Risk of End-Stage Renal Disease in HIV-Positive Potential Live Kidney Donors.

New federal regulations allow HIV-positive individuals to be live kidney donors; however, potential candidacy for donation is poorly understood given the increased risk of end-stage renal disease (ESRD) associated with HIV infection. To better understand this risk, we compared the incidence of ESRD among 41 968 HIV-positive participants of North America AIDS Cohort Collaboration on Research and Design followed for a median of 5 years with the incidence of ESRD among comparable HIV-negative participants of National Health and Nutrition Examination III followed for a median of 14 years. We used risk associations from multivariable Cox proportional hazards regression to derive cumulative incidence estimates for selected HIV-positive scenarios (no history of diabetes, hypertension, AIDS, or hepatitis C virus coinfection) and compared these estimates with those from similarly selected HIV-negative scenarios. For 40-year-old HIV-positive individuals with health characteristics that were similar to those of age-matched kidney donors, viral load <400 copies/mL, and CD4+ count ≥500 cells/µL, the 9-year cumulative incidence of ESRD was higher than that of their HIV-negative peers, yet still low: 2.5 versus 1.1 per 10 000 among white women, 3.0 versus 1.3 per 10 000 among white men, 13.2 versus 3.6 per 10 000 among black women, and 15.8 versus 4.4 per 10 000 among black men. HIV-positive individuals with no comorbidities and well-controlled disease may be considered low-risk kidney donor candidates.

Association of sunlight exposure and photoprotection measures with clinical outcome in systemic lupus erythematosus.

This study was designed to explore the relationship of sunlight exposure and ultraviolet (UV) light protection measures with clinical outcome in systemic lupus erythematosus (SLE). A structured questionnaire was administered to sixty Puerto Rican SLE patients, to assess their attitudes and behavior regarding sunlight exposure and photoprotection measures. Medical records were reviewed to evaluate the clinical outcome measures that included: clinical manifestations, number of SLE-related hospitalizations, number of exacerbations and pharmacologic treatment. Almost all (98.3%) patients were well acquainted of sunlight effects on disease activity. Two thirds were exposed to direct sunlight for an average of less than one hour per day and 33.3% for one hour or more. Thirty patients (50%) reported use of sunscreen, with sun protective factor of 15 or greater, when exposed to sunlight. Less than 40% of patients regularly wore hat or long-sleeves clothes to protect from sunlight. Although there were some clinical differences between the groups with different sunlight exposure times, none reached statistical significance. Also, no significant differences were found between the groups in regards to sunlight protective clothes. However, patients that regularly used sunscreen had significantly lower renal involvement (13.3 vs 43.3%), thrombocytopenia (13.3 vs 40%), hospitalizations (26.7 vs. 76.7%), and requirement of cyclophosphamide treatment (6.7 vs. 30%) than patients that did not used it (P < 0.05). We conclude that use of sunscreen photoprotection was associated with a better clinical outcome in our SLE patients. These findings further support the importance and benefits of photoprotective measures in patients with SLE.

Factors associated with metabolic syndrome in patients with systemic lupus erythematosus from Puerto Rico.

The aim of this study was to determine the factors associated with metabolic syndrome in patients with systemic lupus erythematosus from Puerto Rico. A total of 204 patients with systemic lupus erythematosus (per the American College of Rheumatology classification criteria) were evaluated. Metabolic syndrome was assessed using the American Heart Association and the National Heart, Lung, and Blood Institute classification. Socioeconomic-demographic parameters, health-related behaviours, clinical manifestations, autoantibodies, pharmacological treatments, disease activity (per the Systemic Lupus Activity Measure--Revised), and damage accrual (per the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index) were determined at study visit. Factors associated with metabolic syndrome were examined by univariable analyses and multivariable logistic regression models. A total of 196 (96.2%) were women. The mean age at study visit was 43.6 +/- 13.0 years, and the mean disease duration was 8.7 +/- 7.7 years. Seventy-eight patients (38.2%) had metabolic syndrome. In the multivariable analysis, age (odds ratio [OR] = 1.05; 95% confidence interval [CI] 1.02-1.09), government health insurance (OR = 2.06; 95% CI 1.07-4.22), exercise (OR = 0.33; 95% CI 0.14-0.92), thrombocytopenia (OR = 4.19; 95% CI 1.54-11.37), erythrocyte sedimentation rate (OR = 1.64; 95% CI 1.03-2.63), disease activity (OR = 1.14; 95% CI 1.00-1.30), and prednisone >10 mg/day (OR = 3.69; 95% CI 1.22-11.11) were associated with metabolic syndrome. In conclusion, older age, low socioeconomic status, lack of exercise, thrombocytopenia, increased erythrocyte sedimentation rate , higher disease activity, and prednisone >10 mg/day were independently associated with metabolic syndrome in patients with systemic lupus erythematosus from Puerto Rico.

