Monitoring Renal Function in HIV Patients Without Kidney Disease Using Endothelial Biomarkers: A Prospective Pilot Study.

This study aimed to investigate the association between novel biomarkers and renal injury in people with HIV (PWH). A cohort study was carried out with PWH under chronic use of antiretroviral therapy (ART), followed at a public outpatient service. Clinical and laboratory parameters of the patients were evaluated year by year, from 2015 [at baseline (year 1, Y1)] to 2019 [year 5 (Y5)]. At baseline, biomarkers of renal damage (e.g., neutrophil gelatinase-associated lipocalin-NGAL, monocyte chemoattractant protein-1-MCP-1, and kidney injury molecule-1-KIM-1) and endothelial activation or glycocalyx damage [e.g., intercellular adhesion molecule 1 (ICAM-1), E-selectin, and syndecan-1] were quantified using enzyme-linked immunosorbent assays and their levels were used to classify patients into different groups. However, only syndecan-1 showed a significant correlation with serum creatinine (p < .001) and glomerular filtration rate (GFR) (p = .003) over the years. Moreover, both serum creatinine and GFR in almost 5 years were significantly associated with serum levels of syndecan-1 at baseline. The multivariate linear regression with confounders showed a significant and independent association between GFR and levels of syndecan-1 and CD4 cell count in the beginning of the study, as well as age in Y5. The data reinforce the screening for kidney diseases with novel biomarkers, especially syndecan-1, as an important strategy for a timely diagnostic and therapeutic approach.

Death-related factors in HIV/AIDS patients undergoing hemodialysis in an intensive care unit.

HIV-infected patients are at high risk for developing critical diseases, including opportunistic infections (OI), with consequent admission in intensive care units (ICU). Renal disfunctions are risk factors for death in HIV/AIDS patients, and survival rates in patients undergoing hemodialysis are smaller than the ones observed in the general population. In this context, this study aimed to investigate death-related factors in HIV/AIDS patients in an intensive care setting. This is a retrospective cross-sectional study performed through the analysis of medical records from 271 HIV/AIDS-diagnosed patients hospitalized in an intensive care unit of an infectious disease hospital, in Fortaleza, Ceara State, Brazil. Patients were divided into two groups: those who underwent dialysis during hospitalization and those who did not. Clinical and demographic parameters that could be associated with death were evaluated. Results indicated a prevalence of death of 19.1% (CI 95%: 14.8-24.3). The median age of patients was 47 years, with a male predominance (71.3%). The main causes of admission were pulmonary tuberculosis (16.9%), followed by neurotoxoplasmosis (14.9%). In the bivariate analysis, for those that did not undergo dialysis, age, fever, dyspnea, oliguria, disorientation, kidney injury, use of lamivudine and efavirenz, length of hospitalization, CD4 count, WBC count, platelet count, urea, sodium and LDH levels were the associated variables. In those who needed dialysis, the use of stavudine, abacavir and ritonavir, and the length of hospitalization were associated factors. Renal toxicity by the antiretroviral agents and length of hospitalization increased the risk of death among HIV patients under dialysis.

Epidemiologia das intoxicações medicamentosas registradas no Sistema Nacional de Informações Tóxico-Farmacológicas de 2012-2016 / Epidemiology of medicinal intoxications registered in the National System of Toxic-Pharmacological Information 2012-2016

Dentre o universo de substâncias tóxicas, os medicamentos são os mais envolvidos em intoxicações. Em 2016, eles representaram 34% das intoxicações no Brasil. O objetivo foi analisar as intoxicações medicamentosas registradas entre os anos de 2012 a 2016, identificando as possíveis causas. Trata-se de um estudo documental realizado por meio de dados secundários disponíveis no sinitox e de informações contidas em bases de dados. As variáveis analisadas foram a frequência por região, a zona de ocorrência, o sexo, a faixa etária, a circunstância, a evolução dos casos e a frequência de óbitos. Os resultados mostraram que o Sudeste foi a região mais prevalente; o grupo mais atingido foi as mulheres de 20 a 49 anos, seguido de crianças de um a quatro anos; e a tentativa de suicídio como a principal circunstância. Pretende-se direcionar gestores e profissionais de saúde no planejamento de ações preventivas, amenizando esses incidentes e promovendo melhor qualidade de vida para a população.

