Nutritional assessment of patients under hemodialysis in nepal medical college teaching hospital.

Malnutrition is very common in hemodialysis patients and is predisposed by many factors. Malnutrition is associated with increased morbidity and mortality. Total of 26 patients (16 males and 10 females) who were under hemodialysis in our center were included in the study. With the help of Malnutrition Score (MS) developed by Kalanter-Zadeh, nutritional status of the patients was assessed. Patients also underwent different anthropometric measurements such as Body Mass Index (BMI), Triceps skin fold thickness (TSF), Mid Arm Circumlference (MAC) and Mid Arm Muscle Circumference (MAMC) and laboratory investigations. Mean age of the study population was 42.58 +/- 16.32 years (range 19 to 74 years). Females were older than males. MS of the study population was 15.82 +/- 3.76 (range 9-24). Female patients were having higher MS than males (16.5 +/- 4.11 vs. 15.06 +/- 3.55). Based on MS, 22 patients (84.6%) had mild to moderate malnutrition, 2 (7.7%) patients were having severe malnutrition and remaining 2 (7.7%) had normal nutrition score. Females were having lower BMI, MAC and MAMC but higher value of TSF. Significant negative correlation was present between MS and weight, BMI, MAC and MAMC. Calculated Urea Reduction Ratio (URR) of study population was 57.27 +/- 10.89. URR was higher in females than in males (61.77 +/- 12.74 vs. 54.45 +/- 8.85). Only 23.0% of the study population had URR of >65.0%. Protein Catabolic Rate (nPCR) in our study was 0.77 +/- 0.28 g/kg/day. Malnutrition is very common in our center which is >90% when MS was considered. In our study it negatively correlated with weight, BMI, MAC and MAMC. Dialysis inadequacy was present in around 75.0% of our study population.

Acute renal failure in Nepal Medical College Teaching Hospital.

Total 45 patients (male 27 and female 18) of acute renal failure (ARF) admitted in Nepal Medical College Teaching Hospital over a period of 12 months (1st of Baisakh 2064 BS to 31st of Chaitra 2064 BS) were enrolled in the study. Sixty four percent of study population were of age group 21-60 years. Acute Gastroenteritis 33, sepsis 5, hemorrhage 2, others 5 were the different causes of ARF. Serum creatinine of the study population before and after treatment was 4.35 +/- 2.72 and 1.38 +/- 0.72 mg/dl respectively. Similarly serum urea before and after treatment was 101.78 +/- 57.56 and 42.60 +/- 30.46 mg/dl respectively. Thirty three patients were managed by non dialytic modality of therapy and 12 patients needed hemodialysis. Blood urea of those patients who underwent nondialytic therapy was significantly less than of those who underwent hemodialysis (80.65 +/- 38.21 vs. 151.08 +/- 66.22; p = 0.004). Serum creatinine was also significantly lower in nondialytic therapy group (3.15 +/- 1.15 vs. 7.64 +/- 3.10; p = 0.000) ARF patients with very high urea, creatinine and disturbed electrolytes required dialysis. Average session of hemodialysis was 3.4. Thirty five patients were cured, 6 left against medical advice, 3 were discharged on request, and one patient of sepsis expired during the course of treatment. Acute gastroenteritis was the leading cause of ARF and outcome was excellent even without dialysis in most of the cases provided the treatment was started early and appropriately.

Chronic kidney disease 5 on hemodialysis in Nepal Medical College Teaching Hospital.

