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Wearne N, Davidson B. HIV-associated kidney disease: the changing spectrum and treatment priorities. Curr Opin Nephrol Hypertens 2024:00041552-990000000-00182. [PMID: 39155827 DOI: 10.1097/mnh.0000000000001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
PURPOSE OF REVIEW This review examines the impact of HIV on kidney disease, which remains significant despite advances in antiretroviral therapy (ART). The review is timely due to the shifting epidemiology of kidney disease in people with HIV (PWH), driven by increased ART access, noncommunicable diseases, and region-specific opportunistic infections like tuberculosis. RECENT FINDINGS The literature highlights a decline in HIV-associated nephropathy (HIVAN) and a rise in tubulointerstitial diseases and noncommunicable diseases among PWH. Studies from the United States and South Africa report decreased HIVAN prevalence and increased rates of tubulointerstitial diseases linked to tenofovir disoproxil fumarate (TDF) toxicity and tuberculosis (TB). Immune complex glomerulonephritis (ICGN) and diabetic kidney disease (DKD) are also prevalent. SUMMARY The findings underscore the need for improved diagnostic tools for opportunistic infections, management of ART-related complications, and strategies to address noncommunicable diseases in PWH. There is a need to centralize care to address all health needs simultaneously. Future research should focus on APOL1-targeted therapies and the role of SGLT2 inhibitors in CKD. Enhanced transplantation outcomes and the development of guidelines for managing DKD in PWH are critical for advancing clinical practice and improving patient outcomes.
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Affiliation(s)
- Nicola Wearne
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, South Africa
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Ajantha P, Puri MM, Tayal D, Khalid U. Urinary lipoarabinomannan in individuals with sputum-negative pulmonary tuberculosis. Indian J Med Res 2024; 159:206-212. [PMID: 38577859 PMCID: PMC11050756 DOI: 10.4103/ijmr.ijmr_2074_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND OBJECTIVES Tuberculosis (TB) is a major global cause of ill health. Sputum microscopy for confirmation of presumptive pulmonary TB (PTB) has a reportedly low sensitivity of 22-43 per cent for single smear and up to 60 per cent under optimal conditions. National TB Elimination Programme in India recommends the use of cartridge-based nucleic acid amplification test (CBNAAT) and culture for microbiological confirmation in presumptive PTB individuals with sputum smear negative test. The use of lateral flow urine lipoarabinomannan (LF-LAM) is usually recommended for the diagnosis of TB in HIV-positive individuals with low CD4 counts or those who are seriously ill. The objective of this study was to detect urinary LAM using cage nanotechnology that does not require a physiologic or immunologic consequence of HIV infection for LAM quantification in human urine in 50 HIV-seronegative sputum smear-negative PTB individuals. METHODS To study the diagnostic value of urinary LAM in sputum smear negative PTB individuals, a cage based nanotechnology ELISA technique was used for urinary LAM in three different groups of participants. Fifty smears negative PTB clinically diagnosed, 15 smear positive PTB and 15 post TB sequel individuals. Sputum was tested by smear, CBNAAT, and culture along with urine LAM before treatment. The results were interpreted by ROC curve in comparison to the standard tests like CBNAAT and culture. RESULTS The mean urinary LAM value was 0.84 ng/ml in 37 culture-positive [Mycobacterium tuberculosis (M.tb)] and 0.49 ng/ml in 13 culture-negative (M.tb) smear-negative individuals with PTB, respectively. In 47 smear-negative PTB cases with microbiologically confirmed TB by CBNAAT, the mean urinary LAM was 0.76 ng/ml. The mean urinary LAM in post-TB sequel individuals was 0.47 ng/ml. As per the receiver operating characteristic curve, cut-off value of urinary LAM in individuals with smear-negative PTB microbiologically confirmed by: (i) CBNAAT was 0.695 ng/ml and (ii) culture was 0.615 ng/ml. INTERPRETATION CONCLUSIONS The findings of this study suggest that individuals with smear-negative PTB and a urinary LAM value of >0.615 ng/ml were most likely to have microbiological confirmed TB while those with a LAM value <0.615 ng/ml >0.478 ng/ml are less likely and those with a value <0.478 ng/ml are unlikely to have microbiological confirmed TB.
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Affiliation(s)
- P. Ajantha
- Department of TB and Chest, National Institute of Tuberculosis & Respiratory Diseases, New Delhi, India
| | - Man Mohan Puri
- Department of TB and Chest, National Institute of Tuberculosis & Respiratory Diseases, New Delhi, India
| | - Devika Tayal
- Department of Bio-chemistry, National Institute of Tuberculosis & Respiratory Diseases, New Delhi, India
| | - U. Khalid
- Department of Epidemiology, National Institute of Tuberculosis & Respiratory Diseases, New Delhi, India
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Zhang Y, Chen S, Wei H, Zhong Q, Yuan Y, Wang Y, Lou J, Zhang X. Breakthrough of chemiluminescence-based LAM urine test beyond HIV-positive individuals: Clinical diagnostic value of pulmonary tuberculosis in the general population. Medicine (Baltimore) 2023; 102:e36371. [PMID: 38050275 PMCID: PMC10695621 DOI: 10.1097/md.0000000000036371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/08/2023] [Indexed: 12/06/2023] Open
Abstract
To investigate the diagnostic value of a novel high-sensitivity urine lipoarabinomannan (LAM) test (chemiluminescence-based) for active tuberculosis in the general population. A retrospective study was conducted on 250 clinical suspected tuberculosis patients who were HIV-negative and visited the Fourth People's Hospital of Foshan from January 2022 to December 2022. Among them, there were 135 cases of pulmonary tuberculosis, 34 cases of extrapulmonary tuberculosis, and 81 cases of non-tuberculosis. Urine samples were collected for LAM antigen detection before treatment, and laboratory data of sputum smear acid-fast staining (smear method), sputum culture, and GeneXpert method were collected. Using clinical diagnosis as the reference standard, the diagnostic efficacy of 4 methods for detecting active tuberculosis was evaluated. For the 135 cases of pulmonary tuberculosis, the sensitivity of sputum smears, sputm culture, sputm GeneXpert method, and urine LAM were 29.6% (40/135), 45.9% (62/135), 59.3% (80/135), and 51.9% (70/135), respectively. The combination of LAM + GeneXpert and LAM + culture had the highest sensitivity for detecting active pulmonary tuberculosis, which were 71.0% and 78.2%, respectively. For the detection of sputum culture-negative pulmonary tuberculosis, the positive rates of smear, GeneXpert, and LAM were 0.0% (0/73), 53.4% (39/73), and 52.1% (38/73), respectively. LAM + smear and LAM + Genexpert could detect 52.1% and 68.5% of sputum culture-negative patients, respectively. The high-sensitivity urine LAM test holds promise for tuberculosis diagnosis in the general population. It demonstrates high-sensitivity, enabling the detection of sputum culture-negative pulmonary tuberculosis patients. Furthermore, when combined with existing methods, it can enhance the overall detection rate.
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Affiliation(s)
- Yingxuan Zhang
- Department of Tuberculosis, The Fourth People’s Hospital of Foshan, Jinlan South Road, Foshan, China
| | - Shihao Chen
- Department of Tuberculosis, The Fourth People’s Hospital of Foshan, Jinlan South Road, Foshan, China
| | - Hongxia Wei
- Leide Biosciences Co., Ltd, China, Lanyue Road, Guangzhou, China
| | - Qianhong Zhong
- Department of Tuberculosis, The Fourth People’s Hospital of Foshan, Jinlan South Road, Foshan, China
| | - Yiwu Yuan
- Department of Tuberculosis, The Fourth People’s Hospital of Foshan, Jinlan South Road, Foshan, China
| | - Yongping Wang
- Department of Tuberculosis, The Fourth People’s Hospital of Foshan, Jinlan South Road, Foshan, China
| | - Jianrong Lou
- Leide Biosciences Co., Ltd, China, Lanyue Road, Guangzhou, China
| | - Xilin Zhang
- Department of Tuberculosis, The Fourth People’s Hospital of Foshan, Jinlan South Road, Foshan, China
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Kalyesubula R, Wearne N, Kubo M, Hussey N, Naicker S. HIV and Associated TB: A Lethal Association for Kidney Health? Semin Nephrol 2023; 43:151470. [PMID: 38245391 DOI: 10.1016/j.semnephrol.2023.151470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
Human immunodeficiency virus (HIV) and tuberculosis (TB) are the leading infectious causes of death globally. The combined brunt of these diseases is experienced mainly in low-income and lower-middle-income countries. HIV/TB have devastating effects on the kidneys, leading to accelerated decline of kidney function as well as mortality. Managing the triad of TB/HIV and kidney disease is challenging. We discuss the epidemiology of HIV/TB coinfection and the kidney and the key mechanisms of kidney disease including genetic susceptibility. The clinical presentation and pathology, as well as the challenges of diagnosing CKD in these patients, also are discussed. The strategies to prevent and manage HIV/TB-related kidney disease such as proper assessment, avoiding nephrotoxic regimens, drug dose adjustments, kidney function monitoring, avoidance of drug-drug interactions, and other interventions are explored. We also briefly discuss the complexities around HIV/TB patients on dialysis and kidney transplantation. HIV/TB coinfection presents an increased risk for kidney-related morbidity and mortality; patients with this triad need to be given special consideration for future research and management.
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Affiliation(s)
- Robert Kalyesubula
- Department of Physiology and Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Nicola Wearne
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Mary Kubo
- Department of Clinical Medicine and Therapeutics, East African Kidney Institute, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya.
| | - Nadia Hussey
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Saraladevi Naicker
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Broger T, Koeppel L, Huerga H, Miller P, Gupta-Wright A, Blanc FX, Esmail A, Reeve BWP, Floridia M, Kerkhoff AD, Ciccacci F, Kasaro MP, Thit SS, Bastard M, Ferlazzo G, Yoon C, Van Hoving DJ, Sossen B, García JI, Cummings MJ, Wake RM, Hanson J, Cattamanchi A, Meintjes G, Maartens G, Wood R, Theron G, Dheda K, Olaru ID, Denkinger CM. Diagnostic yield of urine lipoarabinomannan and sputum tuberculosis tests in people living with HIV: a systematic review and meta-analysis of individual participant data. Lancet Glob Health 2023; 11:e903-e916. [PMID: 37202025 DOI: 10.1016/s2214-109x(23)00135-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/19/2023] [Accepted: 02/27/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Sputum is the most widely used sample to diagnose active tuberculosis, but many people living with HIV are unable to produce sputum. Urine, in contrast, is readily available. We hypothesised that sample availability influences the diagnostic yield of various tuberculosis tests. METHODS In this systematic review and meta-analysis of individual participant data, we compared the diagnostic yield of point-of-care urine-based lipoarabinomannan tests with that of sputum-based nucleic acid amplification tests (NAATs) and sputum smear microscopy (SSM). We used microbiologically confirmed tuberculosis based on positive culture or NAAT from any body site as the denominator and accounted for sample provision. We searched PubMed, Web of Science, Embase, African Journals Online, and clinicaltrials.gov from database inception to Feb 24, 2022 for randomised controlled trials, cross-sectional studies, and cohort studies that assessed urine lipoarabinomannan point-of-care tests and sputum NAATs for active tuberculosis detection in participants irrespective of tuberculosis symptoms, HIV status, CD4 cell count, or study setting. We excluded studies in which recruitment was not consecutive, systematic, or random; provision of sputum or urine was an inclusion criterion; less than 30 participants were diagnosed with tuberculosis; early research assays without clearly defined cutoffs were tested; and humans were not studied. We extracted study-level data, and authors of eligible studies were invited to contribute deidentified individual participant data. The main outcomes were the tuberculosis diagnostic yields of urine lipoarabinomannan tests, sputum NAATs, and SSM. Diagnostic yields were predicted using Bayesian random-effects and mixed-effects meta-analyses. This study is registered with PROSPERO, CRD42021230337. FINDINGS We identified 844 records, from which 20 datasets and 10 202 participants (4561 [45%] male participants and 5641 [55%] female participants) were included in the meta-analysis. All studies assessed sputum Xpert (MTB/RIF or Ultra, Cepheid, Sunnyvale, CA, USA) and urine Alere Determine TB LAM (AlereLAM, Abbott, Chicago, IL, USA) in people living with HIV aged 15 years or older. Nearly all (9957 [98%] of 10 202) participants provided urine, and 82% (8360 of 10 202) provided sputum within 2 days. In studies that enrolled unselected inpatients irrespective of tuberculosis symptoms, only 54% (1084 of 1993) of participants provided sputum, whereas 99% (1966 of 1993) provided urine. Diagnostic yield was 41% (95% credible interval [CrI] 15-66) for AlereLAM, 61% (95% Crl 25-88) for Xpert, and 32% (95% Crl 10-55) for SSM. Heterogeneity existed across studies in the diagnostic yield, influenced by CD4 cell count, tuberculosis symptoms, and clinical setting. In predefined subgroup analyses, all tests had higher yields in symptomatic participants, and AlereLAM yield was higher in those with low CD4 counts and inpatients. AlereLAM and Xpert yields were similar among inpatients in studies enrolling unselected participants who were not assessed for tuberculosis symptoms (51% vs 47%). AlereLAM and Xpert together had a yield of 71% in unselected inpatients, supporting the implementation of combined testing strategies. INTERPRETATION AlereLAM, with its rapid turnaround time and simplicity, should be prioritised to inform tuberculosis therapy among inpatients who are HIV-positive, regardless of symptoms or CD4 cell count. The yield of sputum-based tuberculosis tests is undermined by people living with HIV who cannot produce sputum, whereas nearly all participants are able to provide urine. The strengths of this meta-analysis are its large size, the carefully harmonised denominator, and the use of Bayesian random-effects and mixed-effects models to predict yields; however, data were geographically restricted, clinically diagnosed tuberculosis was not considered in the denominator, and little information exists on strategies for obtaining sputum samples. FUNDING FIND, the Global Alliance for Diagnostics.
