Outcomes in Kaposi's sarcoma-associated herpesvirus -associated primary effusion lymphoma and multicentric Castleman's disease in patients with human immunodeficiency virus (HIV) in a safety-net hospital system

OBJECTIVE

To describe cases of Kaposi's sarcoma-associated herpesvirus (KSHV)-associated multicentric Castleman's disease (MCD) and primary effusion lymphoma (PEL) in patients with HIV from a large, safety-net hospital system in Dallas, Texas, USA.

METHODS

We conducted a retrospective review of patients with HIV-associated PEL and/or MCD.

RESULTS

Twelve patients with PEL and 10 patients with MCD were identified. All patients were male and 17 of 20 were men who have sex with men; 66.7% of PEL patients and 50% of MCD patients had concurrent KS at the time of diagnosis; 42% of patients with PEL and 20% of patients with MCD died during the follow-up period. We noted improved survival in our cohort compared to previous studies, particularly in our PEL patients with a median survival of 11.4 months compared to 3-6-month median survival historically. Median follow-up time for MCD patients was 17.5 months. This improved survival is despite suboptimal antiretroviral therapy (ART) adherence at diagnosis, with only 50% of patients on ART at the time of MCD/PEL diagnosis.

CONCLUSION

These data highlight the importance of early recognition of PEL and MCD, and the larger-scale efforts needed to better understand the pathogenetic drivers of clinical outcomes in patients affected by KSHV-related diseases.

Incidence trends of Kaposi Sarcoma among Young Non-Hispanic Black Men by US Regions, 2001-2018

Despite the overall national decline in Kaposi Sarcoma (KS) incidence in the US among persons living with HIV, previous studies suggest there might be specific subgroups of the US population that are associated with higher KS incidence rates than others. Using the 2001-2018 National Program of Cancer Registries and Surveillance, Epidemiology, and End Results Program Database, we assessed KS incidence trends among young men aged 20-34 by race and ethnicity and geographic region. Statistical significance is 2-sided. The KS incidence rate increased nationally by 1.5%/year in non-Hispanic Black men, while the rate decreased significantly by 3.5%/year in non-Hispanic White men. A significant 3.3%/year increase among young non-Hispanic Black men in the South and no change among those living in non-South regions were observed. Targeted HIV prevention and treatment in young non-Hispanic Black men in the South and further research addressing the increased KS incidence and burden in this vulnerable population are needed.

AB0589 TOCILIZUMAB FOR GIANT CELL ARTERITIS: BASELINE AND TWELVE MONTH AUDIT DATA FROM THE UK BRISTOL AND BATH MULTIDISCIPLINARY MEETING

Background

Giant Cell Arteritis (GCA) is a systemic vasculitis involving large and medium-sized blood vessels. Treatment is with high dose glucocorticoids. Steroid-sparing agents and Tocilizumab (TCZ) are used for refractory or relapsing cases. NHS England requires all GCA patients to be discussed in a regional multidisciplinary team meeting (MDT) prior to commencing TCZ. TCZ has only been permitted for a maximum of one year; this time limitation was extended during the Covid-19 pandemic (1). The monthly virtual Bristol and Bath regional MDT started in November 2018.

Objectives

We aimed to review: 1) Baseline data on all patients referred to the Bristol and Bath TCZ for GCA MDT, including demographics, clinical presentation and previous steroid-sparing agents used and 2) 12 month follow up data including number of completions, adverse effects, and flares on treatment.

Methods

The TCZ MDT referral proforma, adapted from the NHS England Blueteq approval form, was reviewed for all patients referred. 12 month follow up data was obtained from clinic letters.

Results

Baseline data

Thirty-eight cases were referred between November 2018 and September 2021. Of these, 31 were approved for TCZ usage; 100% fulfilled the criteria for either refractory (n=11) or relapsing (n=20) disease. Mean age was 74 years and 74.2% were female. Average disease duration was 161.5 days for the refractory and 827.3 days for the relapsing group.

77.4% had cranial GCA, 48.4% had large vessel involvement, 45.2% had visual symptoms and 25.8% had ischaemic visual loss. The positive investigations were PET-CT (48.4%), temporal artery ultrasound (41.9%) and temporal artery biopsy (32.3%).

64.5% had trialled a steroid-sparing agent at time of referral (61.3 % methotrexate, 9.7% azathioprine, 6.5% leflunomide), 35.5% had received intravenous methylprednisolone and 58% were receiving greater than 40mg prednisolone at the time of referral.

