Very low prevalence and no clinical significance of occult hepatitis B in a cohort of HIV-infected patients with isolated anti-HBc seropositivity: the BHOI study

PURPOSE

Data on occult HBV infection in HIV patients are conflicting. We aimed to analyse the prevalence and clinical significance of occult hepatitis B in HIV-infected subjects.

METHOD

An open-label, cross-sectional, multicentre study including all subjects with isolated anti-HBc seropositivity from a cohort of 3,030 HIV-infected patients was undertaken. HBsAg and HBsAb were both negative in all cases, and those patients with acute or convalescent hepatitis B were excluded. HBV DNA was quantified by PCR with a detection limit of 20 IU/mL.

RESULTS

We found 5 cases (2.5%) of occult hepatitis B among 202 HIV-patients with isolated anti-HBc. The mean HBV DNA was 66 (15-112) IU/mL, none had symptomatic hepatitis, and their features, including aminotransferase levels, were similar to those without occult HBV infection.

CONCLUSIONS

Occult hepatitis due to HBV is very unusual in HIV-positive patients with isolated anti-HBc. The use of standard regimens of HAART including drugs with activity against HBV might underestimate the prevalence of occult HBV infection. These patients had a very low viral load, no identifiable risk factors, and no greater risk of hypertransaminasaemia or the development of symptomatic hepatitis.

Mycobacterium gordonae urinary infection in a renal transplant recipient

The authors present a case of urinary infection by a non-tuberculous mycobacteria (NTM) species, Mycobacterium gordonae, in a renal transplant recipient. A 29-year-old female patient had persistent sterile pyuria after her second kidney transplant. An NTM, M. gordonae, was isolated, and the patient was started on antituberculous treatment, with resolution of leukocyturia. Ureteral stenosis with hydronephrosis and deterioration of allograft function was diagnosed later on and, despite the introduction of intraureteral catheter and resolution of hydronephrosis, there was no recovery of baseline renal function. She ultimately resumed dialysis after a severe pyelonephritis. The authors discuss the problems of establishing diagnosis of infection (versus colonization) by NTM and highlight the difficulty of treating these infections, especially because of the possible interaction with immunosuppressant agents, facilitating anti-allograft immune response.

Effectiveness and safety of simplification from tenofovir-lamivudine (TDF-3TC) to tenofovir-emtricitabine (TDF-FTC) co-formulation (Truvada) in virologically suppressed HIV-infected patients on HAART

The objective was to evaluate the effectiveness and safety of simplification from tenofovir-lamivudine (TDF-3TC) to Truvada (TVD) in virologically suppressed HIV patients. We carried out an open-label, multicentre, non-controlled study of HIV patients on a stable regimen including TDF-3TC who switched from TDF-3TC to TVD. Viral load responses at 24 and 48 weeks were evaluated. Changes in the calculated glomerular filtration rates (cGFR; Cockcroft-Gault equation) were analysed at baseline and at 24 and 48 weeks. Patients with drug-related nephrotoxicity (cGFR < 60 mL/min at 48 weeks or interruption of TVD because of renal toxicity) were analysed in detail. Two hundred and ninety-five patients with a mean time on TDF-3TC of 19.9 months (range 8.8-29.8) were enrolled. The third drug was a non-nucleoside reverse transcriptase inhibitor, which was administered to 187 patients (76.4% efavirenz) and a protease inhibitor was administered to 108 (43.5% lopinavir/ritonavir). At 48 weeks, 85.7% of the patients were still taking the same regimen, all with an undetectable viral load. The cGFR (mL/min) decreased from baseline (111 [89-130]) to 48 weeks (105 [84-121]); p < 0.0001. The percentage of patients with a cGFR <60 mL/min at 48 weeks was 3.5. Six patients ceased TVD because of drug-related nephrotoxicity. The only factors associated with nephrotoxicity were age, baseline weight and cGFR. Simplification from TDF-3TC to TVD was associated with a decrease in cGFR, with a low prevalence of nephrotoxicity at 48 weeks.

