Joan Carles Trullàs

Renal transplantation in HIV-infected patients: 2010 update

The prognosis of human immunodeficiency virus (HIV) infection has improved in recent years with the introduction of antiretroviral treatment. While the frequency of AIDS-defining events has decreased as a cause of death, mortality from non-AIDS-related events including end-stage renal diseases has increased. The etiology of chronic kidney disease is multifactorial: immune-mediated glomerulonephritis, HIV-associated nephropathy, thrombotic microangiopathies, and so on. HIV infection is no longer a contraindication to transplantation and is becoming standard therapy in most developed countries. The HIV criteria used to select patients for renal transplantation are similar in Europe and North America. Current criteria state that prior opportunistic infections are not a strict exclusion criterion, but patients must have a CD4+ count above 200 cells/mm(3) and a HIV-1 RNA viral load suppressible with treatment. In recent years, more than 200 renal transplants have been performed in HIV-infected patients worldwide, and mid-term patient and graft survival rates have been similar to that of HIV-negative patients. The main issues in post-transplant period are pharmacokinetic interactions between antiretrovirals and immunosuppressants, a high rate of acute rejection, the management of hepatitis C virus coinfection, and the high cardiovascular risk after transplantation. More studies are needed to determine the most appropriate antiretroviral and immunosuppressive regimens and the long-term outcome of HIV infection and kidney graft.

Dialysis and Renal Transplantation in HIV-Infected Patients : a European Survey

Objectives:To determine prevalence and characteristics of end-stage renal diseases (ESRD) [dialysis and renal transplantation (RT)] among European HIV-infected patients. Methods:Cross-sectional multicenter survey of EuroSIDA clinics during 2008. Results:Prevalence of ESRD was 0.5%. Of 122 patients with ESRD 96 were on dialysis and 26 had received a RT. Median age was 47 years, 73% were males and 43% were black. Median duration of HIV infection was 11 years. Thirty-three percent had prior AIDS; 91% were receiving antiretrovirals; and 88% had undetectable viral load. Median CD4+T-cell count was 341 cells per cubic millimetre; 20.5% had hepatitis C coinfection. Most frequent causes of ESRD were HIV-associated nephropathy (46%) and other glomerulonephritis (28%). Hemodialysis (93%) was the most common dialysis modality; 34% of patients were on the RT waiting list. A poor HIV control was the reason for exclusion from RT waiting list in 22.4% of cases. All the RT recipients were all alive at the time of the survey. Acute rejection was reported in 8 patients (30%). Functioning graft was present in 21 (80%). Conclusions:This is the first multinational cross-sectional study of ESRD among European HIV population. Low prevalence of ESRD was found. Two-thirds of patients were excluded from RT for non-HIV/AIDS-related pathologies. Most patients had a functioning graft despite a high acute rejection rate.

Outcome and prognostic factors in HIV-1-infected patients on dialysis in the cART era: a GESIDA/SEN cohort study.

Background:Prognosis of HIV-infected patients on dialysis has improved. Few studies have compared survival between HIV-infected and HIV-negative patients on dialysis in the combined antiretroviral therapy (cART) era. We compared the outcome of HIV-infected patients on dialysis with a matched HIV-negative cohort. Methods:National, multicenter, retrospective cohort study of HIV-infected patients starting dialysis in Spain (1999-2006). Matching criteria for HIV-negative patients were dialysis center, year of starting dialysis, age, sex, and race. Results:The study population comprised 122 patients, 66 HIV-infected, and 66 HIV-negative patients. Median age was 41 years, and all but 4 HIV-infected patients were white. HIV-associated nephropathy was only present in 4 cases. HIV-infected patients were less frequently included on the kidney transplantation waiting list (17% vs 62%, P < 0.001). They also had more hepatitis C virus coinfection (76% vs 11%, P < 0.001), fewer cardiovascular events (62% vs 88%, P = 0.001), fewer kidney transplants (4.5% vs 38%, P < 0.001), and higher mortality (32% vs 1.5%, P < 0.001). Survival rates [95% confidence interval (CI)] at 1, 3, and 5 years for HIV-infected patients were 95.2% (89.9%-100%), 71.7% (59.7%-83.7%), and 62.7% (46.6%-78.8%). Five-year survival for HIV-negative patients was 94.4% (83.8%-100%) (P < 0.001). Multivariate analysis revealed the following variables to be associated with death in HIV-infected patients: peritoneal dialysis vs hemodialysis [hazard ratio; (95% CI): 2.88 (1.16-7.17)] and being on effective cART [hazard ratio (95% CI): 0.39 (0.16-0.97)]. Conclusions:Medium-term survival of HIV-infected patients on dialysis was lower than that of matched HIV-negative patients. Fewer HIV-infected patients had access to kidney transplantation. Being on effective cART improves survival. Further studies are needed to determine whether peritoneal dialysis increases mortality.

