med J 2021; 11(3): 218-222

Background Emphysematous pyelonephritis (EPN) is a necrotizing infection of the renal parenchyma, collecting system and/or perinephric tissues, characterized by gas accumulation. We describe clinical, laboratory and imaging characteristics and in-hospital outcomes of patients with EPN. Methods This retrospective observational study was carried out at BIRDEM General Hospital, Dhaka, Bangladesh between 2014 and 2020. Results We followed 20 patients (mean age 49.4 years; females 70%). Risk factors for EPN were diabetes mellitus (in 100%) and renal stones (in 10%). Fever, loin pain, vomiting and dysuria were common. Complications included acute kidney injury (AKI, 70%; mostly stage 1, 78.6%), hyponatraemia (55%) and bacteraemia (15%). Escherichia coli was the most common (60%) urinary isolate. Most patients (80%) had class 2 EPN, with 15% class 3B and 5% class 3A. Besides medical management, four (20%) required surgery (nephrectomy in 3). Nephrectomised patients had a higher radiological class (p = 0.032) and incidence of AKI (p = 0.034). No deaths occurred. Conclusion EPN occurred predominantly in female diabetic patients, who presented with fever, loin pain, vomiting and dysuria. Two-thirds of patients had AKI and one-fifth required surgery, and there were no deaths.

Autosomal dominant polycystic kidney disease (ADPKD) primarily affects the kidneys; cysts can develop in other organs like liver and pancreas and sometimes complicated with formation of arterial aneurysms, brain being the commonest site. Aortic aneurysms can lead to thromboembolic events. Thromboembolism is also a recognized complication of coronavirus disease 2019 (COVID-19). Here, we present case history of an elderly diabetic, hypertensive patient with bilateral renal stones, who presented with gangrene of the left 5th toe and raised serum creatinine. He was later diagnosed as a case of COVID-19, ADPKD with aortic aneurysm, which was complicated with intraluminal thrombus formation and unfortunately, he died in course of treatment. Birdem Med J 2020; 10, COVID Supplement: 115-119

Background: Patients with chronic kidney disease (CKD) are at increased risk for infection because of immunosuppressed state. CKD is an independent risk factor for poor outcome in coronavirus disease 2019 (COVID-19). This study was designed to describe clinical and laboratory parameters of COVID-19 patients with preexisting CKD. Methods: This cross-sectional study was conducted in the Department of Nephrology, BIRDEM General Hospital from July to December 2020. Hospitalized adult patients with CKD not yet on dialysis, who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by reverse transcriptase polymerase chain reaction (RT-PCR), irrespective of symptoms were included in this study. RT-PCR negative cases were excluded. Results: Total patients were 40 (mean age 58.3 years, 52.5% male). Common comorbidities were diabetes mellitus (92.5%), hypertension (67.5%) and ischaemic heart disease (27.5%). Fever, cough, shortness of breath, headache and fatigue were common presenting features. Nearly one-fifth had no COVID-related symptoms. Lymphopenia and high inflammatory markers (ESR, CRP) were common. Sixteen patients were complicated by acute kidney injury, four patients required haemodialysis and 23 had electrolyte imbalance. Most cases were mild to moderate; most were transferred to COVID-dedicated hospitals or discharged with home isolation protocols. Three patients required intensive care unit shifting and two patients died. Conclusion: Most CKD patients had comorbid conditions. Clinical presentation was typical in most cases. Case fatality rate was higher than Bangladeshi statistics. Birdem Med J 2020; 10, COVID Supplement: 23-28

Emphysematous pyelonephritis is a rare, severe form of necrotising infection of the kidneys and peri-nephric tissues with gas accumulation, occurring predominantly among patients with diabetes mellitus. Computed tomography scan can identify the distribution of gas in the affected reno-ureteral units and so establish and classify the diagnosis. We report a case of class 4 emphysematous pyelonephritis with emphysematous cystitis, occurring in a young Bangladeshi male, who presented with features of upper urinary tract infection. He had a background history of fibro-calculous pancreatic diabetes and chronic kidney disease. Imaging also revealed renal stones. He responded to conservative treatment.