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Affiliation(s)
- Tobias Broger
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Lisa Koeppel
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Helena Huerga
- Field Epidemiology Department, Epicentre, Paris, France
| | - Poppy Miller
- New Zealand Institute for Plant and Food Research, Auckland, New Zealand
| | - Ankur Gupta-Wright
- Institute for Global Health, University College London, London, UK; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - François-Xavier Blanc
- Service de Pneumologie, l'institut du thorax, Nantes Université, CHU Nantes, Nantes, France
| | - Aliasgar Esmail
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa; South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Byron W P Reeve
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marco Floridia
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Trauma Center, University of California San Francisco, San Francisco, CA, USA; Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Fausto Ciccacci
- UniCamillus, International University of Health and Medical Science, Rome, Italy; Community of Sant'Egidio, DREAM programme, Rome, Italy
| | - Margaret P Kasaro
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; UNC Global Projects, LLC Zambia, Lusaka, Zambia
| | - Swe Swe Thit
- Department of Medicine, University of Medicine 2, Yangon, Myanmar
| | | | | | - Christina Yoon
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Daniël J Van Hoving
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa; Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
| | - Bianca Sossen
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Juan Ignacio García
- Population Health Program, Tuberculosis Group, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Matthew J Cummings
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY, USA; Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rachel M Wake
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, Johannesburg, South Africa; Institute for Infection and Immunity, St George's University of London, London, UK
| | - Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Adithya Cattamanchi
- Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, CA, USA
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Robin Wood
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Keertan Dheda
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK; Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, Cape Town, South Africa; South African MRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - Ioana Diana Olaru
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Claudia M Denkinger
- Division of Infectious Disease and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany; German Center for Infection Research, partner site, Heidelberg University Hospital, Heidelberg, Germany.
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Tayal D, Sethi P, Jain P. Point-of-care test for tuberculosis: a boon in diagnosis. Monaldi Arch Chest Dis 2023; 94. [PMID: 37114932 DOI: 10.4081/monaldi.2023.2528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
Rapid diagnosis of tuberculosis (TB) is an effective measure to eradicate this infectious disease worldwide. Traditional methods for screening TB patients do not provide an immediate diagnosis and thus delay treatment. There is an urgent need for the early detection of TB through point-of-care tests (POCTs). Several POCTs are widely available at primary healthcare facilities that assist in TB screening. In addition to the currently used POCTs, advancements in technology have led to the discovery of newer methods that provide accurate and fast information independent of access to laboratory facilities. In the present article, the authors tried to include and describe the potential POCTs for screening TB in patients. Several molecular diagnostic tests, such as nucleic acid amplification tests, including GeneXpert and TB-loop-mediated isothermal amplification, are currently being used as POCTs. Besides these methods, the pathogenic component of Mycobacterium tuberculosis can also be utilized as a biomarker for screening purposes through immunological assays. Similarly, the host immune response to infection has also been utilized as a marker for the diagnosis of TB. These novel biomarkers might include Mtb85, interferon-γ inducible protein-10, volatile organic compounds, acute-phase proteins, etc. Radiological tests have also been observed as POCTs in the TB screening POCT panel. Various POCTs are performed on samples other than sputum, which further eases the screening process. These POCTs should not require large-scale manpower and infrastructure. Hence, POCT should be able to identify patients with M. tuberculosis infection at the primary healthcare level only. There are several other advanced techniques that have been proposed as future POCTs and have been discussed in the present article.
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Affiliation(s)
- Devika Tayal
- Department of Biochemistry, National Institute of Tuberculosis and Respiratory Disease, New Delhi.
| | - Prabhpreet Sethi
- Department of Pulmonary Medicine, National Institute of Tuberculosis and Respiratory Disease, New Delhi.
| | - Prerna Jain
- Department of Biochemistry, National Institute of Tuberculosis and Respiratory Disease, New Delhi.
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Mapamba DA, Sauli E, Lalashowi J, Buza J, John J, Mwaisango Z, Tarmo P, Sabi I, Rachow A, Ntinginya NE, Mtafya B. Performance of Tuberculosis Molecular Bacterial Load Assay Compared to Alere TB-LAM in Urine of Pulmonary Tuberculosis Patients with HIV Co-Infections. Int J Mol Sci 2023; 24:ijms24043715. [PMID: 36835127 PMCID: PMC9965206 DOI: 10.3390/ijms24043715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/20/2023] [Accepted: 02/03/2023] [Indexed: 02/17/2023] Open
Abstract
Alternative tools are needed to improve the detection of M. tuberculosis (M. tb) in HIV co-infections. We evaluated the utility of Tuberculosis Molecular Bacterial Load Assay (TB-MBLA) compared to lipoarabinomannan (LAM) to detect M. tb in urine. Sputum Xpert MTB/RIF-positive patients were consented to provide urine at baseline, weeks 2, 8, 16, and 24 of treatment for TB-MBLA, culture, and LAM. Results were compared with sputum cultures and microscopy. Initial M. tb. H37Rv spiking experiments were performed to validate the tests. A total of 63 urine samples from 47 patients were analyzed. The median age (IQR) was 38 (30-41) years; 25 (53.2%) were male, 3 (6.5%) had urine for all visits, 45 (95.7%) were HIV positive, of whom 18 (40%) had CD4 cell counts below 200 cells/µL, and 33 (73.3%) were on ART at enrollment. Overall urine LAM positivity was 14.3% compared to 4.8% with TB-MBLA. Culture and microscopy of their sputum counterparts were positive in 20.6% and 12.7% of patients, respectively. Of the three patients with urine and sputum at baseline, one (33.33%) had urine TB-MBLA and LAM positive compared to 100% with sputum MGIT culture positive. Spearman's rank correction coefficient (r) between TB-MBLA and MGIT was -0.85 and 0.89 with a solid culture, p > 0.05. TB-MBLA has the promising potential to improve M. tb detection in urine of HIV-co-infected patients and complement current TB diagnostics.
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Affiliation(s)
- Daniel Adon Mapamba
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
- The Nelson Mandela African Institution of Science and Technology, Arusha P.O. Box 447, Tanzania
- Correspondence: ; Tel.: +255-25-250-3364
| | - Elingarami Sauli
- The Nelson Mandela African Institution of Science and Technology, Arusha P.O. Box 447, Tanzania
| | - Julieth Lalashowi
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
| | - Joram Buza
- The Nelson Mandela African Institution of Science and Technology, Arusha P.O. Box 447, Tanzania
| | - Joseph John
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
| | - Zawadi Mwaisango
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
| | - Peter Tarmo
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
| | - Issa Sabi
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
| | - Andrea Rachow
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), 80802 Munich, Germany
- German Center for Infection Research (DZIF), Partner Site Munich, 81675 Munich, Germany
| | - Nyanda Elias Ntinginya
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
| | - Bariki Mtafya
- National Institute for Medical Research—Mbeya Medical Research Centre (NIM-MMRC), Mbeya P.O. Box 2410, Tanzania
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Lyu M, Zhou Y, Chen Y, Lai H, Wang Y, Cheng Y, Li J, Peng W, Liu T, Jiang X, Li M, Zhao Z, Ying B. Exploring the eligibility of all reported lipoarabinomannan-testing assays in different clinical situations: a systematic review and meta-analysis of 97 articles. Int J Infect Dis 2022; 125:19-34. [PMID: 36244601 DOI: 10.1016/j.ijid.2022.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/17/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES How to choose proper lipoarabinomannan-testing assays for diagnosing tuberculosis (TB) in different populations baffles clinicians. This work assessed all reported lipoarabinomannan assays' performance and aimed to identify the eligibility of each assay and offer guidance for clinicians. METHODS We searched PubMed, Embase, and Web of Science until August 23, 2020. The risk of bias was evaluated by QADAS-2. Heterogeneity was evaluated by the Cochran Q test and I2. Sensitivity and specificity were pooled by a bivariate mixed model (register number: CRD42021270506). RESULTS A total of 97 articles, covering 144 trials, 16 assays, 45,679 participants, and eight sample types, were divided into five groups. Electrochemiluminescence (ECL) had a sensitivity of 65%, specificity of 92%, and an area under curve (AUC) of 0.85 in diagnosing pulmonary TB in adults. ECL showed a promising diagnostic ability (sensitivity: 78%; specificity: 88%; AUC: 0.88) in patients with HIV, especially for urine detection (sensitivity: 90%; specificity: 89%; AUC: 0.95). The enzyme-linked immune assay showed a preference for diagnosing TB in Asians and Africans, especially in Africans who were smear-positive (sensitivity: 80%; specificity: 88%; AUC: 0.91). CONCLUSION ECL was recommended for diagnosing pulmonary TB in adults, especially for TB/HIV co-infection. Taking urine as a sample further enhanced ECL's diagnostic performance. Enzyme-linked immune assay was recommended as an additional TB-related detection for smear-positive Africans.
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Affiliation(s)
- Mengyuan Lyu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Yanbing Zhou
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Yi Chen
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Hongli Lai
- West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Yili Wang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Yuhui Cheng
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Jing Li
- Department of Laboratory Medicine, PanZhihua Central Hospital, PanZhihua, 617067, China
| | - Wu Peng
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Tangyuheng Liu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Xin Jiang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Mei Li
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Zhenzhen Zhao
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China
| | - Binwu Ying
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, 610044, China; West China School of Medicine, Sichuan University, Chengdu, 610044, China.
