Consensus statement on the assessment of comorbidities in people living with HIV in Romania.

INTRODUCTION: The life expectancy of HIV-infected patients has been increased by highly effective therapies. People living with HIV (PLWH) in Romania are exposed to age-related comorbidities occurring earlier than in uninfected individuals. Multidisciplinary care is required to maintain the general health and quality of life in these patients. Currently, the communication among different specialties needs to be enhanced and formalized. METHODS: A panel consisting of 8 Romanian experts in infectious diseases, cardio-metabolic, bone, and kidney diseases and psychology met in May 2019 in Bucharest Romania to discuss the need to evaluate and monitor the most prevalent comorbidities in PLWH. The meeting resulted in practical guidance on the management of several non-infectious associated diseases. The algorithms were endorsed by the Society for Infectious Diseases and HIV/AIDS, Romania. RESULTS: The consensus statement offers practical guidance on how to assess and monitor associated diseases in adult PLWH. The recommendations are grouped for each cluster of comorbidities and are based on international guidelines and clinical experience, including landmarks for referral of PLWH to cardiology, endocrinology, nephrology specialist or clinical psychologist for additional investigations and adequate treatment. Specific indications for diagnosis or treatment were beyond the scope of this consensus. CONCLUSIONS: Screening for associated diseases and adequate management are required to maintain the overall health status of PLWH. When implemented in clinical practice, the recommended algorithms should be used in addition to diagnosis and treatment guidelines and protocols. The infectious diseases specialist plays a key role in coordinating the overall treatment strategy and working within the multidisciplinary team.

Catheter-related infections in chronic hemodialysis: a clinical and economic perspective.

PURPOSE: Central venous catheters emerged as a major risk factor for infectious complications in hemodialysis (HD) patients. We aimed to assess the incidence of bacteremia in catheter-dependent HD patients and to characterize its clinical and economic impact. METHODS: We retrospectively collected clinical data and healthcare costs from 15 months for 75 admitted catheter-dependent HD patients, to document the type of bacteremia (complicated or not), pathogen and inflammation. RESULTS: Bacteremia (97 % with Staphylococcus aureus, 33 % methicillin-resistant) was present in 51 % patients, with an overall infections incidence of 5.79 per 1,000 catheter-days. Metastatic complications occurred in 21 % of bacteremic patients and were associated with higher mortality (38 vs. 4 %; p = 0.001). Although, in patients starting dialysis on catheter (41 %) as compared to those using catheter as bridge angioaccess, inflammation (higher C-reactive protein; p = 0.006) and anemia (lower Hb; p = 0.008) were more pronounced, bacteremia occurred in a lower proportion (32 vs. 64 %, p = 0.007). The total medical costs were 47 % higher in patients with complicated bacteremia than in those without bacteremia (p = 0.008) and 45 % higher in patients starting HD on catheter than in those using catheter as bridge angioaccess (p = 0.002). CONCLUSIONS: Despite the limitations resulting from retrospective cross-sectional single-center design, our study suggests that patients already on HD who required catheters as bridge angioaccess were more prone to bacteremia. This highlights the importance of close angioaccess monitoring to avoid unnecessary catheter usage. A similar increase in costs when initiating dialysis on catheter as in case of complicated bacteremia strongly supports the initial placement of a native arteriovenous fistula.

Nutritional intervention in uremia--myth or reality?

Nutritional intervention in uremia, specifically the restricted protein diet, has been under debate for decades. The results of various clinical trials have not been concordant, as some studies have reported positive effects of the low-protein diets, whereas others have shown no benefit. Recently published data show that the restricted protein diets seem to be effective and safe in ameliorating nitrogen waste products retention and the disturbances in acid-base and calcium-phosphorus metabolism, and in delaying the initiation of renal replacement therapy (RRT), without any deleterious effect on the nutritional status of patients with chronic kidney disease. The nutritional support and particularly the supplemented very low protein diet could be a new link to the RRT-integrated care model. A possible delay in RRT initiation through nutrition could have a major economic effect, particularly in developing countries, where the dialysis facilities still do not meet the requirements. However, a careful selection of motivated patients who could benefit from such a diet, closer nutritional monitoring, and dietary counseling are required.

Global assessment of serum antioxidant status in hemodialysis patients.

BACKGROUND: Since chronic renal failure (CRF) was described as a state of oxidant/antioxidant imbalance augmented after hemodialysis (HD) initiation, we assessed the total antioxidant activity and single antioxidants in sera from uremic patients dialyzed or not, compared to subjects with normal renal function. METHODS: Serum total antioxidant activity (TAA--measured as Trolox equivalent antioxidant capacity; mmol/L), total plasma free thiols (Pt-SH; micromol/g protein), albumin (g/dL) and uric acid (mg/dL) were determined in 19 hemodialyzed patients, 15 CRF non-dialyzed patients (serum creatinine (Cr) = 4.4 +/- 2.7 mg/dL) and in 16 healthy controls. The "antioxidant gap" (mmol/L), as a measure of the combined activity of plasma antioxidants other than albumin and uric acid, was calculated. RESULTS: TAA and the "antioxidant gap" were higher in HD patients (1.21 +/- 0.12 vs. 0.96 +/- 0.13 in the non-HD group, p<0.001, and vs. 0.9 +/- 0.14 in controls, p<0.001, respectively, for TAA; 0.46 +/- 0.15 vs. 0.2 +/- 0.15, p<0.001, and vs. 0.21 +/- 0.16, p<0.001, respectively, for residual antioxidant activity). However, no differences existed in major plasma antioxidant levels (albumin and uric acid) among uremic patients, hemodialyzed or not. Pt-SH were reduced in nondialyzed patients as compared to controls (6.21 +/- 1.1 vs. 7.33 +/- 0.83, p=0.002), but were elevated in HD patients (11.9 +/- 1.1). CONCLUSIONS: These results suggest that HD patients appear to have improved plasma antioxidant status, hyperuricemia not being the sole contributor. Therefore, it seems reasonable to speculate that other antioxidants (thiols or some as yet unrecognized substances) could also be contributors. However, more reliable assays for extracellular antioxidant defense evaluation are required to validate this hypothesis.