Renal impairment is occasionally reported in association with hypothyroidism. We report a case of a middle aged man, who presented with features of rhabdomyolysis and acute kidney injury which was ascribed to underlying undiagnosed hypothyroidism. The etiology is presumed to be multifactorial; hemodynamic effects and a direct effect of thyroid hormone on the kidney play important role. This case enlivens the necessity of assessing thyroid function in cases of unexplained renal failure. Awareness about this rare presentation of a common disease would alert the physician to effectively treat this dreaded yet reversible complication. Birdem Med J 2021; 11(1): 72-74

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: Chikungunya is an emerging viral infection in Bangladesh. This self-limiting febrile illness may have acute life-threating features including cardiomyopathy and encephalitis. Acute kidney injury (AKI) is less well described complication of chikungunya. This study was designed to evaluate risk factors for AKI among patients with chikungunya virus infection. Methods: This case-control study was done in 3 different centers in Dhaka, Bangladesh from July to October 2017. Adult patients (>18 years) with confirmed diagnosis of chikungunya were included in this study. AKI was diagnosed as per Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Acute Kidney Injury. Patients suffering from chikungunya complicated by AKI were cases and those without AKI were controls. Results: Total patients were 107 (male 61) with a mean age of 35.6 (range 19-84) years. Common comorbidities were diabetes mellitus (DM) (20.6%), hypertension (17.8%) and chronic kidney disease (CKD) (12.1%). Common presentations included fever (86.9%) or recent history of fever (13.1%), joint pain (88.8%), rash (23.4%), pruritus (15.9%), gastro-intestinal (GI) features like diarrhea and/or vomiting (28%), lymphadenopathy (12.1%), gum swelling/oral ulcer (4.1%) and oedema (8.4%). Fourteen (13.1%) patients required hospitalization. Eleven (10.3%) cases were complicated by AKI. Among the risk factors for AKI, comorbidities like DM (OR 28.73, 95% CI 5.57-148.10, p 0.0001) and CKD (OR 31.0, 95% CI 2.94-326.7, p

Background: Chikungunya is a rapidly spreading viral infection of global concern. Initial presentation of chikungunya infection is often indistinguishable from other viral infections. In Bangladesh, chikungunya is an emerging infection. In this report, we describe socio-demographic, clinical and laboratory characteristics of chikungunya in a selected group of Bangladeshi patients. Methods: A multi-center descriptive study was done including adult patients with chikungunya virus infection from July 1, 2017 to October 31, 2017. Diagnosis of chikungunya virus infection was confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) or immunoglobulin M (IgM) against chikungunya. Results: Total patients were 107 including 61 (57%) males. Mean age of the study participants was 35.6 (range 19-84) years. Ninety three (86.9%) patients presented with fever and 14 (13.1%) patients (with history of recent fever) presented due to joint pain. Most (93, 86.9%) patients were managed as out-patient basis; while 14 (13.1%) patients required hospitalization. Common features were fever/history of fever, joint pain, rash and lymphadenopathy. Out of 93 patients who presented with fever, 79 (85%) had concomitant arthralgia/ arthritis, 70 (75.3%) had persistent joint symptoms beyond febrile illness requiring paracetamol, 63 (67.2%) patients had joint pain beyond 3 weeks (sub-acute phase) requiring paracetamol, non-steroidal antiinflammatory drugs or corticosteroids and 11 patients had passed 3 months since symptom onset (chronic phase) and only one (9%) had joint symptoms requiring hydroxychloroquine. There was no death. Conclusion: Clinical manifestation of chikungunya virus infection was comparable with other viral infections but arthritis/arthralgia was an important differentiating point. As chikungunya is an emerging infection in Bangladesh, physicians should have a high index of suspicion and care should be taken to exclude other viral infections specially dengue. Birdem Med J 2019; 9(2): 106-110