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Abdulgader SM, Okunola AO, Ndlangalavu G, Reeve BW, Allwood BW, Koegelenberg CF, Warren RM, Theron G. Diagnosing Tuberculosis: What Do New Technologies Allow Us to (Not) Do? Respiration 2022; 101:797-813. [PMID: 35760050 PMCID: PMC9533455 DOI: 10.1159/000525142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/10/2022] [Indexed: 12/11/2022] Open
Abstract
New tuberculosis (TB) diagnostics are at a crossroads: their development, evaluation, and implementation is severely damaged by resource diversion due to COVID-19. Yet several technologies, especially those with potential for non-invasive non-sputum-based testing, hold promise for efficiently triaging and rapidly confirming TB near point-of-care. Such tests are, however, progressing through the pipeline slowly and will take years to reach patients and health workers. Compellingly, such tests will create new opportunities for difficult-to-diagnose populations, including primary care attendees (all-comers in high burden settings irrespective of reason for presentation) and community members (with early stage disease or risk factors like HIV), many of whom cannot easily produce sputum. Critically, all upcoming technologies have limitations that implementers and health workers need to be cognizant of to ensure optimal deployment without undermining confidence in a technology that still offers improvements over the status quo. In this state-of-the-art review, we critically appraise such technologies for active pulmonary TB diagnosis. We highlight strengths, limitations, outstanding research questions, and how current and future tests could be used in the presence of these limitations and uncertainties. Among triage tests, CRP (for which commercial near point-of-care devices exist) and computer-aided detection software with digital chest X-ray hold promise, together with late-stage blood-based assays that detect host and/or microbial biomarkers; however, aside from a handful of prototypes, the latter category has a shortage of promising late-stage alternatives. Furthermore, positive results from new triage tests may have utility in people without TB; however, their utility for informing diagnostic pathways for other diseases is under-researched (most sick people tested for TB do not have TB). For confirmatory tests, few true point-of-care options will be available soon; however, combining novel approaches like tongue swabs with established tests like Ultra have short-term promise but first require optimizations to specimen collection and processing procedures. Concerningly, no technologies yet have compelling evidence of meeting the World Health Organization optimal target product profile performance criteria, especially for important operational criteria crucial for field deployment. This is alarming as the target product profile criteria are themselves almost a decade old and require urgent revision, especially to cater for technologies made prominent by the COVID-19 diagnostic response (e.g., at-home testing and connectivity solutions). Throughout the review, we underscore the importance of how target populations and settings affect test performance and how the criteria by which these tests should be judged vary by use case, including in active case finding. Lastly, we advocate for health workers and researchers to themselves be vocal proponents of the uptake of both new tests and those - already available tests that remain suboptimally utilized.
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Affiliation(s)
- Shima M. Abdulgader
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anna O. Okunola
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gcobisa Ndlangalavu
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Byron W.P. Reeve
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Brian W. Allwood
- Division of Pulmonology, Department of Medicine, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Coenraad F.N. Koegelenberg
- Division of Pulmonology, Department of Medicine, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Rob M. Warren
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Vaezipour N, Fritschi N, Brasier N, Bélard S, Domínguez J, Tebruegge M, Portevin D, Ritz N. Towards Accurate Point-of-Care Tests for Tuberculosis in Children. Pathogens 2022; 11:pathogens11030327. [PMID: 35335651 PMCID: PMC8949489 DOI: 10.3390/pathogens11030327] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 12/20/2022] Open
Abstract
In childhood tuberculosis (TB), with an estimated 69% of missed cases in children under 5 years of age, the case detection gap is larger than in other age groups, mainly due to its paucibacillary nature and children’s difficulties in delivering sputum specimens. Accurate and accessible point-of-care tests (POCTs) are needed to detect TB disease in children and, in turn, reduce TB-related morbidity and mortality in this vulnerable population. In recent years, several POCTs for TB have been developed. These include new tools to improve the detection of TB in respiratory and gastric samples, such as molecular detection of Mycobacterium tuberculosis using loop-mediated isothermal amplification (LAMP) and portable polymerase chain reaction (PCR)-based GeneXpert. In addition, the urine-based detection of lipoarabinomannan (LAM), as well as imaging modalities through point-of-care ultrasonography (POCUS), are currently the POCTs in use. Further to this, artificial intelligence-based interpretation of ultrasound imaging and radiography is now integrated into computer-aided detection products. In the future, portable radiography may become more widely available, and robotics-supported ultrasound imaging is currently being trialed. Finally, novel blood-based tests evaluating the immune response using “omic-“techniques are underway. This approach, including transcriptomics, metabolomic, proteomics, lipidomics and genomics, is still distant from being translated into POCT formats, but the digital development may rapidly enhance innovation in this field. Despite these significant advances, TB-POCT development and implementation remains challenged by the lack of standard ways to access non-sputum-based samples, the need to differentiate TB infection from disease and to gain acceptance for novel testing strategies specific to the conditions and settings of use.
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Affiliation(s)
- Nina Vaezipour
- Mycobacterial and Migrant Health Research Group, University Children’s Hospital Basel, Department for Clinical Research, University of Basel, 4056 Basel, Switzerland; (N.V.); (N.F.)
- Infectious Disease and Vaccinology Unit, University Children’s Hospital Basel, University of Basel, 4056 Basel, Switzerland
| | - Nora Fritschi
- Mycobacterial and Migrant Health Research Group, University Children’s Hospital Basel, Department for Clinical Research, University of Basel, 4056 Basel, Switzerland; (N.V.); (N.F.)
| | - Noé Brasier
- Department of Health Sciences and Technology, Institute for Translational Medicine, ETH Zurich, 8093 Zurich, Switzerland;
- Department of Digitalization & ICT, University Hospital Basel, 4031 Basel, Switzerland
| | - Sabine Bélard
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany;
- Institute of Tropical Medicine and International Health, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - José Domínguez
- Institute for Health Science Research Germans Trias i Pujol. CIBER Enfermedades Respiratorias, Universitat Autònoma de Barcelona, 08916 Barcelona, Spain;
| | - Marc Tebruegge
- Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London WCN1 1EH, UK;
- Department of Pediatrics, The Royal Children’s Hospital Melbourne, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Damien Portevin
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, 4123 Allschwil, Switzerland;
- University of Basel, 4001 Basel, Switzerland
| | - Nicole Ritz
- Mycobacterial and Migrant Health Research Group, University Children’s Hospital Basel, Department for Clinical Research, University of Basel, 4056 Basel, Switzerland; (N.V.); (N.F.)
- Department of Pediatrics, The Royal Children’s Hospital Melbourne, The University of Melbourne, Parkville, VIC 3052, Australia
- Department of Paediatrics and Paediatric Infectious Diseases, Children’s Hospital, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland
- Correspondence: ; Tel.: +41-61-704-1212
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11
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Chernick L, Kalla IS, Venter M. Clinical, radiological, and laboratory predictors of a positive urine lipoarabinomannan test in sputum-scarce and sputum-negative patients with HIV-associated tuberculosis in two Johannesburg hospitals. South Afr J HIV Med 2021; 22:1234. [PMID: 34394971 PMCID: PMC8335785 DOI: 10.4102/sajhivmed.v22i1.1234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 04/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background Tuberculosis (TB) is a major cause of mortality in persons living with HIV (PLWH). Sputum-based diagnosis of TB in patients with low CD4 counts is hampered by paucibacillary disease and consequent sputum scarcity or negative sputum results. Urine lipoarabinomannan (LAM) has shown promise in the point-of-care detection of TB in this patient subset but lacks sensitivity, and its exact role in a diagnostic algorithm for TB in South Africa remains to be clarified. Objectives The objective of this study was to better define the patient profile and the TB characteristics associated with a positive urine LAM (LAM+ve) test. Method This multicentre retrospective record review examined the clinical, radiological, and laboratory characteristics of hospitalised PLWH receiving urine LAM testing with sputum-scarce and/or negative sputum GeneXpert ® (mycobacterium tuberculosis/resistance to rifampicin [MTB/RIF]) results. Results More than a third of patients, 121/342 (35%), were LAM+ve. The positive yield was greater in the sputum-scarce than the sputum-negative group, 66/156 (42%) versus 55/186 (30%), P = 0.0141, respectively. Patients who were LAM+ve were more likely to be confused (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.2–3.7, P = 0.0045), have a higher median heart rate (P = 0.0135) and an elevated quick sepsis-related organ failure assessment score (≥ 2), OR = 3.5, 95% CI = 1.6–7.6, P = 0.0014. A LAM+ve test was significantly associated with disseminated TB (dTB), P < 0.0001, TB-related immune reconstitution inflammatory syndrome (IRIS), P = 0.0035, and abdominal TB, P < 0.0001. Laboratory predictors of a LAM+ve status included renal dysfunction, P = 0.044, severe anaemia, P = 0.0116, and an elevated C-reactive protein, P = 0.0131. Of the 12 PLWH with disseminated non-TB mycobacteria cultured from the blood and/or bone marrow, n = 9 (75%) had a LAM+ve result (OR = 5.8, 95% CI = 1.6–20.8, P = 0.0053). Conclusion Urine LAM testing of hospitalised PLWH with suspected active TB had significant diagnostic utility in those that were sputum-scarce or sputum-negative. A LAM+ve result was associated with dTB, clinical and laboratory markers of severe illness, and TB-IRIS. Disseminated non-tuberculous mycobacterial infection of hospitalised PLWH may also yield urine LAM+ve results, and mycobacterial cultures must be checked in those non-responsive to conventional TB treatment. Selective use of the LAM test in the critically ill is likely to maximise the diagnostic yield, improve the test’s predictive value, and reduce the time to TB diagnosis and initiation of treatment.
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Affiliation(s)
- Lior Chernick
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Ismail S Kalla
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Michelle Venter
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Infectious Diseases, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
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Comella-del-Barrio P, Bimba JS, Adelakun R, Kontogianni K, Molina-Moya B, Osazuwa O, Creswell J, Cuevas LE, Domínguez J. Fujifilm SILVAMP TB-LAM for the Diagnosis of Tuberculosis in Nigerian Adults. J Clin Med 2021; 10:2514. [PMID: 34204120 PMCID: PMC8201264 DOI: 10.3390/jcm10112514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/26/2021] [Accepted: 06/04/2021] [Indexed: 01/14/2023] Open
Abstract
There is a need for diagnostics for tuberculosis (TB) that are easy to use, able to screen non-sputum samples, and able to provide rapid results for the management of both immunocompromised and immunocompetent individuals. The Fujifilm SILVAMP TB LAM (FujiLAM) assay, a new non-sputum based point of need test for the diagnosis of TB, could potentially address most of these needs. We evaluated the performance of FujiLAM in HIV positive and HIV negative patients with presumptive TB attending three district hospitals in Nigeria. Consecutive patients were asked to provide urine samples on the spot, which were tested with FujiLAM. The results were compared against a positive culture and/or Xpert MTB/RIF as the reference standard. Forty-five patients had bacteriologically confirmed TB, and 159 had negative culture and Xpert MTB/RIF (no TB). The FujiLAM test was positive in 23 (sensitivity 65.7%, 95% CI = 48-80) HIV negative and seven (70%, 95% CI = 35-92) HIV positive patients with bacteriological confirmation of TB. FujiLAM was negative in 97 (specificity 99.0%, 95% CI = 94-100) HIV negative and 56 (93.3%, 95% CI = 83-98) HIV positive patients without TB. The FujiLAM test has good diagnostic accuracy for considering its application in both HIV positive and HIV negative patients with TB.
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Affiliation(s)
- Patricia Comella-del-Barrio
- Institut d’Investigació Germans Trias i Pujol, CIBER Enfermedades Respiratorias (CIBERES), Universitat Autònoma de Barcelona, Carretera del Canyet, Camí de les Escoles s/n, Badalona, 08916 Barcelona, Spain; (P.C.-d.-B.); (B.M.-M.)
| | - John S. Bimba
- Zankli Research Centre and Department of Community Medicine, Bingham University, Karu 961105, Nigeria; (J.S.B.); (O.O.); (L.E.C.)
| | - Ramota Adelakun
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK; (R.A.); (K.K.)
| | - Konstantina Kontogianni
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK; (R.A.); (K.K.)
| | - Bárbara Molina-Moya
- Institut d’Investigació Germans Trias i Pujol, CIBER Enfermedades Respiratorias (CIBERES), Universitat Autònoma de Barcelona, Carretera del Canyet, Camí de les Escoles s/n, Badalona, 08916 Barcelona, Spain; (P.C.-d.-B.); (B.M.-M.)
| | - Okoedoh Osazuwa
- Zankli Research Centre and Department of Community Medicine, Bingham University, Karu 961105, Nigeria; (J.S.B.); (O.O.); (L.E.C.)
| | - Jacob Creswell
- Stop TB Partnership, TB REACH, 1218 Geneva, Switzerland;
| | - Luis E. Cuevas
- Zankli Research Centre and Department of Community Medicine, Bingham University, Karu 961105, Nigeria; (J.S.B.); (O.O.); (L.E.C.)