In the universe of toxic substances, medicines are the most involved in intoxications. In 2016, they accounted for 34% poisonings in Brazil. The objective was to analyze drug intoxications recorded between 2012 and 2016, identifying the possible causes. It was a documentary study carried out using secondary data available at Sinitox and information contained in databases. The variables analyzed were: frequency by region, area of occurrence, sex, age, circumstance, evolution of cases, and frequency of deaths. The results showed that the southeast was the most prevalent region; the group most affected were women aged 20 to 49 years, followed by children aged 1 to 4 years; and attempted suicide as the main circumstance. The intention is to guide managers and health professionals in planning preventive actions, mitigating these incidents and promoting a better quality of life for the population.

Acute kidney injury and other factors associated with mortality in hiv-infected patients.

OBJECTIVE: HIV-related mortality is still high, especially in developed countries. The aim of this study is to investigate factors associated to death in HIV-infected patients. METHODS: This is a cross-sectional study with all HIV adult patients admitted to a tertiary infectious diseases hospital in Fortaleza, Northeast Brazil, from January 2013 to December 2014. Patients were divided into two groups: survivors and non-survivors. Demo-graphical, clinical and laboratory data were compared and a logistic regression was performed in order to investigate risk factors for death. P values ≤0.05 were considered statistically significant. RESULTS: A total of 200 patients with mean age of 39 years were including in the study, 69.5% males. Fifteen patients (7.5%) died. Non-survivors presented a higher percentage of males (93.3 vs. 67.3%, p = 0.037). Non-survivors presented AKI (73.3 vs. 10.3%, p < 0.001), liver dysfunction (33.3 vs. 11.5, p = 0.031), dyspnea (73.3 vs. 33.0%, p = 0.002) and disorientation (33.3 vs. 12.4%, p = 0.025) more frequently. Non-survivors also had higher levels of urea (73.8 ± 52.7vs. 36.1 ± 29.1 mg/dL, p < 0.001), creatinine (1.98 ± 1.65 vs. 1.05 ± 1.07 mg/dL, p < 0.001), aspartate aminotransferase (130.8 vs. 84.8 U/L, p = 0.03), alanine aminotransferase (115.6 vs. 85.4 U/L, p = 0.045) and lactate dehydrogenase (LDH) (1208 vs. 608 U/L, p = 0.012), as well as lower levels of bicarbonate (18.0 ± 4.7 vs. 21.6 ± 4.6 mEq/L, p = 0.016) and PCO2 (27.8 ± 7.7 vs. 33.0 ± 9.3 mmHg, p = 0.05). In multivariate analysis, disorientation (p = 0.035, OR = 5.523, 95%CI = 1.130 - 26.998), dyspnoea (p = 0.046, OR = 4.064, 95%CI = 1.028 - 16.073), AKI (p < 0.001, OR = 18.045, 95%CI = 4.308 - 75.596) and disseminated histoplasmosis (p = 0.016, OR = 12.696, 95%CI = 1.618 - 99.646) and LDH > 1000 U/L (p = 0.038, OR = 4.854, 95%CI = 1.093 - 21.739) were risk factors for death.]CONCLUSION: AKI and disseminated histoplasmosis (DH) were the main risk factors for death in the studied population. Neurologic and respiratory impairment as well as higher levels of LDH also increased mortality in HIV-infected patients.