Background: Quality of life (QOL) is one of the chief areas to be addressed when caring for people with end stage renal disease (ESRD). The continual excretory function of native kidneys are replaced in such patients by few hours of rapid urea clearance in a week. This study aimed to explore whether more weekly hemodialysis sessions and dialysis adequacy do actually improve parameters of QOL and if this is beneficial enough at the cost of taking additional dialysis sessions in a low income country like Bangladesh. Whether being diabetic influences QOL was also investigated. Methods: This cross-sectional study recruited 135 adults, who were on maintenance haemodialysis(MHD) for >3 months, from three dialysis centers in Dhaka from January to December, 2013. Patients with malignancy, dementia, and psychosis were excluded. Patients were interviewed once by the investigators to fill a validated Bangla version of the kidney disease quality of life short form questionnaire (KDQOL-SF-36 version 1.3) and calculate a QOL score. Results: Mean age, mean duration of chronic kidney disease (CKD) and MHD were 50±12 years, 4.9±5.1 years and 12±11.8 months respectively. Overall QOL score for the study sample was 50±17. Only 43(31.9%) patients received adequate hemodialysis (mean Kt/V=1.3) while the rest (with Kt/V1.2 (adequate HD). However, when a comparison was made between those with 3 HD sessions/week (n=63, mean MHD duration 24±14 months) with patients receiving 2 HD sessions/week (n=72, mean MHD duration 8.4±11 months), the former group had lower “effect of kidney disease” scores (p=0.021), higher “quality of social interaction” scores (p=0.031) and lower “role emotion” scores (p=0.002). When diabetic patients (n=82, mean age 54±8 years, MHD duration 18.5±9.5 months) and non-diabetic subjects (n=53, aged 42±13 years, MHD duration of 25±16 months) were compared, “effects of kidney disease”, “cognitive function” and “quality of social interaction” scales were significantly higher in those having diabetes (with p

Melioidosis is an emerging infectious disease in many countries including Bangladesh. Patients with diabetes mellitus are at increased risk for infection by Burkholderia pseudomallei, the causative agent for melioidosis. Here, we report an autochthonous case of septicemic melioidosis occurring in a middle-aged non-diabetic Bangladeshi farmer who presented with prolonged pyrexia and splenomegaly. Diagnostic workup revealed splenic micro-abscesses, previously undetected chronic kidney disease (CKD) and beta-thalassemia minor. This case stresses the importance of searching for less common risk factors for melioidosis such as CKD and hemolytic anemia.

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.

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: Diabetic ketoacidosis (DKA) is a medical emergency. DKA may be complicated by acute kidney injury (AKI) and may require renal replacement therapy. Early detection and treatment including treatment of underlying cause and complication(s), if present, is important in determining outcome of DKA. This study was designed to evaluate the incidence of AKI among patients with DKA.Methods: This cross-sectional study was done in BIRDEM General Hospital, Dhaka, Bangladesh from 2008 to 2011. AKI was diagnosed by using acute kidney injury network (AKIN) criteria.Results: Total patients were 200 with slight female predominance (56%). Mean age of the study subjects was 37.6±7.5 years. Incidence of DKA was more in known diabetic patients (71%), more among rural population (53%) and low income group (76.5%). Infection (40.5%) was the commonest precipitating cause followed by non-adherence to insulin therapy (31%). Acute pancreatitis (5%), myocardial infarction (2%), stroke (1%) and surgery (1.5%) were less common causes and aetiology could not be identified in 14% cases. Fifty nine (29.5%) cases were complicated by AKI and among them three (5%) patients required haemodialysis. AKI was more in severe DKA (pH

Rapidly progressive glomerulonephritis is one of the most dramatic and tragic presentations of lupus nephritis (LN) or renal manifestation of systemic lupus erythematosus (SLE). A 35-year-old Bangladeshi gentleman presented with worsening oedema, scanty, high colored, frothy urine and deteriorating renal function. He had puffy face, anaemia, oedema, normal jugular venous pressure (JVP), high blood pressure (150/90 mm Hg), ascites and bilateral pleural effusions. Diagnostic work-up confirmed SLE with class IV LN. His initial response to specific therapy showed improvement Birdem Med J 2020; 10(2): 137-138

Rifampicin is one of the most effective anti-tubercular agents. Among its rare adverse effects, acute interstitial nephritis (AIN) is noteworthy. Here, we describe the case history of a 55-year-old female with tubercular lymphadenitis who developed rifampicin induced AIN upon re-exposure and recovered satisfactorily without requiring steroids. Rifampicin induced AIN should be kept in mind when patients present with acute kidney injury as prompt diagnosis and discontinuation of the drug has excellent prognosis.Birdem Med J 2018; 8(3): 257-259