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK; (R.A.); (K.K.)
| | - José Domínguez
- Institut d’Investigació Germans Trias i Pujol, CIBER Enfermedades Respiratorias (CIBERES), Universitat Autònoma de Barcelona, Carretera del Canyet, Camí de les Escoles s/n, Badalona, 08916 Barcelona, Spain; (P.C.-d.-B.); (B.M.-M.)
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13
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Kamra E, Mehta PK. Current updates in diagnosis of male urogenital tuberculosis. Expert Rev Anti Infect Ther 2021; 19:1175-1190. [PMID: 33688791 DOI: 10.1080/14787210.2021.1902305] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Urogenital tuberculosis (UGTB) is a common manifestation of extrapulmonary TB (EPTB), which affects both men and women in a ratio of 2:1. Similar to other EPTB types, diagnosis of UGTB is quite challenging owing to atypical clinical presentation and paucibacillary nature of specimens. This review is primarily focused on the current updates developed in the diagnosis of male UGTB.Area covered: Smear/culture, imaging, histopathology, and interferon-γ release assays are the main modalities employed for detecting male UGTB cases. Moreover, we described the utility of nucleic acid amplification tests (NAATs), including loop-mediated isothermal amplification, PCR, nested-PCR, and GeneXpert (MTB/RIF) assays. The possibility of using other novel modalities, such as immuno-PCR (I-PCR), aptamer-linked immobilized sorbent assay (ALISA), and identification of circulating cell-free DNA (cfDNA) by NAATs were also discussed.Expert opinion: The current methods used for the diagnosis of male UGTB are not adequate. Therefore, the latest molecular/immunological tools, i.e. Xpert Ultra, Truenat MTBTM, I-PCR, ALISA, and cfDNA detection employed for the diagnosis of other EPTB forms and pulmonary TB may also be exploited for UGTB diagnosis. Reliable and timely diagnosis of male UGTB may initiate an early start of anti-tubercular therapy that would reduce infertility and other complications associated with disease.
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Affiliation(s)
- Ekta Kamra
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak, India
| | - Promod K Mehta
- Centre for Biotechnology, Maharshi Dayanand University, Rohtak, India
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14
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Diagnostic Performance of the Fujifilm SILVAMP TB-LAM in Children with Presumptive Tuberculosis. J Clin Med 2021; 10:jcm10091914. [PMID: 33925008 PMCID: PMC8124322 DOI: 10.3390/jcm10091914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/17/2021] [Accepted: 04/23/2021] [Indexed: 11/16/2022] Open
Abstract
Current diagnostics for tuberculosis (TB) only manage to confirm a small proportion of children with TB and require respiratory samples, which are difficult to obtain. There is a need for non-invasive biomarker-based tests as an alternative to sputum testing. Fujifilm SILVAMP TB lipoarabinomannan (FujiLAM), a lateral-flow test to detect lipoarabinomannan in urine, is a novel non-sputum-based point-of-care diagnostic reported to have increased sensitivity for the diagnosis of TB among human immunodeficiency virus (HIV)-infected adults. We evaluate the performance of FujiLAM in children with presumptive TB. Fifty-nine children attending a paediatric hospital in Haiti with compatible signs and symptoms of TB were examined using Xpert MTB/RIF, smear microscopy and X-rays, and classified according to the certainty of diagnosis into bacteriologically confirmed TB (n = 5), unconfirmed TB (bacteriologically negative, n = 50) and unlikely TB (n = 4). Healthy children (n = 20) were enrolled as controls. FujiLAM sensitivity and specificity were 60% and 95% among children with confirmed TB. FujiLAM's high specificity and its characteristics as a point-of-care indicate the test has a good potential for the diagnosis of TB in children.
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Elhalawany N, Shalaby N, Fathy A, Elmorsy AS, Zaghloul M, El-shahawy H, Hewidy AA. Role of detection of lipoarabinomannan (LAM) in urine for diagnosis of pulmonary tuberculosis in HIV patients: Egyptian experience. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2021. [DOI: 10.1186/s43168-021-00067-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Tuberculosis remains a worldwide problem fueled by the HIV epidemic. TB infection impacts HIV progression and mortality even with treatment. Egypt has increasing HIV prevalence, although still in low prevalent areas.
Results
Urinary LAM was positive in 22 (95.7%) of TB patients and 1 (1.9%) of non TB group. Sensitivity was 95.7%, specificity 98.1%, positive and negative predictive values were 95.7% and 98.1% respectively, with accuracy 97.4%. Urinary LAM ELISA assay has the highest sensitivity (95.7%) in relation to other tests used for TB detection in HIV patients and its concentration was highly correlated to CD4 cell count and the extent of radiological changes.
Conclusion
The use of urinary LAM in HIV patients is rapid, safe, available, and helpful tool for ruling in TB especially for those who cannot expectorate, critically ill, with low CD4, or presented by multiple system affection.
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Gupta A, Kumar A, Ashraf AA, Madigubba H, Chawla K. A pilot study to evaluate urine LAM assay for diagnosis of pulmonary tuberculosis among non-HIV patients. Trop Doct 2020; 50:343-346. [PMID: 32638652 DOI: 10.1177/0049475520936164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is a great need to improve diagnostic tools for tuberculosis where the majority are without HIV co-infection in resource-poor settings and high-burden areas such as India. The urine LAM assay has not hitherto been studied and may have a role to play. Our study found that, as a stand-alone diagnostic tool, the assay was suboptimal when compared to Xpert MTB/Rif. However, a combination of LAM assay along with sputum microscopy may be useful in settings where molecular testing is unavailable.
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Affiliation(s)
- Akshita Gupta
- Junior Resident, Department of Microbiology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Ajay Kumar
- Research Fellow, Department of Microbiology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Asem Ali Ashraf
- Junior Resident, Department of Microbiology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Haritha Madigubba
- Junior Resident, Department of Microbiology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Kiran Chawla
- Professor, Department of Microbiology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Mathabire Rucker SC, Cossa L, Harrison RE, Mpunga J, Lobo S, Kisaka Kimupelenge P, Mandar Kol'Ampwe F, Amoros Quiles I, Molfino L, Szumilin E, Telnov O, Ndlovu Z, Huerga H. Feasibility of using Determine TB-LAM to diagnose tuberculosis in HIV-positive patients in programmatic conditions: a multisite study. Glob Health Action 2020; 12:1672366. [PMID: 31610754 PMCID: PMC6807865 DOI: 10.1080/16549716.2019.1672366] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: Determine TB-LAM is a urine-based point-of-care assay for diagnosis of tuberculosis (TB). Objective: To assess the feasibility of using LAM to diagnose TB in adult HIV-positive patients in resource-limited settings. Methods: We performed a multi-centric mixed-methods cross-sectional descriptive study in the Democratic Republic of Congo, Malawi, and Mozambique. We used the study and program monitoring tools to estimate user workload, turn-around time (TAT), and proportion of patients with LAM and sputum-based results. We conducted semi-structured interviews to assess the user acceptability of the LAM. Results: The duration of the LAM testing activity per patient was 27 min (IQR 26–29); staff continued with other duties whilst waiting for the result. More patients had a LAM versus a sputum-based result: 168/213 (78.9%) vs 77/213 (36.1%), p < 0.001 in DRC; 691/695 (99.4%) vs 429/695 (61.7%), p < 0.001 in Malawi; and 646/647 (99.8%) vs 262/647 (40.5%), p < 0.001 in Mozambique. The median TAT in minutes when LAM was performed in the consultation room was 75 (IQR 45–188) in DRC, 29 (IQR 27–39) in Malawi, and 36 (IQR 35–41) in Mozambique. In comparison, the overall median TAT for sputum-based tests (smear or GeneXpert) was 2 (IQR 1–3) days. The median time to the first anti-TB drug dose for LAM-positive patients was 155 (IQR 90–504) minutes in DRC and 90 (IQR 60–117) minutes in Mozambique. The overall inter-reader agreement for the interpretation of the LAM result as positive or negative was 98.9%, kappa 0.97 (95%CI 0.96–0.99). Overall, LAM users found the test easy to perform. Major concerns were use of the reading card and the prior requirement of CD4 results before LAM testing. Conclusion: It is feasible to implement the LAM test in low resource settings. The short TAT permitted same day initiation of TB treatment for LAM-positive patients.
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Affiliation(s)
| | - Loide Cossa
- Médecins Sans Frontières , Maputo , Mozambique
| | | | | | | | | | | | | | | | | | | | - Zibusiso Ndlovu
- Medecins Sans Frontières, Southern Africa Medical Unit , Cape Town , South Africa
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Abstract
PURPOSE OF REVIEW Diagnosis of tuberculosis (TB) in people living with HIV (PLHIV) remains a challenge, despite it being the most common comorbidity in this group. In this review, we provide an overview of tests for active TB, and their diagnostic performance in PLHIV. RECENT FINDINGS New and updated diagnostic tests have better performance than traditional bacterial culture or smear microscopy in PLHIV. Recent developments in molecular tests have improved the sensitivity at which TB and drug susceptibility can be detected in PLHIV. Notably, the updated Xpert Ultra test can detect HIV-associated TB with high sensitivity, and a rapid lateral flow lipoarabinomannan-based assay has been shown to reduce TB-related mortality in hospitalized PLHIV. New directions in drug-susceptibility testing are being pursued, such as next-generation sequencing and line probe assays, but more evaluation in PLHIV is needed. There is growing understanding of subclinical TB, but methods to detect this type of TB are inadequate. SUMMARY As diagnosis is the weakest link in the TB care cascade, newer more accurate TB tests must be scaled up and fully integrated into existing healthcare systems. Drug-susceptibility testing must become universal to ensure appropriate treatment regimens are prescribed, allowing TB clearance and inhibiting development of antimicrobial resistance.
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Bulterys MA, Wagner B, Redard-Jacot M, Suresh A, Pollock NR, Moreau E, Denkinger CM, Drain PK, Broger T. Point-Of-Care Urine LAM Tests for Tuberculosis Diagnosis: A Status Update. J Clin Med 2019; 9:E111. [PMID: 31906163 PMCID: PMC7020089 DOI: 10.3390/jcm9010111] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/24/2019] [Accepted: 12/25/2019] [Indexed: 12/22/2022] Open
Abstract
Most diagnostic tests for tuberculosis (TB) rely on sputum samples, which are difficult to obtain and have low sensitivity in immunocompromised patients, patients with disseminated TB, and children, delaying treatment initiation. The World Health Organization (WHO) calls for the development of a rapid, biomarker-based, non-sputum test capable of detecting all forms of TB at the point-of-care to enable immediate treatment initiation. Lipoarabinomannan (LAM) is the only WHO-endorsed TB biomarker that can be detected in urine, an easily collected sample. This status update discusses the characteristics of LAM as a biomarker, describes the performance of first-generation urine LAM tests and reasons for slow uptake, and presents considerations for developing the next generation of more sensitive and impactful tests. Next-generation urine LAM tests have the potential to reach adult and pediatric patients regardless of HIV status or site of infection and facilitate global TB control. Implementation and scale-up of existing LAM tests and development of next-generation assays should be prioritized.