Long-term prognosis of HIV-infected patients with Kaposi sarcoma treated with pegylated liposomal doxorubicin

INTRODUCTION

Incidence of Kaposi sarcoma (KS) in human immunodeficiency virus (HIV)-infected persons has dramatically decreased in the highly active antiretroviral therapy era. However, this tumor still represents the most common cancer in this population.

OBJECTIVES

The objectives of this study were to evaluate long-term prognosis of HIV-infected patients with KS who had received pegylated liposomal doxorubicin (PLD) and, more specifically, to assess tumor relapse rate, mortality, and cause of death in these subjects.

DESIGN

This study was a retrospective review of all patients with KS who had received PLD in centers belonging to the Caelyx/KS Spanish Group. Kaplan-Meier analysis and univariate and multivariate Cox-regression analysis were used to assess the rate of and factors associated with relapse and death through January 2006.

RESULTS

A total of 98 patients received PLD from September 1997 through June 2002. Median follow-up after initiation of treatment was 28.7 months (interquartile range, 6.6-73.2 months); during follow-up, 29 patients died (a mortality rate of 14.6% per year). In 9 patients (31%), the cause of death was related to the appearance of other tumors (including 7 lymphomas, 1 gastrointestinal adenocarcinoma, and 1 tongue epidermoid cancer). Death caused by progression of KS occurred in 3 cases. Death risk was inversely related to CD4(+) cell counts at the end of follow-up (hazard ratio for every increase in CD4(+) cell count of 100 cells/microL, 0.7; 95% confidence interval, 0.5-0.9). A relapse study was performed for 61 patients who had complete or partial response to PLD and who attended a control visit after treatment completion. After a median follow-up of 50 months (interquartile range, 17.2-76 months), 8 patients (13%) had experienced relapse; 5 of these patient experienced relapse within the first year after stopping PLD. The only factor that was independently related to risk of relapse was having a CD4(+) cell count >200 cells/microL at baseline (hazard ratio, 6.2; 95% confidence interval, 1.2-30). Lower CD4(+) cell count at the end of follow-up was marginally associated with relapse (hazard ratio for every increase in CD4(+) cell count of 100 cells/microL, 0.7; 95% confidence interval, 0.6-1.01).

CONCLUSIONS

Treatment of KS with PLD in HIV-infected patients is followed by a low relapse rate, with most relapses occurring during the first year after stopping chemotherapy. However, the mortality rate in this population was high, in part because of an unexpectedly high incidence of other tumors, mainly lymphomas.

Impact assessment in living kidney donation: psychosocial aspects in the donor

BACKGROUND

Living donor kidney transplantation has a positive influence on graft survival and recipient quality of life (QoL). We assessed the psychosocial impact of donation to the donor.

METHODS

Before and after the procedure 32 living kidney donors (mean age 41 years) completed the Zung Self-Rating Anxiety and Depression Scales; a Sociodemographic, Short-Form 36 Health Survey (SF-36), and a Donation Perceptions Questionnaire.

RESULTS

Living kidney donors were siblings (62.5%), parents (34.4%), or a daughter (3.1%). Transplantation was not successful in two cases: one recipient death and one graft failure. No significant changes were observed in donor QoL except for the SF-36 social functioning subscale that showed significant improvement after donation (P = .038). A reduction in depression symptom frequency was verified after donation (from 65.6% to 46.9%). There was an almost significant decrease in depression scores (P = .077), which was in fact was significant when one considered only successful transplants (P = .021). There was no significant variation in anxiety scores among donors. Time since transplantation was inversely correlated with overall anxiety (r = .443, P = .011), and with somatic anxiety subscales (r = .357, P = .045). For most donors, the decision to donate was easy and spontaneous. Nearly all donors would donate again and strongly encourage others to donate.