Background: Glomerulonephritis (GN) remains the most probable underlying cause of end stage renal disease of uncertain aetiology in many developing countries including Bangladesh. The pattern of glomerular disease varies widely from country to country. In Bangladesh, the incidence and histological pattern of GN is inadequately described. We performed a study, aiming to determine the pattern of GN in a diabetic hospital of our country.Methods: It was a cross-sectional hospital based prospective study conducted at BIRDEM General Hospital starting from July 2013 to December 2014. It included all patients with suspected GN who underwent native kidney biopsy.Results: Total 57 biopsies were performed and four cases other than primary or secondary GN (renal cortical necrosis 1, tubulointertsitial nephritis 2,chronic GN 1) were excluded i.e total number of PGN was 37 and secondary GN was 16. number of patients with were 53. M:F was 1.2:1.Mean age was 42.35±15(14-72) years. Thirty one (58.49%) of the study subjects had diabetes mellitus (DM). Mesangialproliferative GN (15/37,40.5%) and diabetic nephropathy (9/16,56%) were the commonest histopathological pattern found among primary and secondary GN respectively. Membranoproliferative GN (10/37,27%),was the second commonly observed pattern followed by focal segmental proliferative GN (8%), membranous nephropathy (8%), focal segmental glomerulosclerosis (5.4%) in primary GN and lupus nephritis (6/16,38%) and Wegeners granulomatosis (1/16) were other varieties in secondary group. Among 53 cases, 37 had proliferative variety. Nephrotic range proteinuria (41.5%) was the commonest indication of biopsy and 22% had post biopsy bleeding and 3.7% required blood transfusion.Conclusion: In conclusion, mesangial proliferative and membranoproliferative GN are the two common causes of primary GN. Diabetic nephropathy is the commonest cause of secondary GN. Nephrotic range proteinuria was the main indication of biopsy. Post biopsy complication was negligible. Creation of a national renal registry is essential for obtaining more specific epidemiological data.Birdem Med J 2016; 6(2): 67-73

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

Background and objective : There are approximately two million patients suffering from end stage renal disease (ESRD) worldwide requiring renal replacement therapy (RRT) in the form of dialysis. There are very few statistics regarding the knowledge and attitude towards dialysis among ESRD patients in Bangladesh. The present study was undertaken to understand the existing knowledge of the patients with ESRD regarding dialysis. Methods : This cross sectional descriptive study was done on 104 patients with ESRD requiring immediate dialysis. This study was conducted in the department of Nephrology, BIRDEM General Hospital, Dhaka, Bangladesh over a period of six months. After obtaining informed consent the participants were given a self-administered questionnaire that included questions on socio-demographic status, age, gender, different aspects of knowledge about dialysis and the reasons to accept and refuse dialysis for the treatment of ESRD. Results : A total of 104 patients with ESRD were enrolled in the study. The mean age was 54.20(±11.82) years, 87.5% were more than 40 years of age, and 72.1% were male. Eighty two percent mentioned diabetes as the cause of kidney disease. About half of the respondents (52.88%) knew dialysis as an option for the treatment of ESRD followed by kidney transplant (11.54%). A few (7.3%) mentioned medicine and dietary modification as the treatment. There was no statistical association between prior knowledge and agreeing to do dialysis (χ 2 = 0.7814; p=0.376699). Most of the patients (78%) gathered knowledge about dialysis from doctors. Seventy two patients (69.2%) agreed to do dialysis. Among them 37 patients (51.4%) agreed as they considered it as a part of treatment and 32 patients (44.4%) agreed because they were advised by doctors. Reasons for refusal to do dialysis were - fear of death (59.37%), financial constraints (31.25%) and lack of availability of dialysis centre (9.37%) Among study populations, only 20 patients (19.2%) mentioned about peritoneal dialysis (PD) and all of them (100%) were informed by doctors. Conclusion : The present study has demonstrated that prior knowledge on dialysis has no influence on the decision to do dialysis for the treatment of ESRD. Availability and access to dialysis facility and counseling on beneficial aspects of dialysis is required to motivate the patients for dialysis with ESRD. In addition to health care providers, social media may play an important role in promoting public awareness regarding dialysis as a treatment modality of ESRD. IMC J Med Sci 2017; 11(1): 11-14