Clinical and prognostic value of autoantibodies in puerto Ricans with systemic lupus erythematosus.

The aim of this study was to determine the association between lupus autoantibodies and the clinical manifestations and outcome in a cohort of Puerto Ricans patients with systemic lupus erythematosus (SLE). All patients fulfilled the American College of Rheumatology classification criteria for SLE. Demographic parameters, clinical manifestations over time and damage accrual were obtained at the last study visit. Disease damage was assessed with the Systemic Lupus International Collaborating Clinics Damage Index (SDI). ANA, ANA pattern, and anti-dsDNA, anti-Smith, anti-Ro (SSA), anti-La (SSB) and anti-snRNP antibodies were measured at the time of SLE diagnosis. Chi-square test, Fisher exact test, ANOVA, logistic regression and general lineal model analyses were used to evaluate these associations. Ninety-six percent of patients were females. The cohort had a mean age of 40.2 +/- 12.0 years and mean disease duration of 9.6 +/- 7.0 years. Patients with elevated anti-dsDNA antibodies were more likely to have vasculitis, pericardial effusion, renal involvement, anaemia, leukopenia, lymphopenia and thrombocytopenia. Anti-Smith antibodies were positively associated with skin ulcerations, elevated liver enzymes, renal involvement and thrombocytopenia. Anti-Ro antibodies were related with the presence of discoid lupus, serositis, pneumonitis, elevated liver enzymes, hemolytic anaemia, leukopenia and lymphopenia. No positive associations were found for anti-snRNP or anti-La antibodies. The presence of anti-dsDNA, anti-Smith and anti-Ro antibodies was associated with higher SDI scores. In conclusion, anti-dsDNA, anti-Smith and anti-Ro antibodies are associated with several clinical manifestations and more damage accrual in Puerto Ricans with SLE. These findings provide valuable clinical and prognostic information for this ethnic population.

Gender differences in a cohort of Puerto Ricans with systemic lupus erythematosus.

Variations in systemic lupus erythematosus (SLE) clinical manifestations, serologies and outcomes have been related to gender differences. However, these associations have not been evaluated in Puerto Ricans. A cross-sectional study was performed in a cohort of 235 Puerto Rican SLE patients. Clinical variables, autoantibodies, SLICC/ACR damage index and mortality rate were determined. Of the 235 SLE patients, 12 (5%) were males. Male and female patients were similar with respect to age, disease duration and follow up. Men were more likely to have pericardial effusion (41% vs 5%, p<0.01), pleural effusion (58% vs 10%, p<0.01), proteinuria (>0.5 g/24 hr) (58% vs 24%, p=0.02), renal insufficiency (42% vs 11%, p<0.01) and end-stage renal disease (33% vs 6%, p<0.01) than women. Anti-Sm antibodies (60.0% vs 13%, p<0.01) and anti-snRNP antibodies (56% vs 21%, p=0.03) were more prevalent in men. SLICC/ACR mean damage index (2.7 +/- 2.7 vs 1.0 +/- 1.6, p<0.01) and mortality rate (25% vs 4.5%, p=0.02) were higher in men. In conclusion, male SLE patients of this cohort had higher prevalence of serositis and renal involvement than women. They also had a poorer outcome, presenting higher disease damage and mortality.

Therapeutic response and long-term follow-up in a systemic lupus erythematosus patient presenting with Kikuchi's disease.

Kikuchi's disease (KD) can occur in association with systemic lupus erythematosus (SLE). The treatment of concomitant diseases, however, is unclear. We describe a case of a 45-y-old man who presented with generalized histiocytic necrotizing lymphadenitis, fever, malaise and weight loss. Ten months later he also developed arthritis, serositis, anemia, leukopenia and lymphopenia. ANA, anti-Smith, anti-snRNP and anti-Ro antibodies were positive. He responded rapidly and favorably to mid-dose prednisone. Hydroxychloroquine, added 5 months later, allowed tapering down and discontinuation of prednisone treatment. He has remained in complete remission for 5 years.