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Affiliation(s)
- Michelle A. Bulterys
- FIND, 1202 Geneva, Switzerland
- International Clinical Research Center, University of Washington, Seattle, WA 98105, USA
| | | | | | | | - Nira R. Pollock
- Department of Laboratory Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | | | - Claudia M. Denkinger
- FIND, 1202 Geneva, Switzerland
- Division of Tropical Medicine, Center of Infectious Diseases, University of Heidelberg, 69120 Heidelberg, Germany
| | - Paul K. Drain
- International Clinical Research Center, University of Washington, Seattle, WA 98105, USA
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Bjerrum S, Schiller I, Dendukuri N, Kohli M, Nathavitharana RR, Zwerling AA, Denkinger CM, Steingart KR, Shah M. Lateral flow urine lipoarabinomannan assay for detecting active tuberculosis in people living with HIV. Cochrane Database Syst Rev 2019; 10:CD011420. [PMID: 31633805 PMCID: PMC6802713 DOI: 10.1002/14651858.cd011420.pub3] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The lateral flow urine lipoarabinomannan (LF-LAM) assay Alere Determine™ TB LAM Ag is recommended by the World Health Organization (WHO) to help detect active tuberculosis in HIV-positive people with severe HIV disease. This review update asks the question, "does new evidence justify the use of LF-LAM in a broader group of people?", and is part of the WHO process for updating guidance on the use of LF-LAM. OBJECTIVES To assess the accuracy of LF-LAM for the diagnosis of active tuberculosis among HIV-positive adults with signs and symptoms of tuberculosis (symptomatic participants) and among HIV-positive adults irrespective of signs and symptoms of tuberculosis (unselected participants not assessed for tuberculosis signs and symptoms).The proposed role for LF-LAM is as an add on to clinical judgement and with other tests to assist in diagnosing tuberculosis. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register; MEDLINE, Embase, Science Citation Index, Web of Science, Latin American Caribbean Health Sciences Literature, Scopus, the WHO International Clinical Trials Registry Platform, the International Standard Randomized Controlled Trial Number Registry, and ProQuest, without language restriction to 11 May 2018. SELECTION CRITERIA Randomized trials, cross-sectional, and observational cohort studies that evaluated LF-LAM for active tuberculosis (pulmonary and extrapulmonary) in HIV-positive adults. We included studies that used the manufacturer's recommended threshold for test positivity, either the updated reference card with four bands (grade 1 of 4) or the corresponding prior reference card grade with five bands (grade 2 of 5). The reference standard was culture or nucleic acid amplification test from any body site (microbiological). We considered a higher quality reference standard to be one in which two or more specimen types were evaluated for tuberculosis diagnosis and a lower quality reference standard to be one in which only one specimen type was evaluated. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data using a standardized form and REDCap electronic data capture tools. We appraised the quality of studies using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool and performed meta-analyses to estimate pooled sensitivity and specificity using a bivariate random-effects model and a Bayesian approach. We analyzed studies enrolling strictly symptomatic participants separately from those enrolling unselected participants. We investigated pre-defined sources of heterogeneity including the influence of CD4 count and clinical setting on the accuracy estimates. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 15 unique studies (nine new studies and six studies from the original review that met the inclusion criteria): eight studies among symptomatic adults and seven studies among unselected adults. All studies were conducted in low- or middle-income countries. Risk of bias was high in the patient selection and reference standard domains, mainly because studies excluded participants unable to produce sputum and used a lower quality reference standard.Participants with tuberculosis symptomsLF-LAM pooled sensitivity (95% credible interval (CrI) ) was 42% (31% to 55%) (moderate-certainty evidence) and pooled specificity was 91% (85% to 95%) (very low-certainty evidence), (8 studies, 3449 participants, 37% with tuberculosis).For a population of 1000 people where 300 have microbiologically-confirmed tuberculosis, the utilization of LF-LAM would result in: 189 to be LF-LAM positive: of these, 63 (33%) would not have tuberculosis (false-positives); and 811 to be LF-LAM negative: of these, 174 (21%) would have tuberculosis (false-negatives).By clinical setting, pooled sensitivity was 52% (40% to 64%) among inpatients versus 29% (17% to 47%) among outpatients; and pooled specificity was 87% (78% to 93%) among inpatients versus 96% (91% to 99%) among outpatients. Stratified by CD4 cell count, pooled sensitivity increased, and specificity decreased with lower CD4 cell count.Unselected participants not assessed for signs and symptoms of tuberculosisLF-LAM pooled sensitivity was 35% (22% to 50%), (moderate-certainty evidence) and pooled specificity was 95% (89% to 96%), (low-certainty evidence), (7 studies, 3365 participants, 13% with tuberculosis).For a population of 1000 people where 100 have microbiologically-confirmed tuberculosis, the utilization of LF-LAM would result in: 80 to be LF-LAM positive: of these, 45 (56%) would not have tuberculosis (false-positives); and 920 to be LF-LAM negative: of these, 65 (7%) would have tuberculosis (false-negatives).By clinical setting, pooled sensitivity was 62% (41% to 83%) among inpatients versus 31% (18% to 47%) among outpatients; pooled specificity was 84% (48% to 96%) among inpatients versus 95% (87% to 99%) among outpatients. Stratified by CD4 cell count, pooled sensitivity increased, and specificity decreased with lower CD4 cell count. AUTHORS' CONCLUSIONS We found that LF-LAM has a sensitivity of 42% to diagnose tuberculosis in HIV-positive individuals with tuberculosis symptoms and 35% in HIV-positive individuals not assessed for tuberculosis symptoms, consistent with findings reported previously. Regardless of how people are enrolled, sensitivity is higher in inpatients and those with lower CD4 cell, but a concomitant lower specificity. As a simple point-of-care test that does not depend upon sputum evaluation, LF-LAM may assist with the diagnosis of tuberculosis, particularly when a sputum specimen cannot be produced.
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Affiliation(s)
- Stephanie Bjerrum
- University of Southern DenmarkDepartment of Clinical Research, Research Unit of Infectious DiseasesOdenseDenmark
- Odense University HospitalMyCRESD, Mycobacterial Research Centre of Southern Denmark, Department of Infectious DiseasesSdr. Boulevard 29OdenseDenmark
- Odense University HospitalOPEN, Odense Patient data Explorative NetworkOdenseDenmarkDenmark
| | - Ian Schiller
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealQCCanada
| | - Nandini Dendukuri
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealQCCanada
| | - Mikashmi Kohli
- McGill UniversityDepartment of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
| | - Ruvandhi R Nathavitharana
- Beth Israel Deaconess Medical Center, Harvard Medical SchoolDivision of Infectious DiseasesBostonUSA
| | - Alice A Zwerling
- University of OttawaSchool of Epidemiology & Public Health600 Peter Morand Crescent, Room 301EOttawaOntarioCanadaK1G5Z3
| | - Claudia M Denkinger
- FINDGenevaSwitzerland
- University Hospital HeidelbergCenter of Infectious DiseasesHeidelbergGermany
| | - Karen R Steingart
- Department of Clinical Sciences, Liverpool School of Tropical MedicineHonorary Research FellowPembroke PlaceLiverpoolUK
| | - Maunank Shah
- John Hopkins University School of MedicineDepartment of Medicine, Division of Infectious DiseasesBaltimoreMarylandUSA
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Schutz C, Barr D, Andrade BB, Shey M, Ward A, Janssen S, Burton R, Wilkinson KA, Sossen B, Fukutani KF, Nicol M, Maartens G, Wilkinson RJ, Meintjes G. Clinical, microbiologic, and immunologic determinants of mortality in hospitalized patients with HIV-associated tuberculosis: A prospective cohort study. PLoS Med 2019; 16:e1002840. [PMID: 31276515 PMCID: PMC6611568 DOI: 10.1371/journal.pmed.1002840] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 05/24/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In high-burden settings, case fatality rates are reported to be between 11% and 32% in hospitalized patients with HIV-associated tuberculosis, yet the underlying causes of mortality remain poorly characterized. Understanding causes of mortality could inform the development of novel management strategies to improve survival. We aimed to assess clinical and microbiologic determinants of mortality and to characterize the pathophysiological processes underlying death by evaluating host soluble inflammatory mediators and determined the relationship between these mediators and death as well as biomarkers of disseminated tuberculosis. METHODS AND FINDINGS Adult patients with HIV hospitalized with a new diagnosis of HIV-associated tuberculosis were enrolled in Cape Town between 2014 and 2016. Detailed tuberculosis diagnostic testing was performed. Biomarkers of tuberculosis dissemination and host soluble inflammatory mediators at baseline were assessed. Of 682 enrolled participants, 576 with tuberculosis (487/576, 84.5% microbiologically confirmed) were included in analyses. The median age was 37 years (IQR = 31-43), 51.2% were female, and the patients had advanced HIV with a median cluster of differentiation 4 (CD4) count of 58 cells/L (IQR = 21-120) and a median HIV viral load of 5.1 log10 copies/mL (IQR = 3.3-5.7). Antituberculosis therapy was initiated in 566/576 (98.3%) and 487/576 (84.5%) started therapy within 48 hours of enrolment. Twelve-week mortality was 124/576 (21.5%), with 46/124 (37.1%) deaths occurring within 7 days of enrolment. Clinical and microbiologic determinants of mortality included disseminated tuberculosis (positive urine lipoarabinomannan [LAM], urine Xpert MTB/RIF, or tuberculosis blood culture in 79.6% of deaths versus 60.7% of survivors, p = 0.001), sepsis syndrome (high lactate in 50.8% of deaths versus 28.9% of survivors, p < 0.001), and rifampicin-resistant tuberculosis (16.9% of deaths versus 7.2% of survivors, p = 0.002). Using non-supervised two-way hierarchical cluster and principal components analyses, we describe an immune profile dominated by mediators of the innate immune system and chemotactic signaling (interleukin-1 receptor antagonist [IL-1Ra], IL-6, IL-8, macrophage inflammatory protein-1 beta [MIP-1β]/C-C motif chemokine ligand 4 [CCL4], interferon gamma-induced protein-10 [IP-10]/C-X-C motif chemokine ligand 10 [CXCL10], MIP-1 alpha [MIP-1α]/CCL3), which segregated participants who died from those who survived. This immune profile was associated with mortality in a Cox proportional hazards model (adjusted hazard ratio [aHR] = 2.2, 95%CI = 1.9-2.7, p < 0.001) and with detection of biomarkers of disseminated tuberculosis. Clinicians attributing causes of death identified tuberculosis as a cause or one of the major causes of death in 89.5% of cases. We did not perform longitudinal sampling and did not have autopsy-confirmed causes of death. CONCLUSIONS In this study, we did not identify a major contribution from coinfections to these deaths. Disseminated tuberculosis, sepsis syndrome, and rifampicin resistance were associated with mortality. An immune profile dominated by mediators of the innate immune system and chemotactic signaling was associated with both tuberculosis dissemination and mortality. These findings provide pathophysiologic insights into underlying causes of mortality and could be used to inform the development of novel treatment strategies and to develop methods to risk stratify patients to appropriately target novel interventions. Causal relationships cannot be established from this study.