Acute kidney injury and other factors associated with mortality in hiv-infected patients

SUMMARY OBJECTIVE: HIV-related mortality is still high, especially in developed countries. The aim of this study is to investigate factors associated to death in HIV-infected patients. METHODS: This is a cross-sectional study with all HIV adult patients admitted to a tertiary infectious diseases hospital in Fortaleza, Northeast Brazil, from January 2013 to December 2014. Patients were divided into two groups: survivors and non-survivors. Demo-graphical, clinical and laboratory data were compared and a logistic regression was performed in order to investigate risk factors for death. P values ≤0.05 were considered statistically significant. RESULTS: A total of 200 patients with mean age of 39 years were including in the study, 69.5% males. Fifteen patients (7.5%) died. Non-survivors presented a higher percentage of males (93.3 vs. 67.3%, p = 0.037). Non-survivors presented AKI (73.3 vs. 10.3%, p < 0.001), liver dysfunction (33.3 vs. 11.5, p = 0.031), dyspnea (73.3 vs. 33.0%, p = 0.002) and disorientation (33.3 vs. 12.4%, p = 0.025) more frequently. Non-survivors also had higher levels of urea (73.8 ± 52.7vs. 36.1 ± 29.1 mg/dL, p < 0.001), creatinine (1.98 ± 1.65 vs. 1.05 ± 1.07 mg/dL, p < 0.001), aspartate aminotransferase (130.8 vs. 84.8 U/L, p = 0.03), alanine aminotransferase (115.6 vs. 85.4 U/L, p = 0.045) and lactate dehydrogenase (LDH) (1208 vs. 608 U/L, p = 0.012), as well as lower levels of bicarbonate (18.0 ± 4.7 vs. 21.6 ± 4.6 mEq/L, p = 0.016) and PCO2 (27.8 ± 7.7 vs. 33.0 ± 9.3 mmHg, p = 0.05). In multivariate analysis, disorientation (p = 0.035, OR = 5.523, 95%CI = 1.130 - 26.998), dyspnoea (p = 0.046, OR = 4.064, 95%CI = 1.028 - 16.073), AKI (p < 0.001, OR = 18.045, 95%CI = 4.308 - 75.596) and disseminated histoplasmosis (p = 0.016, OR = 12.696, 95%CI = 1.618 - 99.646) and LDH > 1000 U/L (p = 0.038, OR = 4.854, 95%CI = 1.093 - 21.739) were risk factors for death.]CONCLUSION: AKI and disseminated histoplasmosis (DH) were the main risk factors for death in the studied population. Neurologic and respiratory impairment as well as higher levels of LDH also increased mortality in HIV-infected patients.

RESUMO INTRODUÇÃO: A mortalidade relacionada ao HIV ainda é alta, especialmente nos países em desenvolvimento. O objetivo deste estudo é investigar os fatores associados ao óbito em pacientes com HIV. MÉTODOS: Trata-se de um estudo transversal com todos os pacientes com HIV admitidos consecutivamente em um hospital terciário de doenças infecciosas em Fortaleza, Nordeste do Brasil, entre janeiro de 2013 e dezembro de 2014. Os pacientes foram divididos em dois grupos: sobreviventes e não sobreviventes. Dados demográficos, clínicos e laboratoriais foram comparados e análise de regressão logística foi feita para investigação dos fatores de risco para óbito. RESULTADOS: Um total de 200 pacientes, com média de idade de 39 anos, foi incluído no estudo, sendo 69,5% do sexo masculino. Óbito ocorreu em 15 pacientes (7,5%). Os não sobreviventes apresentaram maior percentual de homens (93,3 vs. 67,3%, p = 0,037) e um menor tempo de internação (8 ± 6 vs. 18 ± 15 dias, p = 0,005). Na análise multivariada, desorientação (p = 0,035, OR = 5,523), dispneia (p = 0,046, OR = 4,064), LRA (p < 0,001, OR = 18,045), histoplasmose disseminada (p = 0,016, OR = 12,696) e desidrogenase lática (LDH) > 1.000 U/L (p = 0,038, OR = 4,854) foram fatores de risco para óbito. CONCLUSÕES: LRA e histoplasmose disseminada foram os principais fatores de risco para óbito na população estudada. Distúrbios neurológicos e respiratórios, bem como níveis elevados de LDH, também estiveram associados com o aumento da mortalidade em pacientes com HIV.

Antiretroviral changes during the first year of therapy.

