Evaluation of Recently Developed Regression Equation with Direct Measurement of Low-density Lipoprotein Cholesterol in a Bangladeshi Population.

Background: Meaningful underestimation of low-density lipoprotein (LDL) cholesterol is an important shortcoming of Friedewald’s formula (FF) at higher triglyceride (TG) levels. Recently a regression equation (RE) has been developed using lipid profiles in one setting and validated externally for the calculation of LDL cholesterol. This newly developed RE requires more studies in different settings. Objective: The aim of this study was to evaluate the performance of the regression equation against direct measurement. Materials and Methods: Lipid profiles of 600 subjects attending a tertiary healthcare center were included in this study. Specimens were collected and lipid profiles were measured by standard methods. Sixty two lipid profiles with TG above 400 mg/dL were excluded. Calculated LDL cholesterol values using FF and RE were compared with measured LDL cholesterol by Pearson’s correlation test, Passing & Bablok regression, accuracy within ±5% and ±12% of measured LDL cholesterol and two-tailed paired t test at various TG ranges. Results: The mean value of LDL cholesterol was 148.6 ± 37.2 mg/dL for direct measurement, 146.9 ± 42.4 mg/dL for FF and 148.6 ± 34.7 mg/dL for RE. The correlation coefficients of calculated LDL cholesterol values with measured LDL cholesterol were 0.949 (p<0.001) for FF and 0.959 (p<0.001) for RE. Passing & Bablok regression equation against measured LDL cholesterol was y = 0.897x + 16.2 for FF and y = 1.0842x – 13.1 for RE. Accuracy within ±5% of measured LDL cholesterol was 45% for FF, 57% for RE and within ±12% of measured LDL cholesterol was 84% for FF, 93% for RE. When calculated LDL cholesterol was compared with measured LDL cholesterol at different TG ranges, FF significantly underestimated LDL cholesterol at TG concentrations above 200 mg/dL whereas no significant difference was observed for RE. Conclusion: This study reveals that RE equation has similar performance to direct measurement for calculation of LDL cholesterol.

Lipid Profile and Atherogenic Index of Plasma (AIP) in Vegetarians.

Background: Diet deficient in fresh fruits and vegetables are associated with an increased risk of coronary diseases. Low levels of vitamin C, vitamin E and other antioxidants may enhance the production of oxidized LDL and are important independent risk factors for coronary disease. Objective: To make a comparative evaluation of lipid profile and atherogenic index of plasma (AIP) between vegetarians and nonvegetarians. Materials and Methods: This case-control study was carried out in the Department of Biochemistry of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka between July 2011 to June 2012. Vegetarian and nonvegetarian subjects of male sex were the study population. Vegetarians were considered as cases while nonvegetarians as controls. After proper ethical consideration a total of 30 vegetarians and 40 nonvegetarians were consecutively included in the study based on predefined inclusion and exclusion criteria. Laboratory investigations were done in the Department of Biochemistry, BSMMU, Dhaka. Results: The vegetarians had significantly lower total cholesterol and LDLcholesterol than the nonvegetarians (p=0.000 and p=0.000 respectively). Serum HDL cholesterol was also lower among the vegetarians (p=0.002) and triglycerides were almost identical in both the groups (p=0.272). Conclusion: The study reveals lower level of total cholesterol, LDLcholesterol and HDL-cholesterol in vegetarians. No difference regarding triglycerides and AIP was found between the groups. So, the findings of this study do not indicate any superiority of vegetarian diet in control and prevention of cardiac diseases.

Admission Serum Uric Acid Levels and In-Hospital Outcomes in Patients with Acute Coronary Syndrome.

Background: Uric acid is an independent risk factor for cardiovascular disease. Hospital admission for ischemic heart disease (IHD) is increasing rapidly in our country. Although studies were conducted abroad regarding association of serum uric acid with in-hospital outcomes in patients with acute coronary syndrome (ACS), no data is yet available to show the association in our country. Objective: The objective of this study was to assess the association of serum uric acid level on admission with in-hospital outcomes of the patients with ACS. Materials and Methods: This cross sectional comparative study was done in the Department of Cardiology, Dhaka Medical College Hospital (DMCH) from January to December 2012. After proper ethical consideration total 93 ACS patients were enrolled in the study by nonrandom sampling. Serum uric acid of all subjects was measured within 24 hours of admission. Then in-hospital outcomes were observed in all subjects. Results: The frequency of hyperuricemia among ACS patients was 24.7% (22.54% in male and 31.82% in female). Hyperuricemic patients significantly developed heart failure (30.4% vs 11.4%, p=0.032) and conduction defect (13.0% vs 1.4%, p=0.017) than normouricemic subjects. The mean ejection fraction was significantly lower in hyperuricemic patients than patients with normal uric acid level (50.87 ± 10.27% vs 55.94 ± 6.66%). The mean ± SD duration of hospital stay of hyperuricemic group was significantly longer in patients with ACS (8.26 ± 1.18 vs 7.51±1.18 days, p=0.010). Conclusion: The measurement of serum uric acid level, an easily available and inexpensive biochemical tool, might turn out as a valuable risk marker for prediction of in-hospital outcomes in patients with ACS.