Glucocorticoid adverse effects of osteoporosis, weight gain, cataracts and hypertension were each seen in 19.4%; whilst diabetes, neuropsychiatric symptoms and sleep disturbance were each reported in 16.1%.

Those with ocular involvement tended to be referred earlier than those without (478.2 days vs 648.1 days), were referred on higher doses of glucocorticoids (71.4% vs 47.1% on ≥ 40mg) and had less steroid-sparing agents prior to referral.

Follow up data

In December 2021, a follow-up audit revealed 14/31 patients had completed at least 12 months of tocilizumab; 5 of these had had an extension under Covid-19 exceptional guidance (mean duration of 5.2 months). Of the remaining 17: 3 patients had stopped early (1 death, 1 moved away, 1 due to adverse effects of headache and gastro-intestinal side effects), 4 had not started tocilizumab and 10 had not completed 12 months of treatment at that point.

Adverse events in the 14 patients at 12 months included: liver abnormalities (2/14; 14.3%), neutropenia (2/14; 14.3%), thrombocytopaenia (1/14; 7.1%), soft tissue infections (3/14; 21.4%), urinary tract infection (1/14; 7.1%) and lipid derangement (4/14 28.6%). One case of GCA relapse occurred on TCZ (mild headache and raised inflammatory markers settled on small increase in prednisolone). After 12 months, mean prednisolone dose was 3mg (range 0-15mg).

Conclusion

All patients approved for Tocilizumab in the GCA MDT fulfilled NHS England criteria for either relapsing or refractory disease. The majority of cases had cranial disease, but almost half had either ocular or large vessel involvement, reflecting a severe spectrum of disease. Cases showed a high burden of glucocorticoid toxicity. Follow up data suggests that TCZ was effective in allowing glucocorticoid weaning and disease control, but with some adverse effects. Future work to follow up patients after stopping Tocilizumab would be informative, as the twelve month limitation on treatment is likely to be re-instated.

References

[1]https://www.england.nhs.uk/coronavirus/publication/tocilizumab-for-giant-cell-arteritis-gca-during-the-covid-19-pandemic-rps-2007/

Disclosure of Interests

Chandrin N. R. Jayatilleke: None declared, Aishwarya Anilkumar: None declared, Shalini Janagan: None declared, Robert W Marshall: None declared, Sarah Skeoch: None declared, Catherine Guly Grant/research support from: Eli Lilly and Company - paid consultant for a research trial, Fang En Sin: None declared, Keziah Austin: None declared, Laith Al-Sweedan: None declared, Alexandra Bourn: None declared, Lynsey Clarke: None declared, Harsha Gunawardena: None declared, Baashar Boyce: None declared, Sally Knights: None declared, John D Pauling: None declared, Elizabeth Reilly: None declared, Timothy D Reynolds: None declared, Sarah Villar: None declared, Joanna C Robson: None declared

827. High KSHV Seroprevalence Among MSM with HIV Associated with Oral Intercourse and Methamphetamine Use in the Southern United States

Background

Despite a decrease in Kaposi’s sarcoma (KS) cases in much of the US, the incidence of KS and associated mortality is increasing in specific subpopulations, particularly young, African American men in the South. To further understand this disparity, we sought to describe the seroprevalence and risk factors associated with Kaposi’s sarcoma herpesvirus (KSHV) among men who have sex with men (MSM) and transgender women (TGW) with HIV in Dallas, Texas.

Methods

We enrolled MSM and TGW with HIV and without known KSHV-related disease from a large urban safety-net clinic in Dallas. Blood samples were collected from participants for IgG testing (K8.1 and ORF73), followed by KSHV PCR on blood and saliva samples for those with positive IgG results. We also collected demographics, sexual history, sexual practices, HIV history, substance use, and insurance status. Multivariate logistic regression modeling was performed to identify associations with KSHV seropositivity.

Results

Of 159 participants, 110 (69.2%) were seropositive for KSHV. Seroprevalence varied by race/ethnicity, with 27/34 (79.4%) Hispanic, 27/37 (73.0%) white, and 54/84 (64.3%) black participants testing positive for KSHV IgG, though this difference was not statistically significant. 31/104 (29.8%) seropositive participants had detectable KSHV in saliva and 10/104 (9.6%) seropositive participants had detectable KSHV in blood. Risk factors independently associated with KSHV seropositivity include oral-anal sex (OR 4.02, 95% CI 1.89 – 8.54), oral-penile sex (OR 3.66, 95% CI 1.16 – 11.57), and methamphetamine use (OR 2.73, 95% CI 1.23 – 6.04). Current CD4 count, HIV viral load, history of intravenous drug use, tobacco or alcohol use were not associated with KSHV seropositivity.