Background and Aims: Urinary tract infection (UTI) is a common illness. The spectrum of bacteria causing UTI and their antibiotic sensitivity is not uniform. This study was designed to describe the bacteriological spectrum causing UTI and their antibiotic sensitivity.Methods: This cross-sectional study was done in the Department of Internal Medicine, BIRDEM General Hospital from January to June, 2013.Results: Total number of patients was 103 with females predominance (F:M ratio 2:1). Mean age was 57.5 years. Most (91.3%) of the study population were diabetic with poor glycaemic control (mean HbA1c 9.9%). Common symptoms were fever, dysuria, increased urinary frequency, suprapubic pain, vomiting and loin pain. Neutrophilic leukocytosis was common (94.2%). E. coli (79.6%) was the commonest aetiological agent followed by Klebsiella (9.7%), Citrobacter (3.9%), Acinetobacter (1.9%), Enterobacter (1.9%), Enterococcus (1.9%) and Pseudomonas (0.9%). Imipenem (100%), aminoglycosides e.g. amikacin and gentamycin and nitrofurantoin were among the most sensitive antibiotics.Conclusion: E. coli is the commonest organism causing UTI and imipenem, amikacin and nitrofurantoin are the most sensitive antibiotics.Birdem Med J 2015; 5(1): 20-23

Background: Organ transplantation saves thousands of lives worldwide. There is discrepancy between organ demand and supply which demands cadaveric donation. Knowledge and attitudes of physicians towards organ donation and transplantation can increase the rate of organ and tissue donation by motivating general population.Methodology: This cross-sectional survey was done on 150 Bangladeshi physicians including specialist and post-graduate students on four teaching hospitals in Dhaka, Bangladesh over a period of six months. After taking informed consent, the participants were given a self-administered questionnaire which includes socio-demographic data, knowledge and attitude about organ donation and transplantation.Results: Male and female were almost equal (Total 102, Male 54, female 48) with mean age was 34.6±5.0 years and 54.9% were specialists and 45.1% were post graduate students. More than 32% respondents were from Medicine, followed by Nephrology (26.5%), Critical Care Medicine (CCM) (25.5%) and Urology (15.6%). Fifty-six (54.9%) physicians agreed with organ donation after death. The most important reason of agreement was to help others (78.4%) and disagreement was religious fear (54.3%). More than 40% respondents agreed and 59.8% completely disagreed with living kidney donation. The most common reason for agreement of living kidney donation was to donate to help family member (82.93%) and disagreement was probable damage to donors (52.46%). More than three-fourth (76.4%) respondents had knowledge about theoretical basis of transplantation, 50% know about cost and 43% about organ transplant Act, Bangladesh. Significant positive correlation was found between physicians’ attitudes towards organ and tissue donation after death and knowledge about theoretical basis of transplantation (p =0.02, r= 0.43) and cost of transplantation in Bangladesh (p= 0.02, r= 0.22) but no statistically significant correlation with knowledge about organ transplant Act, Bangladesh (p value= 0. 19, r= 0.13) whereas significant positive correlation between physicians knowledge about transplant Act (p= 0.008, r= 0.28), cost (p = 0.04, r= 0.23) and theoretical basis of transplantation (p= 0.04, r= 0.20) was found in living kidney donation.Conclusion: Physicians had a good attitude towards organ donation and transplantation although less than half of them had knowledge of transplantation rules and financial issues; therefore, additional awareness and education of physicians is needed in all areas of the organ transplant process in Bangladesh to make organ donation and transplantation successful.Bangladesh Crit Care J March 2016; 4 (1): 23-27