CONCLUSIONS

Except for the social functioning scale that improved, no significant changes were observed in QoL of living kidney donors after the procedure. Depression scores significantly decreased after donation, but anxiety scores remained stable. Donors, who were mostly siblings, showed positive perceptions about donation, did not regret their decision, and strongly recommend it to others.

TÉCNICAS PARA AVALIAÇÃO IN VITRO DO EFEITO DE HERBICIDAS SOBRE BACILLUS THURINGIENSIS BERLINER VAR. KURSTAKI

RESUMO Objetivou-se comparar técnicas para a avaliação in vitro do efeito de herbicidas sobre Bacillus thuringiensis Berliner var. kurstaki (Btk). Foram testados os herbicidas sulfentrazone, lactofen, imazethapyr, fenoxaprop e metribuzin em duas concentrações, sobre células e esporos, em meio ágar nutriente sólido (MS) e caldo nutriente (CN) - líquido (ML), além da metabolização (MT) de tais produtos por Btk. Para células em MS, os herbicidas foram testados incorporados ao meio e em discos de papel-filtro impregnados nos produtos. Avaliou-se, respectivamente, as unidades formadoras de colônia por mililitro (UFC/mL) e a formação de halo de inibição. Para células, a mistura Btk + produtos + CN foi incubada em frascos erlemmeyer (30 ± 2° C, 150 rpm, 24h) e, em seguida, a mistura foi diluída e inoculada em MS, avaliando-se o número de UFC/mL. Os testes de MT e esporos foram realizados em líquido (água para MT e CN para esporos). O efeito dos produtos variou conforme a concentração utilizada, técnica de avaliação e a fase/estágio do microrganismo, sendo a técnica de avaliação em ML a mais indicada para a avaliação do efeito dos herbicidas sobre células de Btk, pois não apresenta limitações para difusão e permite quantificação. Os herbicidas, independentemente da concentração, foram incompatíveis para a célula, porém sulfetrazone e imazethapyr foram metabolizados por Btk. Todos herbicidas foram compatíveis com esporos, possibilitando a germinação, porém a concentração e tempo influenciaram nos resultados.

Report on the World Health Organization Global Observatory for eHealth strategic planning workshop, April 2008

The World Health Organization's Global Observatory for eHealth (GOe) conducted its first strategic workshop at Bellagio, Italy on April 9 to 11, 2008. Supported by a grant from the Rockefeller Foundation, the workshop brought together a select group of twenty-one eHealth experts from around the globe to help plan for the future of the Observatory. Participants were chosen from all six WHO regions and included a mix of researchers, practitioners, specialist physicians, academics and consultants. Key issues addressed included: how to build a dynamic and cohesive network of National Observatories to improve worldwide eHealth data collection; analysis and reporting; developing Thematic Working Groups in specialist eHealth themes; eHealth assessment frameworks; the development of the research agenda for the second global survey; cultivating partnerships; and governance.

The influence of HLA mismatches and immunosuppression on kidney graft survival: an analysis of more than 1300 patients

New immunosuppressive drugs used in kidney transplantation decreased the incidence of acute rejection. It was hypothesized that, with their power, the importance of HLA matching was decreased. To evaluate the influence of HLA matching, immunosuppression, and other possible risk factors, we analyzed data of 1314 consecutive deceased donor kidney transplantation. We divided the patient population into 4 cohorts, according to the era of transplantation: era 1, before 1990, azathioprine (Aza) and cyclosporine (Csa) no microemulsion; era 2, between 1990 and 1995, Csa microemulsion; era 3, between 1996 and 2000, wide use of mycophenolate mofetil (MMF) and anti-thymocyte globulin (ATG); and era 4, after 2000, marked by sirolimus and tacrolimus (TAC) use. Multivariate analysis compared death-censored graft survival. Using as reference the results obtained with 0 HLA mismatches, we verified, during era 1 and era 2, an increased risk of graft loss for all of the subgroups with HLA mismatch >0. However, during era 3 and era 4, the number of HLA mismatches did not influence graft survival. Although acute rejection and delayed graft function, which decreased in the later periods, remained as prognostic factors for graft loss. Considering the immunosuppressive protocol with Csa+Aza+Pred as reference, protocols used after 1995 with Pred+Csa+ATG, with Pred+Csa+MMF, and with Pred+Tac+MMF presented better survival results. Results showed that the significance of HLA matching decreased while the results improved with the new immunosuppressant drugs. These observations support the hypothesis that the weakened importance of HLA matching may be a consequence of the increasing efficacy of the immunosuppression.