Chronic Kidney Disease (CKD) 5 is defined when glomerular filtration rate (GFR) is <15.0 ml/min/1.73m2. Though nephrology service was started in Nepal as early as in 1970, we do not have data regarding CKD 5 patients till date. So this study is being undertaken to know the epidemiological profile and etiology of CKD 5 patients attending hemodialysis (HD) unit of Nepal Medical College Teaching Hospital. This is a prospective study which was carried out in HD unit over a period of one year. CKD 5 patients having GFR of <15 ml/min/1.73m2 under HD were included in the study. Among 100 patients included in the study 57 were male and mean age of the study population was 46.9+/-17.9 years. Most common cause of CKD 5 in the study was hypertension (54.0%); other causes included diabetic nephropathy (18.0%), idiopathic (13.0%) and glomerulonephritis (6.0%). Fifty percent of patients were from outside Kathmandu Valley. Around 20.0% of the study population is on regular follow up while 45.0% were lost to follow up. Twenty percent of the patient underwent transplantation and 15.0% of the study population died. Majority of patients were anemic (85.0%). Correction of anemia was done with blood transfusion in 88.0% and only 12.0% received erythropoietin. Hypertension was the leading cause of CKD 5; majority of patients (45.0%) discontinued hemodialysis most probably due to economical constrain; blood transfusion was the main modality of treatment of anemia.

Effect of preload reduction by haemodialysis on doppler indices of diastolic function in patients with end-stage renal disease.

OBJECTIVE: To assess the influence of preload reduction by haemodialysis on Doppler echocardiographic indices of cardiac diastolic function. METHODOLOGY: Parameters of left ventricular diastolic function were measured in patients with end-stage renal disease before and after a single session of haemodialysis. Patients with valvular heart disease, coronary artery disease, cardiomyopathies, pericardial disease and those not in sinus rhythm were excluded from the study. RESULTS: Seventeen subjects (12 males and 5 females, mean age 48 +/- 16 years) were studied. Over the duration of 3.7 +/- 0.6 hours of haemodialysis, 2.6 +/- 1.3 litres of ultrafiltrate was removed. The comparison of pre and post haemodialysis peak mitral E and A velocities showed a decrease in E velocity (p < 0.01) whereas the change in A velocity was not significant. The E/A ratio decreased significantly (p < 0.05).The decrease in E velocity correlated well with the amount of ultrafiltrate (r = 0.653, p < 0.01). There was a significant increase in isovolumetric relaxation time (p< 0.05) whereas deceleration time did not change (p =0.3). CONCLUSION: Ultrafiltration during haemodialysis causes a rapid reduction in preload. It results in decreased early left ventricular diastolic filling without a change in the atrial phase of filling, hence causing a decrease in calculated E/A ratio.

A Study of Early Neonatal Deaths at Kathmandu Medical College Teaching Hospital.

Introduction: Over 9 million deaths occur each year in the perinatal and neonatal periods globally. 98% of these deaths take place in the developing world. Nepal has a high neonatal mortality rate (NMR) of 38.6 per 1000 live births (2001). Two thirds of the newborn deaths usually occur in the first week of life (early neonatal death). Newborn survival has become an important issue to improve the overall health status and for achieving the millennium developmental goals of a developing country like Nepal. Aims and Objectives: This study was carried out to determine the causes of early neonatal deaths (ENND) at KMCTH in the two-year period from November 2003 to October2005 (Kartik 2060 B.S. to Ashoj 2062). Methodology: This is a prospective study of all the early neonatal deaths in KMCTH during the two-year study period. Details of each early neonatal death were filled in the standard perinatal death audit forms of the Department. Results: Out of the 1517 total births in the two-year period, there were 10 early neonatal deaths (ENND). Early neonatal death rate during the study period was 6.7 per 1000 live births and early neonatal death rate (excluding less than 1 kg) was 6.1 per 1000 live births The important causes of early neonatal deaths were extreme prematurity, birth asphyxia, congenital anomalies and septicaemia. During the study period, there was no survival of babies with a birth weight of less than 1 kg. Among the maternal characteristics, 80% of the mothers of early neonatal deaths were aged between 20-35 years. 50% of the mothers were primigravida. 50% of the mothers of ENNDs had delivered their babies by caesarean section. Discussion: Most of the early neonatal deaths were due to extreme prematurity. Birth asphyxia was the second most important cause of early neonatal deaths. 70% of ENNDs were among LBW babies. Prevention of premature delivery, proper management of very low birth weight babies and early detection and appropriate management of perinatal hypoxia have become important interventional strategies in reducing early neonatal deaths in KMCTH. Conclusion: Early neonatal mortality at KMCTH is fairly low. Good care during pregnancy, labour and after the birth of the baby has helped to achieve these results. Low cost locally made equipments were used to manage the sick newborns. Reduction of early neonatal deaths require more intensive care including use of ventilators, surfactant and parenteral nutrition and prevention of preterm births.