Evaluation of the Novel Method and the Regression Equation for Calculation of Low-Density Lipoprotein Cholesterol.

Background: Friedewald’s formula (FF) is used worldwide to calculate low-density lipoprotein cholesterol (LDL-chol). But it has several shortcomings: overestimation at lower triglyceride (TG) concentrations and underestimation at higher concentrations. In FF, TG to very low-density lipoprotein cholesterol (VLDL-chol) ratio (TG/VLDL-chol) is considered as constant, but practically it is not a fixed value. Recently, by analyzing lipid profiles in a large population, continuously adjustable values of TG/VLDL-chol were used to derive a novel method (NM) for the calculation of LDL-chol. Objective: The aim of this study was to evaluate the performance of the novel method compared with direct measurement and regression equation (RE) developed for Bangladeshi population. Materials and Methods: In this cross-sectional comparative study we used lipid profiles of 955 adult Bangladeshi subjects. Total cholesterol (TC), TG, HDL-chol and LDL-chol were measured by direct methods using automation. LDL-chol was also calculated by NM and RE. LDL-chol calculated by NM and RE were compared with measured LDL-chol by twotailed paired t test, Pearson’s correlation test, bias against measured LDL-chol by Bland-Altman test, accuracy within ±5% and ±12% of measured LDL-chol and by inter-rater agreements with measured LDL-chol at different cut-off values. Results: The mean values of LDL-chol were 110.7 ± 32.0 mg/dL for direct measurement, 111.9 ± 34.8 mg/dL for NM and 113.2 ± 31.7 mg/dL for RE. Mean values of calculated LDL-chol by both NM and RE differed from that of measured LDL-chol (p<0.01 for NM and p<0.0001 for RE). The correlation coefficients of calculated LDL-chol values with measured LDL-chol were 0.944 (p<0.0001) for NM and 0.945 (p<0.0001) for RE. Bland- Altman plots showed good agreement between calculated and measured LDL-chol. Accuracy within ±5% of measured LDL-chol was 49% for NM, 46% for RE and within ±12% of measured LDL-chol was 79% for both NM and RE. Inter-rater agreements (κ) between calculated and measured LDL-chol at LDL-chol <100 mg/dL, 100–130 mg/dL and >130 mg/dL were 0.816 vs 0.815, 0.637 vs 0.649 and 0.791 vs 0.791 for NM and RE respectively. Conclusion: This study reveals that NM and RE developed for Bangladeshi population have similar performance and can be used for the calculation of LDL-chol.

Factors Precipitating Hypokalemia in Diabetic Patients: A Cross Sectional Study.

Background: Hypokalemia is a very common electrolyte imbalance in diabetic patients which leads to substantial morbidity and mortality. Severe hypokalemia is associated with lifethreatening arrhythmias and sudden cardiac death. There are no adequate studies regarding the incidence and factors precipitating hypokalemia in Bangladeshi diabetic subjects. Objective: The objective of this study was to find out the factors precipitaing hypokalemia in diabetic patients. Materials and Methods: A total 95 admitted diabetic patients with hypokalemia were studied. Specimens were collected from all adult diabetic patients with serum potassium level <3.5 mmol/L irrespective of cause of admission. Informations were obtained in a semistructured data collection form and analyzed. Results: Most of the subjects (61.1%) belonged to the age group of 60 years and above, 31.5% to the age group 40–59 years and 7.4% belonged to the age group of 20–39 years. Sixty one (64.2%) patients were females and 34 (35.8%) were males. In 63.2% cases, vomiting was found as a factor causing hypokalemia in the diabetic patients. Other common factors precipitaing hypokalemia were diarrhea (42.1%), inadequate diet (9.5%), severe hyperglycemia (3,2%), diabetic ketoacidosis (6.3%) and drugs especially diuretics (18.9%), bronchodilators (6.3%) and steroids (5.3%). The commonest comorbidity associated with diabetes was hypertension. Conclusion: In this study the commonest precipitating factor causing hypokalemia was vomiting. Majority of hypokalemic patients were female and of older age group. When hypokalemia is identified, the underlying precipitating factor should be sought and the disorder treated. Diuretics should be used with caution in the elderly patients having hypertension, a common comorbid condition of diabetes, as these patients are susceptible to develop hypokalemia.