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Affiliation(s)
- Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - David Barr
- Wellcome Trust Liverpool Glasgow Centre for Global Health Research, University of Liverpool, Liverpool, United Kingdom
| | - Bruno B. Andrade
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Brazil
| | - Muki Shey
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Amy Ward
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Saskia Janssen
- Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Rosie Burton
- Khayelitsha Hospital, Department of Medicine, Cape Town, South Africa
| | - Katalin A. Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
| | - Bianca Sossen
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kiyoshi F. Fukutani
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
- Faculdade de Tecnologia e Ciências (FTC), Salvador, Brazil
| | - Mark Nicol
- Division of Medical Microbiology, University of Cape Town and National Health Laboratory Services, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J. Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
- Department of Medicine, Imperial College, London, United Kingdom
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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Younis H, Kerschbaumer I, Moon JY, Kim RS, Blanc CJ, Chen T, Wood R, Lawn S, Achkar JM. Combining urine lipoarabinomannan with antibody detection as a simple non-sputum-based screening method for HIV-associated tuberculosis. PLoS One 2019; 14:e0218606. [PMID: 31237915 PMCID: PMC6592524 DOI: 10.1371/journal.pone.0218606] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 06/05/2019] [Indexed: 11/28/2022] Open
Abstract
Background Simple methods for the accurate triaging and screening of HIV-associated tuberculosis (TB) are urgently needed. We hypothesized that combining serum antibody with urine lipoarabinomannan (U-LAM) detection can improve the detection of HIV-associated TB. Methods We performed a case-control study with sampling from a prospective study of South African HIV-infected subjects who were screened for TB prior to initiating antiretroviral therapy. Sera from all available TB cases (n = 74) and randomly selected non-TB controls (n = 30), all tested for U-LAM, sputum microscopy, GeneXpert, and cultures, were evaluated for antibodies to LAM and arabinomannan (AM). Diagnostic logistic regression models for TB were developed based on the primary test results and the additive effect of antibodies with leave-one-out cross-validation. Results Antibody responses to LAM and AM correlated strongly (p<0.0001), and IgG and IgM reactivities were significantly higher in TB than non-TB patients (p<0.0001). At 80% specificity, the target specificity for a non-sputum-based simple triage/screening test determined by major TB stakeholders, combining U-LAM with IgG detection significantly increased the sensitivity for HIV-associated TB to 92% compared to 30% for U-LAM alone (p<0.001). Sputum microscopy combined with IgG detection increased sensitivity to 88% compared to 31% for microscopy alone, and Xpert with IgG increased sensitivity to 96% and 99% compared to 57% for testing one, and 70% for testing two sputa with Xpert alone, respectively. Conclusion Combining U-LAM with serum antibody detection could provide a simple low-cost method that meets the requirements for a non-sputum-based test for the screening of HIV-associated TB.
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Affiliation(s)
- Hiba Younis
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Isabell Kerschbaumer
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Jee-Young Moon
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Ryung S. Kim
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Caroline J. Blanc
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Tingting Chen
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Robin Wood
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Steven Lawn
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jacqueline M. Achkar
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, United States of America
- * E-mail:
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Abstract
OBJECTIVE To describe the spectrum of kidney disease in African patients with HIV and tuberculosis (TB). METHODS We used data from three cohorts: consecutive patients with HIV/TB in South London (UK, 2004-2016; n = 95), consecutive patients with HIV/TB who underwent kidney biopsy in Cape Town (South Africa, 2014-2017; n = 70), and consecutive patients found to have HIV/TB on autopsy in Abidjan (Cote d'Ivoire, 1991; n = 100). Acute kidney injury (AKI) was ascertained using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. In the Cape Town cohort, predictors of recovery of kidney function at 6 months were assessed using Cox regression. RESULTS In the London cohort, the incidence of moderate/severe AKI at 12 months was 15.1 (95% CI 8.6-26.5) per 100 person-years, and the prevalence of chronic and end-stage kidney disease (ESKD) 13.7 and 5.7%, respectively. HIV-associated nephropathy (HIVAN) was diagnosed in 6% of patients in London, and in 6% of autopsy cases in Abidjan. Evidence of renal TB was present in 60% of autopsies in Abidjan and 61% of kidney biopsies in Cape Town. HIVAN and acute tubular necrosis (ATN) were also common biopsy findings in Cape Town. In Cape Town, 40 patients were dialyzed, of whom 28 (70%) were able to successfully discontinue renal replacement therapy. Antiretroviral therapy status, CD4 cell count, estimated glomerular filtration rate (eGFR) at biopsy and renal histology, other than ATN, were not predictive of eGFR recovery. CONCLUSION Kidney disease was common in Africans with HIV/TB. Monitoring of kidney function, and provision of acute dialysis to those with severe kidney failure, is warranted.
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Broger T, Sossen B, du Toit E, Kerkhoff AD, Schutz C, Ivanova Reipold E, Ward A, Barr DA, Macé A, Trollip A, Burton R, Ongarello S, Pinter A, Lowary TL, Boehme C, Nicol MP, Meintjes G, Denkinger CM. Novel lipoarabinomannan point-of-care tuberculosis test for people with HIV: a diagnostic accuracy study. THE LANCET. INFECTIOUS DISEASES 2019; 19:852-861. [PMID: 31155318 PMCID: PMC6656794 DOI: 10.1016/s1473-3099(19)30001-5] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/27/2018] [Accepted: 12/19/2018] [Indexed: 12/14/2022]
Abstract
Background Most tuberculosis-related deaths in people with HIV could be prevented with earlier diagnosis and treatment. The only commercially available tuberculosis point-of-care test (Alere Determine TB LAM Ag [AlereLAM]) has suboptimal sensitivity, which restricts its use in clinical practice. The novel Fujifilm SILVAMP TB LAM (FujiLAM) assay has been developed to improve the sensitivity of AlereLAM. We assessed the diagnostic accuracy of the FujiLAM assay for the detection of tuberculosis in hospital inpatients with HIV compared with the AlereLAM assay. Methods For this diagnostic accuracy study, we assessed biobanked urine samples obtained from the FIND Specimen Bank and the University of Cape Town Biobank, which had been collected from hospital inpatients (aged ≥18 years) with HIV during three independent prospective cohort studies done at two South African hospitals. Urine samples were tested using FujiLAM and AlereLAM assays. The conduct and reporting of each test was done blind to other test results. The primary objective was to assess the diagnostic accuracy of FujiLAM compared with AlereLAM, against microbiological and composite reference standards (including clinical diagnoses). Findings Between April 18, 2018, and May 3, 2018, urine samples from 968 hospital inpatients with HIV were evaluated. The prevalence of microbiologically-confirmed tuberculosis was 62% and the median CD4 count was 86 cells per μL. Using the microbiological reference standard, the estimated sensitivity of FujiLAM was 70·4% (95% CI 53·0 to 83·1) compared with 42·3% (31·7 to 51·8) for AlereLAM (difference 28·1%) and the estimated specificity of FujiLAM was 90·8% (86·0 to 94·4) and 95·0% (87·7–98·8) for AlereLAM (difference −4·2%). Against the composite reference standard, the specificity of both assays was higher (95·7% [92·0 to 98·0] for FujiLAM vs 98·2% [95·7 to 99·6] for AlereLAM; difference −2·5%), but the sensitivity of both assays was lower (64·9% [50·1 to 76·7] for FujiLAM vs 38·2% [28·1 to 47·3] for AlereLAM; difference 26·7%). Interpretation In comparison to AlereLAM, FujiLAM offers superior diagnostic sensitivity, while maintaining specificity, and could transform rapid point-of-care tuberculosis diagnosis for hospital inpatients with HIV. The applicability of FujiLAM for settings of intended use requires prospective assessment. Funding Global Health Innovative Technology Fund, UK Department for International Development, Dutch Ministry of Foreign Affairs, Bill & Melinda Gates Foundation, German Federal Ministry of Education and Research, Australian Department of Foreign Affairs and Trade, Wellcome Trust, Department of Science and Technology and National Research Foundation of South Africa, and South African Medical Research Council.
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Affiliation(s)
| | - Bianca Sossen
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Elloise du Toit
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa; National Health Laboratory Service, Cape Town, South Africa
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Charlotte Schutz
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Amy Ward
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - David A Barr
- Wellcome Trust Liverpool Glasgow Centre for Global Health Research, University of Liverpool, Liverpool, UK
| | | | | | - Rosie Burton
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Southern African Medical Unit, Médecins sans Frontières, Cape Town, South Africa
| | | | - Abraham Pinter
- Public Health Research Institute Center, New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | - Todd L Lowary
- Department of Chemistry and Alberta Glycomics Centre, University of Alberta, Edmonton, AB, Canada
| | | | - Mark P Nicol
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa; National Health Laboratory Service, Cape Town, South Africa
| | - Graeme Meintjes
- FIND, Geneva, Switzerland; Wellcome Center for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Broger T, Tsionksy M, Mathew A, Lowary TL, Pinter A, Plisova T, Bartlett D, Barbero S, Denkinger CM, Moreau E, Katsuragi K, Kawasaki M, Nahid P, Sigal GB. Sensitive electrochemiluminescence (ECL) immunoassays for detecting lipoarabinomannan (LAM) and ESAT-6 in urine and serum from tuberculosis patients. PLoS One 2019; 14:e0215443. [PMID: 30998715 PMCID: PMC6472883 DOI: 10.1371/journal.pone.0215443] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/02/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) infection was responsible for an estimated 1.3 million deaths in 2017. Better diagnostic tools are urgently needed. We sought to determine whether accurate TB antigen detection in blood or urine has the potential to meet the WHO target product profiles for detection of active TB. MATERIALS AND METHODS We developed Electrochemiluminescence (ECL) immunoassays for Lipoarabinomannan (LAM) and ESAT-6 detection with detection limits in the pg/ml range and used them to compare the concentrations of the two antigens in the urine and serum of 81 HIV-negative and -positive individuals with presumptive TB enrolled across diverse geographic sites. RESULTS LAM and ESAT-6 overall sensitivities in urine were 93% and 65% respectively. LAM and ESAT-6 overall sensitivities in serum were 55% and 46% respectively. Overall specificity was ≥97% in all assays. Sensitivities were higher in HIV-positive compared to HIV-negative patients for both antigens and both sample types, with signals roughly 10-fold higher on average in urine than in serum. The two antigens showed similar concentration ranges within the same sample type and correlated. CONCLUSIONS LAM and ESAT-6 can be detected in the urine and serum of TB patients, regardless of the HIV status and further gains in clinical sensitivity may be achievable through assay and reagent optimization. Accuracy in urine was higher with current methods and has the potential to meet the WHO accuracy target if the findings can be transferred to a point-of-care TB test.
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Affiliation(s)
| | - Michael Tsionksy
- Meso Scale Diagnostics, LLC., Rockville, Maryland, United States of America
| | - Anu Mathew
- Meso Scale Diagnostics, LLC., Rockville, Maryland, United States of America
| | - Todd L. Lowary
- Department of Chemistry and Alberta Glycomics Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Abraham Pinter
- Public Health Research Institute Center, New Jersey Medical School, Rutgers University, Newark, New Jersey, United States of America
| | - Tatiana Plisova
- Meso Scale Diagnostics, LLC., Rockville, Maryland, United States of America
| | - Daniel Bartlett
- Meso Scale Diagnostics, LLC., Rockville, Maryland, United States of America
| | - Simone Barbero
- Meso Scale Diagnostics, LLC., Rockville, Maryland, United States of America
| | | | | | | | | | - Payam Nahid
- University of California, San Francisco, California, United States of America
| | - George B. Sigal
- Meso Scale Diagnostics, LLC., Rockville, Maryland, United States of America
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Huerga H, Mathabire Rucker SC, Cossa L, Bastard M, Amoros I, Manhiça I, Mbendera K, Telnov A, Szumilin E, Sanchez-Padilla E, Molfino L. Diagnostic value of the urine lipoarabinomannan assay in HIV-positive, ambulatory patients with CD4 below 200 cells/μl in 2 low-resource settings: A prospective observational study. PLoS Med 2019; 16:e1002792. [PMID: 31039161 PMCID: PMC6490904 DOI: 10.1371/journal.pmed.1002792] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 03/28/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Current guidelines recommend the use of the lateral flow urine lipoarabinomannan assay (LAM) in HIV-positive, ambulatory patients with signs and symptoms of tuberculosis (TB) only if they are seriously ill or have CD4 count ≤ 100 cells/μl. We assessed the diagnostic yield of including LAM in TB diagnostic algorithms in HIV-positive, ambulatory patients with CD4 < 200 cells/μl, as well as the risk of mortality in LAM-positive patients who were not diagnosed using other diagnostic tools and not treated for TB. METHODS AND FINDINGS We conducted a prospective observational study including HIV-positive adult patients with signs and symptoms of TB and CD4 < 200 cells/μl attending 6 health facilities in Malawi and Mozambique. Patients were included consecutively from 18 September 2015 to 27 October 2016 in Malawi and from 3 December 2014 to 22 August 2016 in Mozambique. All patients had a clinical exam and LAM, chest X-ray, sputum microscopy, and Xpert MTB/RIF assay (Xpert) requested. Culture in sputum was done for a subset of patients. The diagnostic yield was defined as the proportion of patients with a positive assay result among those with laboratory-confirmed TB. For the 456 patients included in the study, the median age was 36 years (IQR 31-43) and the median CD4 count was 50 cells/μl (IQR 21-108). Forty-five percent (205/456) of the patients had laboratory-confirmed TB. The diagnostic yields of LAM, microscopy, and Xpert were 82.4% (169/205), 33.7% (69/205), and 40.0% (84/205), respectively. In total, 50.2% (103/205) of the patients with laboratory-confirmed TB were diagnosed only through LAM. Overall, the use of LAM in diagnostic algorithms increased the yield of algorithms with microscopy and with Xpert by 38.0% (78/205) and 34.6% (71/205), respectively, and, specifically among patients with CD4 100-199 cells/μl, by 27.5% (14/51) and 29.4% (15/51), respectively. LAM-positive patients not diagnosed through other tools and not treated for TB had a significantly higher risk of mortality than LAM-positive patients who received treatment (adjusted risk ratio 2.57, 95% CI 1.27-5.19, p = 0.009). Although the TB diagnostic conditions in the study sites were similar to those in other resource-limited settings, the added value of LAM may depend on the availability of microscopy or Xpert results. CONCLUSIONS LAM has diagnostic value for identifying TB in HIV-positive patients with signs and symptoms of TB and advanced immunodeficiency, including those with a CD4 count of 100-199 cells/μl. In this study, the use of LAM enabled the diagnosis of TB in half of the patients with confirmed TB disease; without LAM, these patients would have been missed. The rapid identification and treatment of TB enabled by LAM may decrease overall mortality risk for these patients.