Introduction : Renal replacement therapy (RRT) is often used to treat critically ill patients associated with acute or chronic renal failure. Peritoneal dialysis (PD) is an option when intermittent hemodialysis (IHD), sustained low efficiency dialysis (SLED) or Continuous renal replacement therapy (CRRT) are not feasible. PD customarily uses rigid catheter and cannot be used for more than 3 days as there is increased chance of infection and it can cause perforation of hollow viscera and often there is hemorrhage due to trauma to the adjacent organs. In this study we used Tenckhoff flexible PD catheter with double cuff and reinforced purse string suture1, So it can be used on an emergency basis and for indefinite period with minimal chances of complications commonly associated with rigid PD catheter. In this observational study emergency CPD using the procedure mentioned above in a compromised group of renal insufficiency patients was explored.Objectives : To determine if emergency RRT can be achieved by CPD using flexible Tenckhoff catheter placed with special reinforced sutures when IHD, SLED or CRRT is not feasible in critically ill patients.Material and Methods : Patients who failed to tolerate IHD, SLED or CRRT because of resulting hemodynamic instability and those who required dialysis urgently and for a prolonged period in Intensive Care Unit (ICU) were selected. There were 58 study cases who received emergency CPD after fulfilling inclusion criteria using flexible Tenckhoff catheter placed with special reinforced suture. These patients were on various life-support modalities having multiple co-morbidities. Regular exchanges were started manually with small volume on the day or the next day of catheter implantation, initially with 0.5-1 liter/session and subsequently with 2 liters per session after 15 days. Serum creatinine of study subjects were followed for 45 days and study subjects were followed for up to a year to check for survivability.Results : In 58 critically ill cases that fulfilled the criteria were included in the study. Average age was 67.05±14.43 years and 66% were male. Majority were diabetic 48 (82.75%) and the cause of AKI were sepsis in 39 cases (67.2%) acute cardiovascular insufficiency in 9 cases (AMI & NSTEMI 15.5%), gastroenteritis in 3 cases (5.2%), stroke in 4 cases (6.9%) and multi organ failure in 7 cases (12.1%). Average creatinine at the initiation of dialysis was 7.68 ± 3.15 and after 5 days it was 5.86± 2.8, after 10 days 4.08 ± 2.61, after 15 days 2.87 ± 2.1, one month 2.32± 1.90 and after one and a half months 2.31± 1.88. Volume overload was the indication of CPD in 22 (37.93%) patients but main indication was uremia in 36 (62.06%) cases. In ICU 23 (39.7%) patients expired within a short (within 7 days) period. In the remaining 30(42.9%) survived beyond 4 weeks (51.7); 22 (37.9%) beyond 12 weeks; 14(24.1%) beyond 24 weeks and 5(8.6)% beyond 1 year. In 4 (2.32%) patients PD catheter was removed as renal function improved. 35 patients were on mechanical ventilator and out of them 18 patients were weaned of mechanical ventilator (MV). 26 MV patents (including weaned off) survived beyond 4 weeks. Mechanical complications from PD catheter in situ were very low and there was catheter related infection only in two cases.Conclusion : Emergency CPD can be an alternate mode of renal replacement therapy (RRT) in critically ill patients where emergency IHD, SLED or CRRT are not feasible. It was accompanied with low risk of procedure related complications and well tolerated.Bangladesh Crit Care J March 2016; 4 (1): 3-8

Continuous ambulatory peritoneal dialysis (CAPD) is becoming increasingly known to the patients of Bangladesh, and patient numbers are increasing. Here, we report our experience and clinical outcomes in this field.Our analysis included all CAPD patients managed in a tertiary care hospital in Bangladesh between 2003 and 2015. All patients received a Tenckhoff double-cuff catheter by mini-laparotomy, and twin bags were used in most patients. In acute cases, regular exchanges were started manually with small-volume dwells the same or the next day.During the study period, 500 patients (mean age: 62 ± 18 years; 62% men; 86% percent with diabetes) were managed. Selection of CAPD was made by choice (47%) or for hemodynamic instability (32%), remote residence (17%), or poor vascular access (4%). Total duration of follow-up was 9364 patient-months (range: 1 - 78 months). The peritonitis rate was 1 episode in 30 patient-months. Fewer than 5% of patients required catheter removal. Similarly, the percentages of catheter tip migration and fluid leak were at the lower end. Patient survival was 68%, 48%, 38%, 22%, and 8% at 1, 2, 3, 5, and 7 years. Deaths were mostly attributable to vascular events.In a population with predominantly diabetic patients, CAPD was shown to be a viable mode of renal replacement therapy. The rates of peritonitis and catheter-related complications were low. Survival in the initial years can be considered acceptable.