Cystatin C: A Marker of Renal Function.

The most widely used investigation of renal function and GFR is the measurement of serum creatinine and creatinine clearance rate. This has been extremely popular in clinical medicine despite formidable difficulties associated with its quantification and interpretation. The main pathophysiological difficulties include variations in the rates of creatinine generation and its secretion by the renal tubules. Concentration of serum creatinine is now recognized as an unreliable measure of kidney function as it is affected by age, body weight, muscle mass, race and various medications. Several equations have been developed to improve the accuracy of serum creatinine level as a measure of GFR. The most widely used in adult populations are the Cockroft-Gault equation and the abbreviated Modification of Diet in Renal Disease (MDRD) equation. Even with these equations, measurement of GFR is difficult because the equations are less accurate with higher levels of kidney function and are affected by interlaboratory variation in measuring creatinine level. In the above perspective, cystatin C concentration has become a promising marker for kidney function in both native and transplanted kidneys. Because of the possible potentiality of cystatin C to be an emerging endogenous marker for quick and accurate assessment of renal function, we have decided to review elaborately on cystatin C as a marker of renal function and to review the sensitivity and specificity of cystatin C as an endogenous marker compared to serum creatinine. Results of our review study suggest that cystatin C is a better marker of renal function compared to serum creatinine and other endogenous markers irrespective of age, sex and clinical condition.

Treatment and Prevention of Common Complications of Chronic Kidney Disease.

Chronic kidney disease (CKD) is a worldwide public health problem with an increasing incidence and prevalence. Outcomes of CKD include not only complications of decreased kidney function and cardiovascular disease but also kidney failure causing increased morbidity and mortality. Unfortunately, CKD is often undetected and undertreated because of its insidious onset, variable progression, and length of time to overt kidney failure. Diabetes is now the leading cause of CKD requiring renal replacement therapy in many parts of the world, and its prevalence is increasing disproportionately in the developing countries. This review article outlines the current recommendations from various clinical guidelines and research studies for treatment, prevention and delaying the progression of both CKD and its common complications such as hypertension, anemia, renal osteodystrophy, electrolyte and acid-base imbalance, and hyperlipidemia. Recommendations for nutrition in CKD and measures adopted for early diabetic kidney disease to prevent further progression have also been reviewed. There is strong evidence that early detection and management of CKD can prevent or reduce disease progression, decrease complications and improve outcomes. Evidence supports that achieving optimal glucose control, blood pressure, reduction in albuminuria with a multifactorial intervention slows the progression of CKD. Angiotensin-converting enzyme inhibitors and angiotensin-II receptor antagonists are most effective because of their unique ability to decrease proteinuria, a factor important for the progression of CKD.

Tragedy in Savar: Management of Victims in Enam Medical College Hospital.

Background: Rana Plaza collapse is the worst and deadliest man-made industrial disaster in the history of garment sector in the world. Around 1200 people died and thousands more were injured. Most of the victims of the disaster were treated in Enam Medical College Hospital (EMCH). We conducted this study to give an overview on the disaster victims and services provided by EMCH. Objective: The study was done to observe the length of time between accident and admission in EMCH, length of time between admission and discharge, to observe the numbers, types and sites of injuries to the victims, medical measures given to the victims and finally to observe the status of the victims at the time of discharge. Materials and Methods: This descriptive type of observational study was carried out among the victims of Rana Plaza tragedy during the period of May to October 2013. All admitted patients in EMCH were included in the study. Purposive nonprobability sampling technique was applied in this research work. Data were collected from the hospital record. After collection, data were manually compiled, edited and analyzed. Results: Among 621 victims treated in different wards, 276 (44.45%) were admitted to the hospital on the day of accident. Among the admitted patients, 255 (41.06%) stayed in the hospital for 1--3 days,133 (21.42%) for 4--7 days and 88 (14.17%) for more than 10 days. Fracture and dislocation were present in 32.70% patients, lacerated injury in 18.20%, abrasion in 15.78%, bruise in 13.53%, incised wound in 15.45% and punctured wound in 4.34% patients. Single injury was present in 56.68% and rest had multiple injuries. Lower limbs were the most (33.01%) affected part of the body followed by head and neck (22.06%), upper limbs (18.52%), thorax (17.55%) and abdomen (8.86%). Two hundred seventy two patients (43.80%) were improved after treatment and 56 (9.02%) were fully cured; 23.83% of the victims were referred to higher medical centers for special measures. Conclusion: The collapse of Rana Plaza has fueled a greater call for reform and safety in garment industry. At the same time, all health care centers should adopt a broad-based approach to disaster-preparedness by providing a framework to ensure a well-coordinated response to mass casualty event.