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Affiliation(s)
| | | | - Loide Cossa
- Médecins Sans Frontières, Maputo, Mozambique
| | | | | | | | | | - Alex Telnov
- Médecins Sans Frontières, Geneva, Switzerland
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Correia-Neves M, Fröberg G, Korshun L, Viegas S, Vaz P, Ramanlal N, Bruchfeld J, Hamasur B, Brennan P, Källenius G. Biomarkers for tuberculosis: the case for lipoarabinomannan. ERJ Open Res 2019; 5:00115-2018. [PMID: 30775376 PMCID: PMC6368998 DOI: 10.1183/23120541.00115-2018] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/05/2018] [Indexed: 02/07/2023] Open
Abstract
Tuberculosis (TB) is considered the most onerous of infectious diseases according to recent reports from the World Health Organization. Available tests for TB diagnosis present severe limitations, and a reliable point-of-care (POC) diagnostic test does not exist. Neither is there a test to discern between the different stages of TB, and in particular to predict which patients with Mycobacterium tuberculosis infection and no clinical signs are more at risk of advancing to overt disease. We here review the usefulness of mycobacterial lipoarabinomannan (LAM) as a diagnostic marker for active and latent TB and, also, aspects of the immune response to LAM relevant to such tests. There is a high potential for urinary LAM-based POC tests for the diagnosis of active TB. Some technical challenges to optimised sensitivity of the test will be detailed. A method to quantify LAM in urine or serum should be further explored as a test of treatment effect. Recent data on the immune response to LAM suggest that markers for host response to LAM should be investigated for a prognostic test to recognise individuals at the greatest risk of disease activation. There is a high potential for a urinary LAM-based point-of-care test to diagnose TB. Markers for host response to LAM should be explored to identify those at highest risk of developing active TB.http://ow.ly/FyCs30n4uFE
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Affiliation(s)
- Margarida Correia-Neves
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal.,Division of Infectious Diseases, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Gabrielle Fröberg
- Division of Infectious Diseases, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Dept of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | | | - Sofia Viegas
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Paula Vaz
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique.,Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo, Mozambique
| | - Nehaben Ramanlal
- Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo, Mozambique
| | - Judith Bruchfeld
- Division of Infectious Diseases, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Dept of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Beston Hamasur
- Biopromic AB, Solna, Sweden.,Dept of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Patrick Brennan
- Dept of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, USA
| | - Gunilla Källenius
- Division of Infectious Diseases, Dept of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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A Novel Sensitive Immunoassay Targeting the 5-Methylthio-d-Xylofuranose-Lipoarabinomannan Epitope Meets the WHO's Performance Target for Tuberculosis Diagnosis. J Clin Microbiol 2018; 56:JCM.01338-18. [PMID: 30257899 PMCID: PMC6258851 DOI: 10.1128/jcm.01338-18] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 09/19/2018] [Indexed: 12/30/2022] Open
Abstract
The only currently commercialized point-of-care assay for tuberculosis (TB) that measures lipoarabinomannan (LAM) in urine (Alere LF-LAM) has insufficient sensitivity. We evaluated the potential of 100 novel monoclonal antibody pairs targeting a variety of LAM epitopes on a sensitive electrochemiluminescence platform to improve the diagnostic accuracy. The only currently commercialized point-of-care assay for tuberculosis (TB) that measures lipoarabinomannan (LAM) in urine (Alere LF-LAM) has insufficient sensitivity. We evaluated the potential of 100 novel monoclonal antibody pairs targeting a variety of LAM epitopes on a sensitive electrochemiluminescence platform to improve the diagnostic accuracy. In the screening, many antibody pairs showed high reactivity to purified LAM but performed poorly at detecting urinary LAM in clinical samples, suggesting differences in antigen structure and immunoreactivity of the different LAM sources. The 12 best antibody pairs from the screening were tested in a retrospective case-control study with urine samples from 75 adults with presumptive TB. The best antibody pair reached femtomolar analytical sensitivity for LAM detection and an overall clinical sensitivity of 93% (confidence interval [CI], 80% to 97%) and specificity of 97% (CI, 85% to 100%). Importantly, in HIV-negative subjects positive for TB by sputum smear microscopy, the test achieved a sensitivity of 80% (CI, 55% to 93%). This compares to an overall sensitivity of 33% (CI, 20% to 48%) of the Alere LF-LAM and a sensitivity of 13% (CI, 4% to 38%) in HIV-negative subjects in the same sample set. The capture antibody targets a unique 5-methylthio-d-xylofuranose (MTX)-dependent epitope in LAM that is specific to the Mycobacterium tuberculosis complex and shows no cross-reactivity with fast-growing mycobacteria or other bacteria. The present study provides evidence that improved assay methods and reagents lead to increased diagnostic accuracy. The results of this work have informed the development of a sensitive and specific novel LAM point-of-care assay with the aim to meet the WHO's performance target for TB diagnosis.
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29
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Druszczynska M, Wawrocki S, Szewczyk R, Rudnicka W. Mycobacteria-derived biomarkers for tuberculosis diagnosis. Indian J Med Res 2018; 146:700-707. [PMID: 29664027 PMCID: PMC5926340 DOI: 10.4103/ijmr.ijmr_1441_16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Tuberculosis (TB) remains an escalating problem worldwide. The current diagnostic methods do not always guarantee reliable diagnosis. TB treatment is a time-consuming process that requires the use of several chemotherapeutics, to which mycobacteria are becoming increasingly resistant. This article focuses on the potential utility of biomarkers of mycobacterial origin with potential implications for TB diagnosis. Properly standardized indicators could become new diagnostic tools, improving and streamlining the identification of Mycobacterium tuberculosis infection and the implementation of appropriate therapy. These markers can also potentially provide a quick confirmation of effectiveness of new anti-mycobacterial drugs and TB vaccines, leading to a possible application in practice.
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Affiliation(s)
- Magdalena Druszczynska
- Department of Immunology & Infectious Biology, Faculty of Biology & Environmental Protection, Institute of Microbiology, Biotechnology & Immunology, University of Lodz, Lodz, Poland
| | - Sebastian Wawrocki
- Department of Immunology & Infectious Biology, Faculty of Biology & Environmental Protection, Institute of Microbiology, Biotechnology & Immunology, University of Lodz, Lodz, Poland
| | - Rafal Szewczyk
- Department of Industrial Microbiology & Biotechnology, Faculty of Biology & Environmental Protection, Institute of Microbiology, Biotechnology & Immunology, University of Lodz, Lodz, Poland
| | - Wieslawa Rudnicka
- Department of Immunology & Infectious Biology, Faculty of Biology & Environmental Protection, Institute of Microbiology, Biotechnology & Immunology, University of Lodz, Lodz, Poland
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30
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Paris L, Magni R, Zaidi F, Araujo R, Saini N, Harpole M, Coronel J, Kirwan DE, Steinberg H, Gilman RH, Petricoin EF, Nisini R, Luchini A, Liotta L. Urine lipoarabinomannan glycan in HIV-negative patients with pulmonary tuberculosis correlates with disease severity. Sci Transl Med 2018; 9:9/420/eaal2807. [PMID: 29237757 PMCID: PMC6037412 DOI: 10.1126/scitranslmed.aal2807] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 05/25/2017] [Accepted: 10/30/2017] [Indexed: 11/12/2022]
Abstract
An accurate urine test for pulmonary tuberculosis (TB), affecting 9.6 million patients worldwide, is critically needed for surveillance and treatment management. Past attempts failed to reliably detect the mycobacterial glycan antigen lipoarabinomannan (LAM), a marker of active TB, in HIV-negative, pulmonary TB–infected patients’ urine (85% of 9.6 million patients). We apply a copper complex dye within a hydrogel nanocage that captures LAM with very high affinity, displacing interfering urine proteins. The technology was applied to study pretreatment urine from 48 Peruvian patients, all negative for HIV, with microbiologically confirmed active pulmonary TB. LAM was quantitatively measured in the urine with a sensitivity of >95%and a specificity of >80% (n = 101) in a concentration range of 14 to 2000 picograms per milliliter, as compared to non-TB, healthy and diseased, age-matched controls (evaluated by receiver operating characteristic analysis; area under the curve, 0.95; 95% confidence interval, 0.9005 to 0.9957). Urinary LAM was elevated in patients with a higher mycobacterial burden (n = 42), a higher proportion of weight loss (n = 37), or cough (n = 50). The technology can be configured in a variety of formats to detect a panel of previously undetectable very-low-abundance TB urinary analytes. Eight of nine patients who were smear-negative and culture-positive for TB tested positive for urinary LAM. This technology has broad implications for pulmonary TB screening, transmission control, and treatment management for HIV-negative patients.
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Affiliation(s)
- Luisa Paris
- George Mason University, Manassas, VA 20110, USA
| | - Ruben Magni
- George Mason University, Manassas, VA 20110, USA
| | - Fatima Zaidi
- George Mason University, Manassas, VA 20110, USA
| | - Robyn Araujo
- Queensland University of Technology, Brisbane, Queensland 4000, Australia
| | - Neal Saini
- George Mason University, Manassas, VA 20110, USA
| | | | | | | | | | | | | | | | | | - Lance Liotta
- George Mason University, Manassas, VA 20110, USA
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31
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Detection of lipoarabinomannan in urine and serum of HIV-positive and HIV-negative TB suspects using an improved capture-enzyme linked immuno absorbent assay and gas chromatography/mass spectrometry. Tuberculosis (Edinb) 2018; 111:178-187. [PMID: 30029905 DOI: 10.1016/j.tube.2018.06.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/25/2018] [Accepted: 06/05/2018] [Indexed: 11/22/2022]
Abstract
TB diagnosis and treatment monitoring in resource limited regions rely heavily on serial sputum smear microscopy and bacterial culture. These microbiological methods are time-consuming, expensive and lack adequate sensitivity. The WHO states that improved TB diagnosis and treatment is imperative to achieve an end to the TB epidemic by 2030. Commercially available lipoarabinomannan (LAM) detection tools perform at low sensitivity that are highly dependent on the underlying immunological status of the patient; those with advanced HIV infection perform well. In this study, we have applied two novel strategies towards the sensitive diagnosis of TB infection based on LAM: Capture ELISA to detect LAM in paired urine and serum samples using murine and human monoclonal antibodies, essentially relying on LAM as an 'immuno-marker'; and, secondly, detection of α-d-arabinofuranose and tuberculostearic acid (TBSA)- 'chemical-markers' unique to mycobacterial cell wall polysaccharides/lipoglycans by our recently developed gas chromatography/mass spectrometry (GC/MS) method. Blinded urine specimens, with microbiologically confirmed active pulmonary TB or non TB (HIV+/HIV-) were tested by the aforementioned assays. LAM in patient urine was detected in a concentration range of 3-28 ng/mL based on GC/MS detection of the two LAM-surrogates, d-arabinose and tuberculostearic acid (TBSA) correctly classifying TB status with sensitivity > 99% and specificity = 84%. The ELISA assay had high sensitivity (98%) and specificity (92%) and the results were in agreement with GC/MS analysis. Both tests performed well in their present form particularly for HIV-negative/TB-positive urine samples. Among the HIV+/TB+ samples, 52% were found to have >10 ng/mL urinary LAM. The detected amounts of LAM present in the urine samples also appears to be associated with the gradation of the sputum smear, linking elevated LAM levels with higher mycobacterial burden (odds ratio = 1.08-1.43; p = 0.002). In this small set, ELISA was also applied to parallel serum samples confirming that serum could be an additional reservoir for developing a LAM-based immunoassay for diagnosis of TB.