Background: Escherichia coli and Klebsiella pneumoniae are two common organisms responsible for urinary tract infection (UTI) world-wide. Extended-spectrum beta-lactamase (ESBL) producing E. coli and K. pneumoniae are increasingly being reported as urinary isolates. Objectives: This study was aimed to describe the frequency of ESBL positive E. coli and K. pneumoniae causing UTI, associated risk factors and antibiotic sensitivity pattern of these organisms. Methods: This prospective cross-sectional study was conducted in BIRDEM General Hospital from January 2014 to March 2014. One hundred consecutive culture positive UTI cases due to E. coli or K. pneumoniae infection, irrespective of ESBL positivity were purposively included in this study. UTI due to organisms other than E. coli and K. pneumoniae and culture negative cases were excluded from the study. Results: Total patients were 100, male were 21 and female 79. Mean age was 59.1 (range 19-81) years. Out of 100 patients, 96 were diabetic. Fever, vomiting, dysuria and increased urinary frequency were common symptoms. Among the 100 culture positive samples, E. coli were 84 and K. pneumoniae were 16. Forty eight (48/84, 57.1%) of E. coli and 10 (10/16, 62.5%) of K. pneumoniae were ESBL positive. Female patients, presence of diabetes mellitus (DM), long duration and poor control of DM, chronic kidney disease (CKD), renal stone and past history of UTI were significant risk factors for ESBL positivity. Amikacin, netilmycin and imipenem were among the most sensitive antibiotics. Conclusion: Two-thirds of the E. coli and K. pneumoniae in this study were ESBL positive. Female gender with poor control of DM, CKD and past history of UTI were significant risk factors for ESBL positivity. Aminoglycosides and carbapenems remain the drug of choice. Bangladesh Crit Care J September 2015; 3 (2): 49-52

Aim: Glomerulonephritis remains the most probable underlying cause of end stage renal disease of uncertain aetiology in many developing countries, including Bangladesh. The pattern of glomerular disease varies widely from country to country. In Bangladesh, the incidence and histological pattern of glomerulonephritis is inadequately described. We performed a study, aiming to determine pattern of primary glomerulonephritis in a tertiary care hospital of our country.Material & Methods: It was a cross-sectional hospital based prospective study conducted at BIRDEM general hospital starting from from July 2013 to June 2015. It included all patients with primary glomerulonephritis and who underwent native kidney biopsy.Result: Total 67 biopsy were performed and among them primary glomerulonephritis was 42. Female and male ratio was 1.3:1 and mean age was 42.73±14 (14-75) years. Indications of biopsy were proteinuria (>1gm/day) and unexplained acute kidney injury. The commonest histopathological pattern in primary glomerulonephritis was membranoproliferative glomerulonephritis 33.33% (14/ 42) followed by mesangial proliferative glomerulonephritis 30.95% (13/42). Only three (7%) patient required blood transfusion for post biopsy bleeding. No one required nephrectomy.Conclusion: In conclusion, mesangial proliferative and membranoproliferative glomerulonephritis are the two most common causes of primary glomerulonephritis. Nephrotic range proteinuria was the main indication of biopsy. Post biopsy complication was negligible. Creation of a national renal registry is essential for obtaining more specific epidemiological data.Bangladesh J Medicine Jul 2016; 27(2) : 68-70

not available Birdem Med J 2020; 10(1): 78

Bilimbi/belembu fruit belongs to the family of Oxalidacae, species Averrhoa bilimbi. Freshly prepared concentrated juice of bilimbi has very high oxalic acid content and consumption carries a high risk of developing acute kidney injury (AKI) by deposition of calcium oxalate crystals in renal tubules. AKI due to Averrhoa bilimbi juice injestion is very rare. We report the case history of a 60-year-old hypertensive, dyslipidemic patient, with normal renal function, who ingested around 600ml of juice in fasting state for treating dyslipidemia. The patient developed AKI and required three sessions of hemodialysis. Her renal function returned to normal after five weeks.Bangladesh Crit Care J September 2015; 3 (2): 71-73