Evaluation of Performance of the Newly Developed de Cordova's Formula for Calculation of Low-Density Lipoprotein Cholesterol without Use of Triglycerides.

Background: Various formulas are available to estimate serum low-density lipoprotein (LDL) cholesterol. All of these are serum triglycerides (TG) dependent. But very recently de Cordova et al developed a simple formula (CF) to calculate LDL cholesterol without using serum TG and claimed it to be more accurate than Friedewald.s formula (FF). Objective: The objective of the present study was to evaluate the performance of the CF for the calculation of LDL cholesterol in a Bangladeshi population. Materials and Methods: Three hundred and sixty adult Bangladeshi subjects were purposively included in this study. Serum total cholesterol (TC), TG, high-density lipoprotein (HDL) cholesterol and LDL cholesterol were measured by direct automated methods. LDL cholesterol was also calculated by CF and FF. Results were expressed in conventional unit as mean ± SD and compared by two-tailed paired t test, bias against measured LDL cholesterol, Pearson's correlation coefficient (r), Passing & Bablok regression and accuracy within ±10% of the measured LDL cholesterol. Results: The mean values of directly measured LDL cholesterol, LDL cholesterol calculated by CF and FF were 117.7 ± 31.0, 111.8 ± 31.0 and 108.9 ± 39.7 mg/dL respectively. Bias of calculated LDL cholesterol against measured LDL cholesterol was -5.2% for CF and -9.6% for FF. The correlation coefficients of measured LDL cholesterol were 0.9796 (p<0.001) for CF and 0.9525 (p<0.001) for FF. Passing & Bablok regression yielded the equation y = 0.9938x - 6.2 for CF and y = 1.2774x - 40.9 for FF. Accuracy within ±10% of measured LDL cholesterol was 81% for CF and 49% for FF. Conclusion: This study revealed better performance of the de Cordova's formula than Friedewald's formula for approximate calculation of LDL cholesterol without using serum triglycerides.

Serum Creatinine and Uric Acid Levels in Hypothyroid Patients: A Cross Sectional Study.

Background: Hypothyroidism is associated with many biochemical abnormalities including increased serum creatinine and uric acid levels. Many studies were done abroad regarding serum creatinine and uric acid levels in hypothyroid patients. We designed this study in our population for evaluation of serum creatinine and uric acid levels in hypothyroid patients. Objective: To assess serum creatinine and uric acid levels in hypothyroid patients and to find out relationship of creatinine and uric acid levels with severity of hypothyroidism. Materials and Methods: This retrospective cross sectional study to evaluate the serum creatinine and uric acid levels of hypothyroid patients and to find out relationship of hyperuricemia and hypercreatininemia with severity of hypothyroidism was done in the department of Biochemistry, Bangabandhu Sheikh Mujib Medical University, Dhaka. Results were compared with that of age and sex matched healthy euthyroid controls. Statistical analyses were performed by using SPSS for Windows version 10.0. ANOVA and unpaired ‘t’ tests were done to see the significance among the groups and between groups respectively. Pearson’s correlation coefficient test was done to see the correlation of serum creatinine and uric acid levels with the severity of hypothyroidism. Results: Mean serum creatinine and uric acid levels in cases were 1.38 ± 0.53 and 7.00 ± 2.54 mg/dL respectively compared to 1.01 ± 0.17 and 5.21 ± 1.35 mg/dL in controls. Conclusion: Mean serum creatinine and uric acid levels were found significantly higher in hypothyroid patients compared to controls. These findings suggest that hyperuricemia and hypercreatininemia are associated with hypothyroidism. Therefore, patients presenting with these biochemical abnormalities are recommended to be investigated to explore hypothyroidism.