Table 1. Patient Characteristics

Conclusion

We found that over two-thirds of MSM and TGW with HIV in Dallas are KSHV seropositive, which is relatively high compared to other studies of US MSM with HIV (30-70%). In our study, KSHV was more common among Hispanic and white individuals, and was associated with higher rates of oral sex and methamphetamine use. Differences in KSHV seroprevalence alone are unlikely to explain racial disparities in the incidence of KS. Further study is needed to better understand drivers of KSHV infection and KSHV-related diseases in highly impacted groups in the US.

Disclosures

All Authors: No reported disclosures

329. Health Disparities Among HIV-Positive Patients with Kaposi’s Sarcoma

Background

Kaposi’s sarcoma (KS) is an AIDS-related condition that is mediated by HHV-8. Although incidence and mortality of KS in the United States have decreased over time since the advent of HAART, there may be disparities in mortality based on geographic location and race/ethnicity, particularly African-American men in the South.

Methods

A retrospective electronic medical record review was conducted using integrated inpatient and outpatient data in EPIC from PHHS. We included all individuals with a diagnosis of HIV and Kaposi’s sarcoma between January 1, 2009 and December 31, 2018 based on ICD-9/10 codes. We collected demographic information, HIV history, variables related to HIV and KS diagnosis, treatment and outcomes data for each patient. We calculated hazard ratios using Cox proportional hazards modeling.

Results

We identified 252 patients with KS. 95% of patients were male, and the majority were MSM (men who have sex with men; 77% of all patients). 35% of patients were Hispanic, 34% were African-American and 31% were Caucasian. Over half (56%) of patients were funded through Ryan White or were uninsured. The median CD4 count and viral load at the time of cancer diagnosis were 44 and 73,450, respectively. 24% of patients were confirmed to have died by the end of the study time frame. However, due to loss to follow-up, 35% of the cohort had an unknown vital status at the time of the final chart review. Variables most strongly associated with mortality were >2 hospitalizations in the first 6 months of cancer diagnosis (aHR=4.93, P = 0.0003), IV drug use (aHR=3.61, P = 0.0009), and T1 stage of KS (aHR= 2.13, P = 0.0264). African American patients had lower survival than Caucasian or Hispanic patients, with a 5-year survival of 69%, 81% and 80% respectively, although this did not reach statistical significance (aHR 1.77, P = 0.1396).

Conclusion

We describe a large cohort of patients with HIV and HHV-8-related disease, who are predominantly of minority race/ethnicity, uninsured, and have advanced HIV disease. Factors associated with mortality include Black/African-American ethnicity, number of hospitalizations, IV drug use and T1 stage of KS. Our mortality analysis is limited due to high lost to follow-up rates, so we suspect overall mortality in our cohort is higher than currently reported.

Disclosures

Ank E. Nijhawan, MD, MPH, Gilead Sciences, Inc.: Research Grant.

Gestational diabetes mellitus. At what time should the postprandial glucose level be monitored?

OBJECTIVE

To compare selected pregnancy outcomes for women with gestational diabetes mellitus (GDM) with management based on testing either 1 hour or 2 hours postprandially according to the ADIPS recommendations.

METHODS

Prospective study of consecutive women referred for the medical management of their GDM. Women were allowed to select whether they would test either 1 hour postprandial with a target glucose of < 8.0 mmol/L or 2 hours postprandial with a target glucose of <7.0 mmol/L. Changes to diet and the introduction and adjustment of insulin therapy were designed to maintain postprandial glucose levels below these targets.

RESULTS

166 women elected to test 1 hour postprandial and 101 elected to test 2 hours postprandial. There were no significant demographic differences between these 2 groups. The fetal birthweight, percentage of women requiring insulin and the total daily dose of insulin were similar in both groups.

CONCLUSIONS

For women with GDM, monitoring either 1 hour or 2 hours postprandially led to similar outcomes. This would suggest that the ADIPS recommendations are equivalent and therefore women can choose the most convenient time for their postprandial monitoring.

Birth weight of women with gestational diabetes

OBJECTIVE

Epidemiological observations have suggested a relationship between type 2 diabetes and a low birth weight. However, there are many confounding variables and problems with retrospective data collection. Women with gestational diabetes mellitus (GDM), who are likely to develop type 2 diabetes in the future, may help clarify these observations.

RESEARCH DESIGN AND METHODS

Consecutive women with GDM (n = 138) were included in the study if they had a singleton pregnancy delivered between 37 and 41 weeks of gestation, if they had themselves been born in the local hospital, and if their own delivery data were available. With respect to their own births, a matched group was obtained by considering the next female delivery of the same gestational age.