Hemoglobin status in children in the age group 6 to 60 months.

Objective of this study was to see the prevalence rate of anemia in children among the age of 6-60 months who attended paediatric out patient department of Kathmandu Medical College. 100 children aged 6-60 months were randomly selected for hemoglobin measurement and anthropometry. Detailed clinical examination including anthropometry was done. Hemoglobin was checked by Hemocue machine with prior consent from the attendant. Mean height, weight, and body mass index (BMI) were measured. Forty six percent of the study group population had hemoglobin <11 gm/dl, similar numbers of the children were in the various state of malnutrition. Twenty eight percent of the children came from outside of the valley residing in Kathmandu. Fifty percent were illiterate or had primary level education only. Poverty, high rate of illiteracy and lack of awareness on taking appropriate food were important factors related to such a high childhood anemia. Iron supplementation should be given to the children particularly in the age group of 6 months to 3 years.

Two year audit of perinatal mortality at Kathmandu Medical College Teaching Hospital.

INTRODUCTION: Perinatal mortality rate is a sensitive indicator of quality of care provided to women in pregnancy, at and after child birth and to the newborns in the first week of life. Regular perinatal audit would help in identifying all the factors that play a role in causing perinatal deaths and thus help in appropriate interventions to reduce avoidable perinatal deaths. AIMS AND OBJECTIVES: This study was carried out to determine perinatal mortality rate (PMR) and the factors responsible for perinatal deaths at KMCTH in the two year period from November 2003 to October 2005 (Kartik 2060 B.S. to Ashoj 2062). METHODOLOGY: This is a prospective study of all the still births and early neonatal deaths in KMCTH during the two year period from November 2003 to October 2005. Details of each perinatal death were filled in the standard perinatal death audit forms of the Department of Pediatrics, KMCTH. Perinatal deaths were analyzed according to maternal characteristics like maternal age, parity, type of delivery and fetal characteristics like sex, birth weight and gestational age and classify neonatal deaths according to Wigglesworth's classification and comparison made with earlier similar study. RESULTS: Out of the 1517 total births in the two year period, 22 were still births (SB) and 10 were early neonatal deaths (ENND). Out of the 22 SB, two were of < 1 kg in weight and out of 10 ENND, one was of <1 kg. Thus, perinatal mortality rate during the study period was 19.1 and extended perinatal mortality rate was 21.1 per 1000 births. The important causes of perinatal deaths were extreme prematurity, birth asphyxia, congenital anomalies and associated maternal factors like antepartum hemorrhage and most babies were of very low birth weight. According to Wigglesworth's classification, 43.8% of perinatal deaths were in Group I, 12.5% in Group II, 28.1% in Group III, 12.5% in Group IV and 12.5% in Group V. DISCUSSION: The perinatal death audit done in KMCTH for 1 year period from September 2002 to August 2003 showed perinatal mortality rate of 30.7 and extended perinatal mortality rate of 47.9 per 1000 births. There has been a significant reduction in the perinatal mortality rate in the last 2 years at KMCTH. Main reasons for improvement in perinatal mortality rate were improvement in care of both the mothers and the newborns and the number of births have also increased significantly in the last 2 years without appropriate increase in perinatal deaths. CONCLUSION: Good and regular antenatal care, good care at the time of birth including appropriate and timely intervention and proper care of the sick neonates are important in reducing perinatal deaths. Prevention of preterm births, better care and monitoring during the intranatal period and intensive care of low birth weight babies would help in further reducing perinatal deaths. Key words: Perinatal mortality rate (PMR), still births, early neonatal death (ENND), Total perinatal death (PND).

Prevalence of childhood and adolescent disabilities in rural Nepal.