INTRODUCTION: The Brazilian HIV/AIDS management and treatment guideline (PCDT), published in 2013, recommends and standardizes the use of highly active antiretroviral therapy (HAART) in all adult patients, in spite of LTCD4 count. This study aimed to analyze the first year of HAART use in patients from a reference center on HIV/AIDS management in Fortaleza, Ceará. METHOD: This descriptive study reviewed all prescription forms of antiretroviral regimens initiation and changes from January to July 2014. All antiretroviral regimen changes that occurred during the first year of therapy were evaluated. Data were analyzed with SPSS version 20. Mean, standard deviation and frequency, Student's t and Mann-Whitney tests calculations were used, with significance at p<0.05. RESULTS: From 527 patients initiating HAART, 16.5% (n=87) had a regimen change in the first year. These patients were mostly male (59.8%; n=52), aged 20 to 39 years, with only one HAART change (72.4%; n=63). Efavirenz was the most often changed drug, followed by tenofovir, zidovudine and lopinavir/ritonavir. Mean time of HAART changes was 120 days, with adverse reactions as the most prevalent cause. HAART was effective in decreasing viral load since second month of treatment (p=0.003) and increasing LTCD4 lymphocytes since fifth month (p<0.001). CONCLUSION: The main cause of initial HAART changes was adverse reaction and most patients had only one change in the HAART regimen. HAART prescription was in accordance to the PCDT from 2013.

Antiretroviral changes during the first year of therapy / Mudanças de terapia antirretroviral durante o primeiro ano de tratamento

Summary Introduction: The Brazilian HIV/AIDS management and treatment guideline (PCDT), published in 2013, recommends and standardizes the use of highly active antiretroviral therapy (HAART) in all adult patients, in spite of LTCD4 count. This study aimed to analyze the first year of HAART use in patients from a reference center on HIV/AIDS management in Fortaleza, Ceará. Method: This descriptive study reviewed all prescription forms of antiretroviral regimens initiation and changes from January to July 2014. All antiretroviral regimen changes that occurred during the first year of therapy were evaluated. Data were analyzed with SPSS version 20. Mean, standard deviation and frequency, Student's t and Mann-Whitney tests calculations were used, with significance at p<0.05. Results: From 527 patients initiating HAART, 16.5% (n=87) had a regimen change in the first year. These patients were mostly male (59.8%; n=52), aged 20 to 39 years, with only one HAART change (72.4%; n=63). Efavirenz was the most often changed drug, followed by tenofovir, zidovudine and lopinavir/ritonavir. Mean time of HAART changes was 120 days, with adverse reactions as the most prevalent cause. HAART was effective in decreasing viral load since second month of treatment (p=0.003) and increasing LTCD4 lymphocytes since fifth month (p<0.001). Conclusion: The main cause of initial HAART changes was adverse reaction and most patients had only one change in the HAART regimen. HAART prescription was in accordance to the PCDT from 2013.

Resumo Introdução: O Protocolo Clínico e Diretrizes Terapêuticas para manejo da infecção pelo HIV em adultos (PCDT) de 2013 recomenda e normatiza início de terapia antirretroviral (TARV) em pacientes com qualquer contagem de LTCD4. O objetivo do estudo foi analisar o primeiro ano de TARV de pacientes em acompanhamento em um centro de referência em HIV/AIDS de Fortaleza, Ceará. Método: O estudo descritivo revisou formulários de solicitação de início e modificação de TARV em pacientes que iniciaram tratamento entre janeiro e julho de 2014. Foram avaliadas todas as mudanças que ocorreram durante o primeiro ano de terapia. Os dados foram analisados no programa Statistical Package for the Social Sciences (SPSS) versão 20. Foram calculados médias, desvios padrão, frequências, testes t Student e Mann-Whitney, com significância de p<0,05. Resultados: Dos 527 pacientes que iniciaram TARV, 16,5% (n=87) realizaram troca no primeiro ano. A maioria era do sexo masculino (59,8%; n=52), de 20 a 39 anos, com apenas uma mudança da TARV (72,4%; n=63). Efavirenz foi o fármaco mais substituído, seguido por tenofovir, zidovudina e lopinavir/ritonavir. O tempo médio de ocorrência das modificações da TARV foi de 120 dias, tendo reações adversas como causas principais. TARV foi efetiva na queda da carga viral desde o 2ºmês de tratamento (p=0,003) e na elevação de LTCD4 desde o 5º mês (p<0,001). Conclusão: Os principais fatores envolvidos em modificações de TARV inicial foram reações adversas, com apenas uma mudança de esquema na maioria dos pacientes. O manejo da TARV estava de acordo com o PCDT de 2013.