RESULTS

For women with GDM, the mean (+/- 1 SD) birth weight was 3,293 +/- 493 g and the ponderal index was 27.0 +/- 2.4. Their values were not significantly different from the matched group, which had a birth weight of 3,315 +/- 460 g and a ponderal index of 27.0 +/- 2.5. After adjusting for the gestational age of delivery, the birth weight of women with GDM did not show a U-shaped distribution.

CONCLUSIONS

After adjustment for the gestational age of delivery, women with GDM do not themselves have either a lower or higher birth weight than a matched group. These data suggest that women with GDM are either not a good surrogate for investigating the relationship between birth weight and type 2 diabetes or that correction for the gestational age of delivery removes the most important confounding variable. It is also possible that modern dietary changes may have altered the relationship.

Measurement of the delivery of dialysis in acute renal failure

BACKGROUND

Recent studies in patients with acute renal failure (ARF) have shown a relationship between the delivered dose of dialysis and patient survival. However, there is currently no consensus on the appropriate method to measure the dose of dialysis in ARF patients. In this study, the dose of dialysis was measured by blood- and dialysate-based kinetic methods in a group of ARF patients who required intermittent hemodialysis.

METHODS

Treatments were performed using a Fresenius 2008E volumetric hemodialysis machine with the ability to fractionally collect the spent dialysate. Single-, double-pool, and equilibrated Kt/V were determined from the pre-, immediate post-, and 30-minute post-blood urea nitrogen (BUN) measurements. The solute reduction index was determined from the collected dialysate, as well as the single- and double-pool Kt/V.

RESULTS

Forty-six treatments in 28 consecutive patients were analyzed. The mean prescribed Kt/V (1.11 +/- 0.32) was significantly greater than the delivered dose estimated by single-pool (0.96 +/- 0.33), equilibrated (0.84 +/- 0.28), and double-pool (0.84 +/- 0.30) Kt/V (compared with prescribed, each P < 0.001). There was no statistical difference between the equilibrated and double-pool Kt/V (P = NS). The solute removal index, as determined from the dialysate, corresponded to a Kt/V of 0.56 +/- 0.27 and was significantly lower than the single-pool and double-pool Kt/V (each P < 0.001).

CONCLUSION

Blood-based kinetics used to estimate the dose of dialysis in ARF patients on intermittent hemodialysis provide internally consistent results. However, when compared with dialysate-side kinetics, blood-based kinetics substantially overestimated the amount of solute (urea) removal.

Prescribed versus delivered dialysis in acute renal failure patients

The current study was designed first to determine separately the prescribed and delivered dose of dialysis and, second, to determine what factors lead to failure to deliver the prescribed dose of dialysis in patients with acute renal failure (ARF). Forty patients, who collectively underwent 136 dialysis treatments, were studied prospectively at two institutions. The results showed that almost half the prescriptions (49%) were for a Kt/V less than 1.2 and, more importantly, nearly 70% of the treatments delivered a Kt/V less than 1.2, the minimally acceptable dose defined in the Dialysis Outcomes Quality Initiative (DOQI) guidelines for chronic hemodialysis (CHD) patients. Patient predialysis weight was the most important variable associated with a low prescribed and delivered dose of dialysis, as well as lack of delivery of the prescribed dose of dialysis. From the statistical model, it is estimated that for every 10-kg increase in predialysis weight, the chance of prescribing or delivering a Kt/V less than 1.2 increased 4.6- and 1.95-fold, respectively. The lower than prescribed blood flow achieved by the temporary catheters and patients not receiving anticoagulation were variables also associated with not receiving the prescribed Kt/V. It is concluded that patients with ARF are prescribed and receive a dose of dialysis that would be considered inadequate for CHD patients. Until the association between dose of dialysis and outcome is better defined, it would be prudent that both the dialysis prescription and the delivery of dialysis to patients with ARF should be performed with the same care and goals as that currently received by patients with end-stage renal disease (ESRD).