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32
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Point of care diagnostics for tuberculosis. Pulmonology 2018; 24:73-85. [DOI: 10.1016/j.rppnen.2017.12.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 12/07/2017] [Indexed: 01/01/2023] Open
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33
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Crawford AC, Laurentius LB, Mulvihill TS, Granger JH, Spencer JS, Chatterjee D, Hanson KE, Porter MD. Detection of the tuberculosis antigenic marker mannose-capped lipoarabinomannan in pretreated serum by surface-enhanced Raman scattering. Analyst 2018; 142:186-196. [PMID: 27924983 DOI: 10.1039/c6an02110g] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The ability to detect tuberculosis (TB) continues to be a global health care priority. This paper describes the development and preliminary assessment of the clinical accuracy of a heterogeneous immunoassay that integrates a serum pretreatment process with readout by surface-enhanced Raman scattering (SERS) for the low-level detection of mannose-capped lipoarabinomannan (ManLAM). ManLAM is a major virulence factor in the infectious pathology of Mycobacterium tuberculosis (Mtb) that has been found in the serum and other body fluids of infected patients. The effectiveness of ManLAM as a TB diagnostic marker, however, remains unproven for reasons not yet well understood. As reported herein, we have found that (1) ManLAM complexes with proteins and possibly other components in serum; (2) these complexes have a strongly detrimental impact on the ability to detect ManLAM using an immunoassay; (3) a simple pretreatment step can disrupt this complexation; and (4) disruption by pretreatment improves detection by 250×. We also describe the results from a preliminary assessment on the utility of serum pretreatment by running immunoassays on archived specimens from 24 TB-positive patients and 10 healthy controls. ManLAM was measurable in 21 of the 24 TB-positive specimens, but not in any of the 10 control specimens. These findings, albeit for a very small specimen set, translate to a clinical sensitivity of 87.5% and a clinical specificity of 100%. Together, these results both provide much needed evidence for the clinical utility of ManLAM as a TB marker, and demonstrate the potential utility of our overall approach to serve as a new strategy for the development of diagnostic tests for this disease.
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Affiliation(s)
- Alexis C Crawford
- Department of Chemistry, University of Utah, Salt Lake City, UT 84112, USA and Nano Institute of Utah, University of Utah, Salt Lake City, UT 84112, USA.
| | - Lars B Laurentius
- Nano Institute of Utah, University of Utah, Salt Lake City, UT 84112, USA.
| | | | - Jennifer H Granger
- Nano Institute of Utah, University of Utah, Salt Lake City, UT 84112, USA.
| | - John S Spencer
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO 80523, USA
| | - Delphi Chatterjee
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO 80523, USA
| | - Kimberly E Hanson
- Departments of Internal Medicine and Pathology, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Marc D Porter
- Department of Chemistry, University of Utah, Salt Lake City, UT 84112, USA and Nano Institute of Utah, University of Utah, Salt Lake City, UT 84112, USA. and Department of Chemical Engineering, University of Utah, Salt Lake City, UT 84112, USA and Department of Bioengineering, University of Utah, Salt Lake City, UT 84112, USA and Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA
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Laurentius LB, Crawford AC, Mulvihill TS, Granger JH, Robinson R, Spencer JS, Chatterjee D, Hanson KE, Porter MD. Importance of specimen pretreatment for the low-level detection of mycobacterial lipoarabinomannan in human serum. Analyst 2018; 142:177-185. [PMID: 27934985 DOI: 10.1039/c6an02109c] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Patient care and prevention of disease outbreaks rely heavily on the performance of diagnostic tests. These tests are typically carried out in serum, urine, and other complex sample matrices, but are often plagued by a number of matrix effects such as nonspecific adsorption and complexation with circulating proteins. This paper demonstrates the importance of sample pretreatment to overcome matrix effects, enabling the low-level detection of a disease marker for tuberculosis (TB). The impact of pretreatment is illustrated by detecting a cell wall component unique to mycobacteria, lipoarabinomannan (LAM). LAM is a major virulence factor in the infectious pathology of Mycobacterium tuberculosis (Mtb) and has been successfully detected in the body fluids of TB-infected individuals; however, its clinical sensitivity - identifying patients with active infection - remains problematic. This and the companion paper show that the detection of LAM in an immunoassay is plagued by its complexation with proteins and other components in serum. Herein, we present the procedures and results from an investigation of several different pretreatment schemes designed to disrupt complexation and thereby improve detection. These sample pretreatment studies, aimed at determining the optimal conditions for complex disruption, were carried out by using a LAM simulant derived from the nonpathogenic M. smegmatis, a mycobacterium often used as a model for Mtb. We have found that a perchloric acid-based pretreatment step improves the ability to detect this simulant by ∼1500× with respect to that in untreated serum. This paper describes the approach to pretreatment, how pretreatment improves the detection of the LAM simulant in human serum, and the results from a preliminary investigation to identify possible contributors to complexation by fractionating serum according to molecular weight. The companion paper applies this pretreatment approach to assays of TB patient samples.
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Affiliation(s)
- Lars B Laurentius
- The Nano Institute of Utah, University of Utah, Salt Lake City, UT 84112, USA.
| | - Alexis C Crawford
- The Nano Institute of Utah, University of Utah, Salt Lake City, UT 84112, USA. and Department of Chemistry, University of Utah, Salt Lake City, UT 84112, USA
| | | | - Jennifer H Granger
- The Nano Institute of Utah, University of Utah, Salt Lake City, UT 84112, USA.
| | - Ryan Robinson
- The Nano Institute of Utah, University of Utah, Salt Lake City, UT 84112, USA. and Department of Bioengineering, University of Utah, Salt Lake City, UT 84112, USA
| | - John S Spencer
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO 80523, USA
| | - Delphi Chatterjee
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO 80523, USA
| | - Kimberly E Hanson
- Department of Internal Medicine, University of Utah, Salt Lake City, UT 84112, USA and Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA
| | - Marc D Porter
- The Nano Institute of Utah, University of Utah, Salt Lake City, UT 84112, USA. and Department of Chemistry, University of Utah, Salt Lake City, UT 84112, USA and Department of Bioengineering, University of Utah, Salt Lake City, UT 84112, USA and Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA and Department of Chemical Engineering, University of Utah, Salt Lake City, UT 84112, USA
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35
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Lawn SD, Gupta-Wright A. Detection of lipoarabinomannan (LAM) in urine is indicative of disseminated TB with renal involvement in patients living with HIV and advanced immunodeficiency: evidence and implications. Trans R Soc Trop Med Hyg 2016; 110:180-5. [PMID: 26884498 PMCID: PMC4755427 DOI: 10.1093/trstmh/trw008] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
TB is the leading cause of HIV/AIDS-related deaths globally. New diagnostic tools are urgently needed to avert deaths from undiagnosed HIV-associated TB. Although simple assays that detect lipoarabinomannan (LAM) in urine have been commercially available for years, their specific role and utility were initially misunderstood, such that they have been slower to emerge from the diagnostics pipeline than otherwise might have been expected. In this article, we review and explain how urine-LAM assays should be understood as diagnostics for disseminated TB in HIV-positive patients with advanced immunodeficiency, in whom haematogenous TB dissemination to the kidneys serves as the primary mechanism by which LAM enters the urine. These insights are critical for the appropriate design of studies to evaluate these assays and to understand how they might be most usefully implemented. This understanding also supports the 2015 WHO recommendations on the restricted use of these assays in sick HIV-positive patients with advanced immunodeficiency.
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Affiliation(s)
- Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK Malawi-Liverpool-Wellcome Trust Clinical Research Program, University of Malawi College of Medicine, Blantyre, Malawi
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36
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Gupta-Wright A, Peters JA, Flach C, Lawn SD. Detection of lipoarabinomannan (LAM) in urine is an independent predictor of mortality risk in patients receiving treatment for HIV-associated tuberculosis in sub-Saharan Africa: a systematic review and meta-analysis. BMC Med 2016; 14:53. [PMID: 27007773 PMCID: PMC4804532 DOI: 10.1186/s12916-016-0603-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/17/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Simple immune capture assays that detect mycobacterial lipoarabinomannan (LAM) antigen in urine are promising new tools for the diagnosis of HIV-associated tuberculosis (HIV-TB). In addition, however, recent prospective cohort studies of patients with HIV-TB have demonstrated associations between LAM in the urine and increased mortality risk during TB treatment, indicating an additional utility of urinary LAM as a prognostic marker. We conducted a systematic review and meta-analysis to summarise the evidence concerning the strength of this relationship in adults with HIV-TB in sub-Saharan Africa, thereby quantifying the assay's prognostic value. METHODS We searched MEDLINE and Embase databases using comprehensive search terms for 'HIV', 'TB', 'LAM' and 'sub-Saharan Africa'. Identified studies were reviewed and selected according to predefined criteria. RESULTS We identified 10 studies eligible for inclusion in this systematic review, reporting on a total of 1172 HIV-TB cases. Of these, 512 patients (44 %) tested positive for urinary LAM. After a variable duration of follow-up of between 2 and 6 months, overall case fatality rates among HIV-TB cases varied between 7 % and 53 %. Pooled summary estimates generated by random-effects meta-analysis showed a two-fold increased risk of mortality for urinary LAM-positive HIV-TB cases compared to urinary LAM-negative HIV-TB cases (relative risk 2.3, 95 % confidence interval 1.6-3.1). Some heterogeneity was explained by study setting and patient population in sub-group analyses. Five studies also reported multivariable analyses of risk factors for mortality, and pooled summary estimates demonstrated over two-fold increased mortality risk (odds ratio 2.5, 95 % confidence interval 1.4-4.5) among urinary LAM-positive HIV-TB cases, even after adjustment for other risk factors for mortality, including CD4 cell count. CONCLUSIONS We have demonstrated that detectable LAM in urine is associated with increased risk of mortality during TB treatment, and that this relationship remains after adjusting for other risk factors for mortality. This may simply be due to a positive test for urinary LAM serving as a marker of higher mycobacterial load and greater disease dissemination and severity. Alternatively, LAM antigen may directly compromise host immune responses through its known immunomodulatory effects. Detectable LAM in the urine is an independent risk factor for mortality among patients receiving treatment for HIV-TB. Further research is warranted to elucidate the underlying mechanisms and to determine whether this vulnerable patient population may benefit from adjunctive interventions.
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Affiliation(s)
- Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
- Malawi-Liverpool-Wellcome Trust Clinical Research Program, College of Medicine, University of Malawi, Blantyre, Malawi.
| | - Jurgens A Peters
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Clare Flach
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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