Are corticosteroids or end-stage renal failure associated with an afebrile presentation of Gram-negative bacteraemia?

OBJECTIVES: Assertions regarding afebrile presentation of sepsis frequently lead to superfluous antibiotic treatment. This study aimed to identify the risk factors for afebrile presentation of bacteraemia, focusing on glucocorticoid (GC) treatment and end-stage renal disease (ESRD). METHODS: This retrospective cohort study included all patients with bacteraemia caused by common Gram-negative bacteria in one hospital. The exposure variables were GC treatment, administered for at least 48 hours before bacteraemia onset, and ESRD, defined as patients undergoing dialysis. Risk factors were assessed for afebrile presentation, defined as temperature between 36.0-37.7°C for all measurements, 48 hours prior to blood culture collection. Analyses were subgrouped by community-onset and hospital-acquired Gram-negative bacteraemia (GNB). Propensity score (PS)-weighted multivariate analyses were conducted. RESULTS: Of 4179 patients with GNB, 1090 (26.1%) presented without fever before blood culture collection. In community-onset GNB, GC treatment was significantly associated with afebrile presentation, PS-weighted OR 1.42 (95% CI 1.25-1.61), absolute risk increase 7% (95% CI 4.3-9.8%), while ESRD was not. For hospital-acquired GNB, ESRD was significantly associated with afebrile presentation (OR 1.53; 95% CI 1.25-1.86; absolute risk increase 8.5%; 95% CI 4.4-13.1%); GC was not. Other risk factors for afebrile presentation in both subgroups included increasing Charlson comorbidity score, bacteraemia with non-fermenters Pseudomonas aeruginosa or Stenotrophomonas maltophilia (compared with Enterobacteriaceae), and lower albumin levels. Aging was not associated with afebrile presentation of GNB. CONCLUSION: Although significant associations between GC and ESRD and afebrile presentation of GNB were observed, they were different in community-onset and hospital-acquired GNBs, and absolute risk increases were small.

[HEMODIALYSIS: PRESENT INNOVATIONS FOR PATIENTS' FUTURE].

INTRODUCTION: End-stage renal disease (ESRD) is a major cause of morbidity and mortality worldwide. Survival of ESRD patients depends on renal replacement therapies, such as kidney transplantation and dialysis. Due to the shortage of potential kidney donors and patients' comorbidities, dialysis is the major therapeutic option offered to such patients. In this review, recent advances in hemodialysis and hemodiafiltration, and their potential impact on improving patient survival will be discussed.

High plasma high-density lipoprotein levels, very low cardiovascular risk profile, and subclinical carotid atherosclerosis in postmenopausal women.

BACKGROUND: Low plasma concentrations of high-density lipoprotein (HDL) are associated with increased risk of cardiovascular disease. However, recently several studies have questioned the protective role of high plasma HDL levels. OBJECTIVE: This study was designed to evaluate HDL functions in women with high plasma HDL cholesterol and very low risk profile with relation to subclinical carotid atherosclerosis (ATS). METHODS: Included were 158 middle-aged women with plasma HDL >60 mg/dL and Framingham risk score <7% who had B-mode ultrasound of the carotid arteries. Subclinical ATS was determined by the presence of plaques and/or intima-media thickness (IMT) >1.0 mm. RESULTS: ATS was observed in 51 women, with the majority (n=41) having carotid plaques, some with advanced morphology. In a multivariable model analysis, each, HDL or age, were independently associated with increased prevalence of ATS. Odds ratios for ATS were 3.1 and 2.5 greater for age>60 years and HDL >70 mg/dL, respectively. None of HDL functions determined by its antioxidative properties, reverse-cholesterol transport, or activities of HDL-associated enzyme were different between -ATS and +ATS. C-reactive protein was similar in both groups. CONCLUSION: Subclinical carotid ATS is present in one-third of middle-aged women independently of conventional risk factors. A greater ATS prevalence was associated with very high HDL values. We could not find association between ATS and HDL dysfunction.

[The importance of ACE2 in regulating the cardiovascular system].

A recently discovered homologue of the angiotensin-converting enzyme, ACE2, insensitive to ACE inhibitors, was found in rodents and humans. ACE2 is expressed mainly in the vasculature, heart and kidney. ACE2 removes a single amino acid of the carboxy terminal of peptides. In the renin-angiotensin-aldosterone system (RAAS), it is responsible for the conversion of angiotensin I (Ang I) and angiotensin II (Ang II) to Ang 1-9 and Ang 1-7, respectively. While ACE forms Ang II, a potent vasoconstrictor, ACE2 degrades this peptide to form Ang 1-7 which has an opposite action. Therefore, ACE2 counteracts ACE in the balance of vasopressor/vasodilator as well as heart and kidney function. The importance of ACE2 in physiological and pathophysiological conditions is unclear and is currently being studied.