Emphysematous pyelonephritis is a rare, severe, necrotizing renal parenchymal infection characterized by gas accumulation in kidney(s) with or without involving surrounding tissues. Patients with diabetes mellitus are the usual sufferers. Here we describe a case history of a young Bangladeshi diabetic lady who presented with dysuria, fever and abdominal pain. Investigations confirmed left sided emphysematous pyelonephritis. She responded to and recovered with intravenous antibiotics.J Enam Med Col 2015; 5(2): 122-124

Bangladesh Journal of Medicine, Vol 24 No 1, 2013, Page 10-13 DOI: http://dx.doi.org/10.3329/bjmed.v24i1.15029

Background Purtscher’s retinopathy and renal cortical necrosis are two rare vaso-occlusive complications of acute pancreatitis. Purtscher’s retinopathy causes sudden impairment of vision, which was first reported in a patient with head trauma. Subsequently, it was also reported as a complication of acute pancreatitis and few other clinical conditions. Acute pancreatitis also rarely causes renal cortical necrosis leading to acute kidney injury. However, the simultaneous presence of both complications is rarely reported. Case presentation A 20-year-old Bengali man presented to our hospital with a history of acute upper abdominal pain, vomiting, anuria, and disorientation. He was ultimately found to have bilateral complete blindness due to Purtscher’s retinopathy and acute kidney injury due to renal cortical necrosis, as sequelae of acute pancreatitis. He became dialysis-dependent, his vision did not recover, and he died 16 months after diagnosis. Conclusions This case highlights Purtscher’s retinopathy and renal cortical necrosis might be considered as a recognized pair complication of acute pancreatitis.

Star fruit (Avarrhoa carambola) is a fruit from oxalidace family. lt is found in many countries of the world including Bangladesh. But its ingestion or drinking star fruit juice may lead to intoxication especially in patients with chronic kidney disease and manifestations might be neurological or nephrological. lt may also cause acute kidney injury in patients with previously normal renal function. Here we are presenting a case who presented with acute kidney injury after star fruit ingestion with previously unknown renal function impairment. The etiology was confirmed by histopathological exami­nation after doing renal biopsy. This renal function impairment is mainly due to oxalate crystal induce nephropathy which is richly abundant in star fruit. His renal function was improved ·with conservative management. Physicians should be alert to consider the ingestion of star fruit as a cause of acute kidney injury in a patient even in the absence of previous renal function impairment.

The most common renal manifestation of Human immunodeficiency virus (HIV), is HIV associated nephropathy (HIVAN). In this report, we describe a case that was referred for evaluation of proteinuria. Diagnostic workup revealed HIV infection with membranous nephropathy (MN). As he had sub-nephrotic range proteinuria and normal renal function we did not start any treatment for membranous nephropathy and for anti-retroviral therapy he was sent to a referral center. Being an uncommon variety of nephropathy in HIV infected patient in one of the lowest HIV prevalent country, we are reporting the case.DOI: http://dx.doi.org/10.3329/jom.v16i1.22408 J MEDICINE 2015; 16 : 61-63

Infective spondylodiscitis (ISD) is an uncommon, devastating but potentially preventable and treatable condition specially in patients receiving haemodialysis (HD) through central venous (CV) catheters. Here, we present an elderly diabetic patient who was on HD through CV line placed in right femoral vein, who came because of pyrexia and neck pain. Diagnostic workup was in favour of ISD and excluded tuberculosis or malignancy. He responded well to anti-staphylococcal antibiotics.Birdem Med J 2014; 4(2): 108-110

A case of urinary ascites in a 37-year-old woman caused by an unrecognized bladder injury inflicted during hysterectomy done seven months earlier is presented here. The site of injury was located by conventional retrograde cystography and repaired by laparotomy. The medical record suggesting uneventful peri and postoperative period, absence of expected typical changes in serum biochemistry and the unusual aetilogy of the ascites led to the delay in the diagnosis.The case demonstrates the importance of high index of suspicion of bladder injury following pelvic surgery in patients with ill-defined symptoms and unexplained ascites even in the absence of typical biochemical changes. DOI: http://dx.doi.org/10.3329/birdem.v2i1.12364 Birdem Med J 2012; 2(1) 60-62