The study aimed to determine the number of children and young people reported as having a disability by family members, and to classify impairments leading to disability. A Cross-sectional census was conducted of all households in 24 rural geopolitical units of Makwanpur district, Nepal. Heads of household were asked about family members under the age of 20 with disability. Such members were resident in 733 of 28,376 households, a household prevalence of 2.58%. 829 people under the age of 20 were reported as having a disability, a population prevalence of 0.95%. The commonest functional impairments reported were motor and the commonest anatomical impairments involved the limbs. More males with disability were identified than females.

One year follow up study of term babies born at Kathmandu medical college teaching hospital.

OBJECTIVE: To study the mean, standard deviation and centiles for anthropometry and haemoglobin in healthy term infants followed up to 12 months of age. DESIGN: Cohort study. SETTINGS: Kathmandu Medical College Teaching Hospital (KMCTH) in Kathmandu. SUBJECT: Consecutive healthy term newborns Method: 100 consecutive healthy term newborns were enrolled at birth.19 babies were lost in follow up. So, 81(45 male, 36 female) healthy, full term infants were followed up from birth to 12 months of age. Anthropometry (weight, length, and head circumference) and haemoglobin were measured at birth, 6 weeks, 6 months, 9 months and 12 months of age. Haemoglobin was estimated by Hemocue microcuvette method. The data so obtained was subjected to statistical analysis by using SPSS computer package. MAIN OUTCOMES: Mean, centile and standard deviation score values for weight (Kgs), infant length (cms), head circumference (cms) and haemoglobin (gm/dl) at birth, 6 weeks, 6 months, 9 months and 12 months of age. RESULTS: Out of 100 babies enrolled, data presented here is for the remaining 81 babies. Among 81 babies, 76 were appropriate for gestational age (AGA) and 3 were small for gestation (SFD). The mean, standard deviation and percentile values are presented for anthropometry (weight, length and head circumference) and haemoglobin at birth, 6 weeks, 6 months, 9 months and 12 months of age. The mean birth weight was 3.05 kg (SD 0.41). The mean infant length and head circumference at birth were 49 cm (2.28) and 33.8 cm (SD1.4) respectively. The mean haemoglobin at birth was 15.7 gm/dl (SD 2.29). At 12 months of age mean weight, length, head circumference and haemoglobin were 9 kg (SD 0.81), 73.5 cm (SD 2.9), 45 cm (SD 1.2 ) and 11.1 gm/dl (SD 1.41) respectively. Almost 50% of the babies at 6 weeks, 9 months and 12 months of age were found to be anaemic (Hb < 11 gm/dl). Among the babies, 49% were exclusively breast fed for 6 months of age. Other feeding practices seen were, mothers breast feed with water supplementation (25%), mothers breast feeding with formula feed (16%) and formula feeding only (5%). National and international comparisons of anthropometry and haemoglobin data are shown in table.

Perinatal death audit.

Perinatal mortality rate (PMR), which indicates quality of care provided to women in pregnancy, at and after child birth and to the newborns in the first week of life, is high in Nepal. Published results show wide variation in PMR in the country. Higher rates are in the community and hospitals outside Kathmandu. Reduction of PMR is an important strategy in improving maternal and neonatal health and requires identification of factors related to perinatal deaths. Perinatal death audit is a process of assessing factors related to a perinatal death. It helps in reducing perinatal mortality by identifying preventable factors related to perinatal deaths. Classifying perinatal deaths into 5 groups of Wigglesworth helps in identifying major obstetric or neonatal factors related perinatal deaths. Major factors related to perinatal deaths in Nepal are poor antenatal care, poor monitoring and assistance at birth and lack of adequate neonatal care services. Regular perinatal audit would identify factors and lapses related to perinatal deaths and thus help in taking appropriate interventions to reduce avoidable perinatal deaths.

One year audit of perinatal mortality at Kathmandu Medical College Hospital.