Endothelial Glycocalyx Damage and Renal Dysfunction in HIV Patients Receiving Combined Antiretroviral Therapy.

Widespread use of combined antiretroviral therapy (cART) increased HIV patients' life expectancy, however, favored the development of kidney and cardiovascular diseases. The aim of this study was to investigate endothelial glycocalyx (eGC) damage and its association with renal function in HIV patients receiving cART. This is a cross-sectional study with HIV-infected patients with no renal and cardiovascular disease, recruited in public health centers in Brazil. Clinical and laboratory parameters of HIV patients were compared according to cART use and with a healthy control group. Blood ICAM-1 and syndecan-1 levels were quantified by ELISA kit. Estimated glomerular filtration rate (eGFR) was evaluated. A total of 69 HIV patients were included, with mean age of 33.4 ± 8.9 years, and 77.3% were male. Serum urea, creatinine, and eGFR were similar in all groups. No HIV patient had decreased GFR <60 ml/min. All HIV patients had higher systemic syndecan-1 compared with healthy controls (71.8 ± 25.4 ng/ml vs. 36.5 ± 14.3 ng/ml, p < .001). Syndecan-1 showed a significant positive correlation with serum creatinine (r = 0.437, p = .001), serum urea levels (r = 0.352, p = .006), and a negative correlation with eGFR (r = -0.315, p = .015) in HIV patients. Syndecan-1 remained independently associated with serum creatinine and reduced GFR even after we forced variables related with HIV infection status, tenofovir use, treatment time, dyslipidemia, and others in a multivariate analysis. HIV patients using cART with no clinical renal and cardiovascular disease presented eGC damage and it is associated with clinical markers of kidney dysfunction. Syndecan-1 may be a useful early biomarker to monitoring renal dysfunction in HIV patients in chronic use of cART. Further research is needed to evaluate this applicability.

Acute kidney injury in HIV-infected children: comparison of patients according to the use of highly active antiretroviral therapy / Lesão renal aguda em crianças com HIV: estudo comparativo entre pacientes com e sem terapia antirretroviral altamente ativa

Abstract Objective: To assess clinical and laboratory data, and acute kidney injury (AKI) in HIV-infected children using and not using highly active antiretroviral therapy (HAART) prior to admission. Methods: A retrospective study was conducted with HIV-infected pediatric patients (<16 years). Children who were using and not using HAART prior to admission were compared. Results: Sixty-three patients were included. Mean age was 5.3 ± 4.27 years; 55.6% were females. AKI was observed in 33 (52.3%) children. Patients on HAART presented lower levels of potassium (3.9 ± 0.8 vs. 4.5 ± 0.7 mEq/L, p = 0.019) and bicarbonate (19.1 ± 4.9 vs. 23.5 ± 2.2 mEq/L, p = 0.013) and had a higher estimated glomerular filtration rate (102.2 ± 36.7 vs. 77.0 ± 32.8 mL/min/1.73 m2, p = 0.011) than those not on HAART. In the multivariate analysis, the use of HAART prior to the admission was a protective factor for AKI (p = 0.036; OR = 0.30; 95% CI = 0.097-0.926). Conclusion: AKI is a common complication of pediatric HIV infection. Use of HAART prior to the admission preserved glomerular filtration and was a protective factor for AKI, but increased medication side effects, such as hypokalemia and renal metabolic acidosis.