Recurrent pneumonia mortality risk in a HIV/AIDS Puerto Rican cohort.

Recurrent pneumonia (RP) within 12 months is one of the AIDS diagnosis criteria. To gain knowledge of RP infection in HIV-infected patients, we studied 145 RP cases detected in a cohort of 2,996 HIV patients in Puerto Rico between Jan. 1992-Dec. 2001. The RP prevalence was 4.8%; 77.2% were males and 62.1% were injecting drug users (IDU). At the time of RP diagnosis, the mean CD4+ T cell count was 93.8 cells/mm3, 59.3% were in antiretroviral treatment, 13% had received the pneumococcal vaccine and 84.8% had another AIDS related condition. Over 37% received two or more antiretroviral medications. The death rate in the first year after the RP diagnosis was 63.4%. A Cox proportional hazard analysis showed that CD4+ T cells <200/mm3 (p<0.05), history of toxoplasmosis (p<0.01), wasting syndrome (p<0.01), esophageal candidiasis (p<0.05) and lower number of antiretroviral medications (p<0.05) increased their mortality risk. The studied patients had a highly compromised immune system and a very low pneumococcal vaccination percent at the time of RP diagnosis. Low CD4+ T cells significantly increased the hazard and mortality risk of the cases studied. Antecedents of antiretroviral therapy in these patients ensure a better outcome with lower mortality. Efforts to increase the vaccination rate should reduce the RP incidence in our HIV-infected population.

Differences between patients with non-Hodgkin's lymphomas in a cohort of HIV/AIDS patients in Puerto Rico.

The close association between AIDS and non-Hodgkin's lymphoma (NHL) is well known. Few studies are available that evaluate the profile of NHL in a cohort of HIV-infected patients who reside in Puerto Rico. The present study was performed in a cohort of 2,843 HIV-infected patients followed in the Retrovirus Research Center at Bayamón, Puerto Rico, evaluated between January 1992 until December 2000. NHL prevalence was determined and differences between AIDS defining and non-AIDS defining NHL were evaluated with the Fisher and ANOVA test. NHL prevalence was 0.9%. Nine (33%) were AIDS-defining (AIDS-d) NHL and 18 (67%) were non-AIDS-d NHL. Both groups were similar in gender distribution and mean diagnosis age. The median CD4+ T cell count at diagnosis was below 150/mm3 in both groups. Injecting drug use was higher in AIDS-d NHL patients and Homo-Bisexual contact was higher in non-AIDS-d NHL patients. Death rate in the first year after the NHL was 67% in the AIDS-d group and 56% in the non-AIDS-d group. AIDS-d NHL incidence decreased after the implementation of combined antiretroviral therapy in the cohort, a finding not seen in the non-AIDS-d NHL. In summary the study detected low NHL prevalence, with high degree of immunological damage at the time of the lymphoma diagnosis. Conversely dissimilar response to the antiretroviral therapies was also perceived in the incidence of the two NHL groups.

Clinical outcome and predictors of disease evolution in patients with incomplete lupus erythematosus.

To determine the outcome and identify risk factors for evolution into systemic lupus erythematosus (SLE) in a population of incomplete lupus erythematosus (ILE) patients, we studied the clinical and serologic manifestations in a cohort of 87 ILE patients. ILE patients had at least one but less than four of the American College of Rheumatology (ACR) classification criteria of SLE and did not present distinctive clinical features or meet classification criteria of other connective tissue diseases. The patients that remained with ILE were compared with patients that evolved into SLE and with a cohort of 94 SLE patients. The mean disease duration and follow up of ILE patients were 4.4 +/- 4.1 and 2.2 +/- 2.4 years respectively. Eight patients evolved into SLE, but none presented major organ damage. At baseline, patients that remained with ILE were less likely to have photosensitivity, elevated anti-dsDNA and decreased C3 complement than patients that evolved into SLE. At the end of the study, malar rash and oral ulcerations were also less frequent in the ILE group. Compared with all SLE cases, ILE patients were less likely to have photosensitivity, malar rash, oral ulcers, Raynaud's phenomenon, arthritis, low C3, low C4, positive anti-dsDNA, anti-Sm, anti-RNP, anti-Ro and anti-La antibodies at baseline. Hazard analyses showed that malar rash, oral ulcers, elevated anti-dsDNA and decreased C4 were associated with SLE occurrence. In conclusion, this study suggests that ILE represents a mild spectrum of lupus in which mucocutaneous and serological abnormalities are associated with progression into SLE.