Cervical lipomatosis in HIV-infected patients: a case-control study

OBJECTIVES

The aim of the study was to analyse the prevalence of cervical lipomatosis (CL) in HIV-infected patients on highly active antiretroviral therapy (HAART) and the factors associated with its development.

METHODS

This was a multicentre, observational, 1:1 case-control study. HIV-infected patients with CL (cases) and HIV-infected patients from the same cohort, controlled for age (+/-5 years), sex and body mass index (+/-2.5 kg/m(2)) (controls), were included in the study, and a multiple conditional logistic regression was performed to identify factors related to CL.

RESULTS

CL was reported in 80 patients (1.8%) from a cohort of 4214 patients on HAART followed up in 10 Spanish hospitals. CL was associated with time of exposure to stavudine [for each 6-month increase, odds ratio (OR) 5.82, 95% confidence interval (CI) 5.70-5.94, P=0.0073] and lipoatrophy (OR 8.04, 95% CI 2.93-22.02, P=0.00001).

CONCLUSIONS

Although lipodystrophy is very frequent among HIV-infected patients on HAART, CL is an uncommon type of fat redistribution in this population, and in our cohort it was related to time of exposure to stavudine and lipoatrophy.

Incidence and prevalence of the metabolic syndrome in a cohort of naive HIV-infected patients: prospective analysis at 48 weeks of highly active antiretroviral therapy

We undertook a prospective study to assess the prevalence of the metabolic syndrome (MetS) in HIV patients at the start of highly active antiretroviral therapy (HAART), and at 48 weeks, and we also studied its relationship with high-sensitivity C-reactive protein (hs-CRP) in 60 HIV patients who maintained the same regimen during follow-up. The prevalence of MetS rose from 16.6% at baseline to 25% at 48 weeks (P=0.0001). During follow up, 7/50 patients developed MetS, leading an incidence of 14/100 patients/year. The MetS was associated with age, homosexuality, and lower hepatitis C virus prevalence; only age remained significant in the multivariate analysis (for each five-year increase: beta coefficient 4.26, 95% confidence interval, 3.80-4.75; P=0.0039). The hs CRP values were similar in patients with and without the MetS, and they did not increase at 48 weeks of HAART.

Cardiac remodeling and dysfunction in nephrotic syndrome

There is an increased incidence of heart disease in patients with chronic nephrotic syndrome (NS), which may be attributable to the malnutrition and activated inflammatory state accompanying the sustained proteinuria. In this study, we evaluated renal function, cardiac morphometry, contractile function, and myocardial gene expression in the established puromycin aminonucleoside nephrosis rat model of NS. Two weeks after aminonucleoside injection, there was massive proteinuria, decreased creatinine clearance, and a negative sodium balance. Skeletal and cardiac muscle atrophy was present and was accompanied by impaired left ventricular (LV) hemodynamic function along with decreased contractile properties of isolated LV muscle strips. The expression of selected cytokines and proteins involved in calcium handling in myocardial tissue was evaluated by real time polymerase chain reaction. This revealed that the expression of interleukin-1beta, tumor necrosis factor-alpha, and phospholamban were elevated, whereas that of cardiac sarco(endo)plasmic reticulum calcium pump protein was decreased. We suggest that protein wasting and systemic inflammatory activation during NS contribute to cardiac remodeling and dysfunction.