INTRODUCTION: Perinatal mortality is a sensitive indicator of the quality of service provided to pregnant women and their new borns. Regular audit of perinatal mortality will help in finding out preventive factors and thus helps in reducing perinatal mortality rate in an institution. OBJECTIVE: This study was carried out to determine perinatal mortality rate (PMR) and the factors associated with it at KMCTH in the one year period (Bhadra 2059-Shrawan 2060) MATERIALS AND METHODS: This is a retrospective study of entire still births and early neonatal deaths that occurred at KMCTH during the one year period (Bhadra 2059-Shrawan 2060). The study was done by collecting the data of all stillbirths and early neonatal deaths from record books of the Special Care Baby Unit, Labour Room and operation theatre. RESULTS: Out of 563 total births in the one year study period, 17 were still births (SB) and 10 were early neonatal death (ENND). Out of 17 SB, 7 were of < 1 kg and out of 10 ENND, 3 were of < 1 kg. Thus, perinatal mortality rate during the study period was 30.7 and extended perinatal mortality rate was 47.9 per 1000 births. Perinatal deaths were mostly due to extreme prematurity, birth asphyxia, septicemia and congenital anomalies. According to Wiggleworths classification, 18.5% of perinatal deaths were in Group I, 14.8% in Group II, 22.3% in Group III, 40.7% in Group IV and 3.7% in Group V. Intrapartum asphyxia was the commonest cause of perinatal deaths, but majority of these babies were of low birth weight. Prevention of preterm births, better care during intrapartum period, more intensive care of very low birth weight and preterm babies would help in reducing the present high perinatal mortality.

A case report of Gilbert Syndrome.

Gilbert syndrome is benign, often familial condition characterized by recurrent but asymptomatic mild unconjugated hyperbilirubinemia in the absence of haemolysis or underlying liver disease. If, it becomes apparent, it is not until adolescence and then usually in association with stress such as intercurrent illness, fasting or strenuous exercise. Virtually all patients have decreased level of UDP-Glucuronosyltransferase, but there also is evidence for a defect in hepatic uptake of bilirubin as well. This case is reported due to its rarity. The prevalence of Gilbert syndrome in U.S is 3-7% of the population.

Reye's syndrome.

Five and half years male child with one day history of pain abdomen and vomiting who was on aspirin for suspected rheumatoid arthritis presented initially with acute gastritis. Next day, however he developed the signs of encephalopathy with altered liver function.

A case report of Wilson's disease.

Wilson's disease (hepatolenticuler degeneration), an inborn error of copper metabolism, is an autosomal recessive disorder characterized by degenerative changes in brain, liver disease and Kayser Fleisher (KF) rings in the cornea. It is due to a defect of p-type ATPase which is probably required for normal extrusion of copper from cells. In this case report, we present a seven and half year old male who presented with complaints of slurring of speech, drooling of saliva, intentional tremor and dark pigmentation over face and trunk for last 9 months. On examination KF ring was present, spleen was palpable and intentional tremor was present. Laboratory investigations confirmed the diagnosis.

An Apgar score of three or less at one minute is not diagnostic of birth asphyxia but is a useful screening test for neonatal encephalopathy.

OBJECTIVE: To evaluate the relationship between an Apgar score of three or less at one minute of life and the subsequent risk of developing neonatal encephalopathy (NE). DESIGN: Prospective. SETTING: The principal maternity hospital of Kathmandu, Nepal, a low income country, where over 50% of the local population deliver. METHODS: All liveborn infants over a 12 month period with a birthweight of 500 g or more were assessed by the Apgar scoring system at one minute of age. All term infants with neurological abnormalities presenting in the first day of life were systematically examined and described according to a conventionally defined encephalopathy grading system. Major congenital malformations and neonatal infections were excluded. RESULTS: Over 12 months there were 14,771 total births of a weight of 500 g or more of which 14,371 were live births and 400 were stillbirths. Of 734 infants with 1 min Apgar of three or less, 91 developed NE. The positive and negative predictive values of 1 min Apgar of three or less for NE were 11.4% and 99.9%, respectively. The probability of developing NE rose from 0.6% (amongst all infants born at this hospital) to 11.2% (amongst infants born with a one minute Apgar of three or less). CONCLUSIONS: An Apgar score of 3 or less at one minute is a useful screening test for clinically significant birth asphyxia (NE). It overestimates by eight fold the scale of the birth asphyxia problem, but identifies a high risk group requiring further observation of their neurological condition.