Lipid Profile of Postmenopausal Women with Central Obesity.

Background: Following menopause there are changes in values of lipid profile parameters. Abdominal obesity has also been linked to significant metabolic abnormalities including changes in lipid parameter values. So, we designed this study to observe the pattern of lipid profile parameters in postmenopausal central obese women. Objective: To assess the lipid profile status of postmenopausal women with central obesity. Materials and Methods: This cross sectional study was carried out in the department of Biochemistry, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh during the period of January 2005 to December 2005. Seventy four postmenopausal women with central obesity and age matched 56 nonobese postmenopausal women were included in the study. Central obesity was defined having waist hip ratio more than 0.8. All statistical analyses were done by SPSS 12.0. p values <0.05 were considered significant. Results: Statistically no significant difference was observed between the central obese women and nonobese women in total cholesterol and LDL-cholesterol levels. But HDL-cholesterol was found lower and triacylglycerol was found higher in postmenopausal central obese women. Conclusion: Dyslipidaemia is a feature of postmenopausal women with central obesity.

Measurements of HbA1c by High Performance Liquid Chromatography in D-10 analyzer and Immunological Method by Beckman Coulter AU480 System: A Comparative Study.

Background: HbA1c can be measured by different methods. Enzymatic, boronate affinity chromatographic and cation-exchange high performance liquid chromatographic (HPLC) methods are considered as gold standard methods. To make the test cost-effective many laboratories use the immunological method installed in a chemistry analyzer. Objective: To compare the values of HbA1c measured by high performance liquid chromatographic method and immunological method in two laboratory settings. Materials and Methods: This observational and comparative study was conducted in Bangladesh Institute of Health Sciences (BIHS) and Enam Medical College, Savar, Dhaka. HbA1c levels measured by HPLC in BIHS were compared with that measured by immunological method in Enam Medical College, Savar, Dhaka. p values <0.05 were considered significant. Results: Statistically no difference was observed in mean HbA1c% between two methods in <7.0% HbA1c group and 7.1-10.0% HbA1c group. Significant statistical difference was found in mean HbA1c >10.0% group, but it was within acceptable limit. Conclusion: HbA1c can be measured by immunological method installed in an automated chemistry analyzer to make the test costeffective. But HPLC method is preferable.

Association of High Density Lipoprotein Cholesterol with Renal Function in Type 2 Diabetic Subjects in a Bangladeshi Population.

Background: Abnormalities in lipid metabolism are associated with renal diseases. Association of serum lipid parameters with renal function is less studied in subjects with type 2 diabetes in Bangladeshi population. Objective: To assess the correlation of high density lipoprotein cholesterol with glomerular filtration rate (GFR) in type 2 diabetic subjects. Materials and Methods: One thousand three hundred thirty confirmed diabetic subjects advised for HbA1c, serum creatinine, serum total cholesterol, serum triglycerides, serum HDL cholesterol and LDL cholesterol were included in the study. Serum total cholesterol, HDL cholesterol, triglyceride, serum creatinine, HbA1c were measured by standard methods and serum LDL cholesterol was calculated by Friedewald’s formula. GFR was calculated by MDRD4 variables prediction equation. Total subjects were grouped according to sex; both males and females were subdivided into three subgroups depending on GFR values. Results of lipid parameters were compared by one-way ANOVA among different groups and correlation of lipid parameters with GFR were expressed by Pearson r. Results: HDL cholesterol was significantly different among different GFR groups (p<0.05) and positively correlated with GFR (r = 0.1386, p<0.001) in males. Total cholesterol and LDL cholesterol showed feeble positive correlation with GFR (r = 0.0789, p<0.05 for total cholesterol and r = 0.0768, p<0.05 for LDL cholesterol), but are not significantly different among GFR groups (p>0.05) in males. Total cholesterol, HDL cholesterol, LDL cholesterol, non-HDL cholesterol and LDLC/ HDL-C were significantly different among three different GFR groups (p<0.01) and only HDL cholesterol and LDL-C/HDL-C showed weak correlation with GFR (r = 0.0770, p<0.05 for HDL cholesterol and r = -0.0803, p<0.05 for LDL-C/HDL-C) in females. Conclusion: The study revealed that HDL cholesterol was significantly and positively correlated with glomerular filtration rate in both male and female diabetic subjects and assessment of lipid parameters might be a helpful tool to prevent or delay the progression of renal insufficiency.