Predictive measures of vascular access thrombosis: a prospective study

Malfunction of permanent vascular accesses remains a cause of frequent and costly morbidity in patients receiving chronic hemodialysis (CHD). Several recommendations for routine monitoring of these permanent vascular accesses for incipient failure have been proposed. In this study, multiple indicators of incipient vascular access dysfunction, including "venous" and "arterial" pressures at serial blood flows (200 ml/min, 300 ml/min, and 400 ml/min), percent urea recirculation, Doppler ultrasound, and access blood flow by ultrasound dilution technique were simultaneously evaluated in a total of 220 vascular accesses in 170 chronic hemodialysis patients in two separate study periods (6 months apart). The rate of thrombosis was determined within the subsequent 12 weeks of each study period to assess the short-term predictive power of access thrombosis. During the period of follow-up, there were 34 thrombotic events in 172 polytetrafluoroethylene (PTFE) grafts and only one thrombotic event in 48 arterio-venous fistulas (AVF). Therefore, the statistical analysis was limited to the PTFE grafts. When grafts with thromboses were compared to those without thrombosis by univariate analysis, access blood flow measured either by ultrasound dilution technique (875 +/- 426 ml/min with thrombosis vs. 1193 +/- 677 ml/min without thrombosis, P = 0.001) or by Doppler ultrasound (762 +/- 420 ml/min with thrombosis vs. 1171 +/- 657 ml/min without thrombosis, P = 0.001) were significantly different in the two groups. There was good correlation (r = 0.79, P = 0.0001) between the blood flows determined by both techniques. The grade of stenosis determined by ultrasound was also a statistically significant predictor (P = 0.02). "Venous" and "arterial" pressures were numerically similar and were not statistically different between the accesses that did and those that did not thrombose. When multivariate analysis was used, there was a significantly increased risk of thrombosis only with decreasing access blood flow determined by ultrasound dilution techniques after adjusting for other confounding variables. When the average blood flow of all grafts (1134 ml/min) is considered as the reference access blood flow (relative risk of 1.0), the relative risk of a PTFE thrombotic event within the subsequent 12 weeks was 1.23 at a blood flow 950 ml/min, 1.67 at a blood flow of 650 ml/min and to 2.39 at a blood flow of 300 ml/min. In summary, access blood flow measured by either Dilution or Doppler is a reliable indicator of subsequent short-term thrombosis risk. Other proposed methods of evaluating access dysfunction were not useful in our patients. If simple to use, cost-effective devices to measure dialysis access blood flow become readily available, the measurement of access blood flow will likely become the method of choice for screening of PTFE vascular access dysfunction in hemodialysis patients.

Chemical synthesis of dual-radiolabelled cyclandelate and its metabolism in rat hepatocytes and mouse J774 cells

1. The chemical synthesis of 3,3,5-trimethyl[1-3H]cyclohexanol, 3,3,5-trimethyl[2,3-3H]cyclohexanol and 3,3,5-trimethyl[2,3-3H]cyclohexanyl[1-14C]mandelate (cyclandelate) are described. The ratio of 3H/14C radioactivity in the ester was 27:1. 2. Cultured rat hepatocytes accumulated trimethylcyclohexanol rapidly and excreted its glucuronide into the culture medium. Rat hepatocytes also accumulated cyclandelate rapidly, hydrolysing the ester and excreting trimethylcyclohexanol into the medium. This trimethylcyclohexanol then re-entered the cells and was converted to its glucuronide prior to excretion. 3. In contrast, no hydrolysis of cyclandelate was seen on incubation with J774 cells, a transformed mouse macrophage. 4. Similar differences in hydrolytic activity were seen with microsomal fractions prepared from rat liver and J774 cells. Hepatic microsomes caused a rapid hydrolysis of cyclandelate while no hydrolysis was detectable after incubations of over an hour with J774 microsomes. 5. This difference in hydrolytic activity may have important implications for the action of cyclandelate on cholesterol metabolism in extrahepatic tissues.

A controlled trial of health education in the physician's office

Screening of 6,144 patients in a general practice clinic to assist physician case-finding uncovered 983 (16%) who were uncontrolled hypertensives. Following physician recommendation, 115 patients volunteered for a controlled trial to test the effectiveness of supplementary strategies to the pharmaceutical management of high blood pressure. A study of nonparticipants indicated that about 7% of the practice population was eligible for cardiovascular health education. One group received a health education program, a second was allocated to self-monitor their blood pressure for 6 months, a third group was allocated to both strategies, and the final group, acting as a control, continued to receive their usual care. Physician monitoring of patients continued for the duration of the study and blood pressures decreased in all patients. The study's most important outcome was the joint reduction of blood pressure and medication strength. These were assessed by a "blind" clinician before and after the interventions according to criteria set out in the "stepped-care" approach to management of high blood pressure. People allocated to a health education program conducted in the doctor's common room did twice as well on this measure as those who were not so educated. Daily self-monitoring of blood pressure for 6 months proved to be too much for the majority of those so instructed. It is concluded that the general practice setting remains an important place for health education to prevent cardiac disease and suggestions are made for incorporating this into everyday practice.