Resumo Objetivo: Avaliar dados clínicos e laboratoriais, bem como ocorrência de lesão renal aguda (LRA), em crianças HIV positivas com e sem uso de terapia antirretroviral altamente ativa (TARV) antes da admissão. Métodos: Estudo retrospectivo em pacientes pediátricos HIV positivos (< 16 anos). Foram comparadas as crianças que estavam em uso com aquelas sem uso de TARV prévia à internação. Resultados: Foram incluídos 63 pacientes, com média de 5,3 ± 4,27 anos, 55,6% do sexo feminino. LRA foi encontrada em 33 casos (52,3%). Os pacientes que usavam TARV apresentaram menores níveis de potássio (3,9 ± 0,8 vs. 4,5 ± 0,7 mEq/L, p = 0,019) e bicarbonato (19,1 ± 4,9 vs. 23,5 ± 2,2 mEq/L, p = 0,013), bem como maior taxa de filtração glomerular estimada (102,2 ± 36,7 vs. 77,0 ± 32,8 mL/min/1,73m2, p = 0,011), do que o pacientes sem TARV prévia. Na análise multivariada o uso de TARV prévia à internação foi fator protetor contra LRA (p = 0,036; RC = 0,30; IC de 95% = 0,097-0,926). Conclusão: A LRA é uma complicação comum da infecção pediátrica pelo HIV. O uso de TARV antes da internação foi associado a melhor taxa de filtração glomerular e foi fator de proteção contra LRA, porém desencadeou efeitos colaterais como hipocalemia e acidose metabólica.

Acute kidney injury in HIV-infected children: comparison of patients according to the use of highly active antiretroviral therapy.

OBJECTIVE: To assess clinical and laboratory data, and acute kidney injury (AKI) in HIV-infected children using and not using highly active antiretroviral therapy (HAART) prior to admission. METHODS: A retrospective study was conducted with HIV-infected pediatric patients (<16 years). Children who were using and not using HAART prior to admission were compared. RESULTS: Sixty-three patients were included. Mean age was 5.3±4.27 years; 55.6% were females. AKI was observed in 33 (52.3%) children. Patients on HAART presented lower levels of potassium (3.9±0.8 vs. 4.5±0.7mEq/L, p=0.019) and bicarbonate (19.1±4.9 vs. 23.5±2.2mEq/L, p=0.013) and had a higher estimated glomerular filtration rate (102.2±36.7 vs. 77.0±32.8mL/min/1.73m2, p=0.011) than those not on HAART. In the multivariate analysis, the use of HAART prior to the admission was a protective factor for AKI (p=0.036; OR=0.30; 95% CI=0.097-0.926). CONCLUSION: AKI is a common complication of pediatric HIV infection. Use of HAART prior to the admission preserved glomerular filtration and was a protective factor for AKI, but increased medication side effects, such as hypokalemia and renal metabolic acidosis.

CLINICAL CHARACTERISTICS, OUTCOMES AND RISK FACTORS FOR DEATH AMONG CRITICALLY ILL PATIENTS WITH HIV-RELATED ACUTE KIDNEY INJURY.

BACKGROUND: The aim of this study is to describe clinical characteristics, outcomes and risk factors for death among patients with HIV-related acute kidney injury (AKI) admitted to an intensive care unit (ICU). METHODS: A retrospective study was conducted with HIV-infected AKI patients admitted to the ICU of an infectious diseases hospital in Fortaleza, Brazil. All the patients with confirmed diagnosis of HIV and AKI admitted from January 2004 to December 2011 were included. A comparison between survivors and non-survivors was performed. Risk factors for death were investigated. RESULTS: Among 256 AKI patients admitted to the ICU in the study period, 73 were identified as HIV-infected, with a predominance of male patients (83.6%), and the mean age was 41.2 ± 10.4 years. Non-survivor patients presented higher APACHE II scores (61.4 ± 19 vs. 38.6 ± 18, p = 0.004), used more vasoconstrictors (70.9 vs. 37.5%, p = 0.02) and needed more mechanical ventilation - MV (81.1 vs. 35.3%, p = 0.001). There were 55 deaths (75.3%), most of them (53.4%) due to septic shock. Independent risk factors for mortality were septic shock (OR = 14.2, 95% CI = 2.0-96.9, p = 0.007) and respiratory insufficiency with need of MV (OR = 27.6, 95% CI = 5.0-153.0, p < 0.001). CONCLUSION: Non-survivor HIV-infected patients with AKI admitted to the ICU presented higher severity APACHE II scores, more respiratory damage and hemodynamic impairment than survivors. Septic shock and respiratory insufficiency were independently associated to death.