Survival of AIDS according to injecting drug use among Puerto Rican AIDS patients.

This paper aims to: 1/ describe IDU's and non-IDU's according to age, gender, AIDS criteria and antiretroviral therapy; and 2/ assess survival differences between IDU's and non-IDU's according to age, gender, AIDS diagnosis criteria and antiretroviral therapy. This study is a survival study of a longitudinal cohort. The sample was composed of 1,258 AIDS patients of a cohort of HIV-infected adults who sought medical care at either the Immunology clinic of Bayamon or the Ramon Ruiz Arnau University Hospital between 1992 and 1999. The variables studied were: survival time of AIDS, intravenous drug use, age, gender, AIDS defining criteria and antiretroviral therapy (yes/no). The results have been that IDU's had lower survival than non-IDU's. Significant differences in the survival functions (IDU's vs non-IDU's) were found among male patients, older patients, patients with immunological criteria and patients with antiretroviral therapy. The survival among these variables was lower in IDU's than non-IDU's. This study suggested that decreased survival of IDU's may be related to later diagnosis and decreased access to drug therapy. Clinical endeavors should take into consideration the variables related to IDU's survival to develop health programs in order to enhance the quality of life and the survival of the AIDS patients.

Pulmonary tuberculosis mortality risks in a cohort of HIV/AIDS patients in Puerto Rico.

Pulmonary tuberculosis (TB) has re-emerged in relation to the HIV epidemic. To gain knowledge of TB infection in HIV-infected patients, we studied 106 HIV-TB cases in a cohort of 2,646 patients in Puerto Rico between January 1992 and September 1999. The TB prevalence was 4%; 82% were males and 73.6% were injecting drug users (IDU). At the time of TB diagnosis, the mean CD4+ T-cell count was 174/mm3, 35% were in antiretroviral treatment and 42.5% had another AIDS related condition. Only 9% received two or more antiretroviral medications. The death rate in the first year after the TB diagnosis was 55%. A Cox proportional hazard analysis showed that CD4+ T-cells <200/mm3 (p<0.01), history of toxoplasmosis (p<0.01), wasting syndrome (p<0.01) and lack of antiretroviral treatment (p=0.12) increased their mortality risk. The studied patients had a highly compromised immune system at the time of TB diagnosis. Low CD4+ T-cells (essential to control the TB infection) significantly increased the hazard and mortality risk of the cases studied. Early antiretroviral therapy in combination is recommended in HIV-infected patients, particularly in those with IDU, TB history and low CD4+ T-cell levels, to ensure an optimal immune system function that limits the pulmonary TB morbidity and mortality.

Clinical and immunological manifestations in 134 Puerto Rican patients with systemic lupus erythematosus.

To gain a better understanding of systemic lupus erythematosus (SLE) in Puerto Ricans we studied the clinical and serologic manifestations in a cohort of 134 patients. The female to male ratio was 18:1. Mean age at diagnosis was 32 +/- 12 y. The mean duration of disease and follow-up were 7.4 +/- 6.0 and 5.8 +/- 6.0 years respectively. Mortality was 3%. Photosensitivity (76.9%) and malar rash (71.9%) were the most common clinical manifestations. Arthritis was observed in 67.5% of patients. Anemia was seen in 67.2% of patients, but only 12.7% had autoimmune hemolytic anemia. Leukopenia (41.8%) and lymphopenia (64.9%) were also common. Serositis was observed in only 28%. Severe kidney damage such as nephrotic syndrome (14.2%) or renal failure (4%) was infrequent. Cardiovascular (12.7%) and neurologic (9.0%) manifestations were also uncommon. Antinuclear antibodies (ANA) were detected in 93.3%, anti-dsDNA antibodies in 54.5%, anti-Ro antibodies in 30.1% and anti-La antibodies in 14.2%. Low C3 and low C4 were observed in 38.3% and 35.7% respectively. This study suggests that Puerto Ricans with SLE present a mild form of disease predominantly manifested by cutaneous, musculoskeletal and hematologic involvement, but low prevalence of major organ damage and low mortality.

Iliac arteriovenous fistula secondary to iliac aneurysm rupture associated with pulmonary embolism and anuria.

We present a case of iliac aneurysm rupture that started with high-output cardiac failure and anuria and later presented as a pulmonary embolism that needed a preoperatory filter for the cava vein.