Simultaneous Pancreas-Kidney Transplantation in HIV-infected Patients: A Case Report and Literature Review

Since the introduction of combined antiretroviral therapy (cART), solid organ transplantation (SOT) has become a therapeutic option for the HIV-positive population. In contrast with liver and kidney transplantation, only three simultaneous pancreas-kidney transplants (SPKT) have been reported among HIV-infected patients. Herein we have reported the first SPKT in an HIV-infected patient in Spain. The pancreas graft failed at 2 weeks and the patient died at 9 months because of a Pseudomonas aeruginosa infection. The three recipients reported in the literature lived, despite the failure of both the pancreas and kidney grafts in one subject. Despite the poor outcome of our case, HIV-1 infection was controlled after transplantation (stable CD4(+) cells and no AIDS-related events), and the kidney graft functioned with no episodes of rejection. The cART regimen used in the pretransplant period was switched at the time of transplantation to raltegravir and two nucleoside reverse transcriptase inhibitors (NRTI). Raltegravir has no interactions with immunosuppressive drugs. Target plasma levels of tacrolimus were achieved at a dose similar to that used in HIV-negative transplant recipients. The most adequate antiretroviral regimen for HIV-infected SOT recipients has not yet been established; however, one may consider switching protease inhibitors or non-NRTI-based regimens for a raltegravir-based regimen at the time of transplantation.

Renal Dysfunction in the Setting of HIV/AIDS

Antiretroviral therapy has been immensely successful in reducing the incidence of opportunistic infections and death after HIV infection. This has resulted in heightened interest in noninfectious comorbidities including kidney disease. Although HIV-associated nephropathy, the most ominous kidney disease related to the direct effects of HIV, may be prevented and treated with antiretrovirals, kidney disease remains an important issue in this population. In addition to the common risk factors for kidney disease of diabetes mellitus and hypertension, HIV-infected individuals have a high prevalence of other risk factors, including hepatitis C and exposure to antiretrovirals and other medications. Therefore, the differential diagnosis is vast. Early identification (through efficient screening) and prompt treatment of kidney disease in HIV-infected individuals are critical to lead to better outcomes. This review focuses on clinical and epidemiological issues, treatment strategies (including dialysis and kidney transplantation), and recent advances among kidney disease in the HIV population.

Impact of weight loss on mortality in chronic heart failure: Findings from the RICA Registry ☆

BACKGROUND Obesity increases the risk of heart failure (HF), but a significant survival benefit in obese patients has been described once they have been diagnosed with HF. There is little information about the effects of weight loss among patients with HF. We aimed to assess the frequency of weight loss in patients with HF from the RICA Registry and whether weight loss is associated with mortality. METHODS We investigated weight changes in 731 patients with HF and analysed the effect of weight loss of 5% or more of their baseline bodyweight during follow-up. RESULTS 419 (57.3%) patients lost weight during follow-up but only 152 (20.8%) lost at least 5% of the baseline bodyweight. We did not find significant differences in demographic, clinical, functional and analytical parameters between patients with and without weight loss or 5% or more of their bodyweight. We observed a significant improvement in the mean NYHA functional class value and a non-significant improvement in the LVEF in all patients. A significant decrease in the natriuretic peptide levels was only observed in the patients who lost weight. Survival rates at 1year follow-up for patients with and without weight loss or 5% or more were 75.7% (95% CI: 67.1-84.3%) and 77.1% (95% CI: 72.8-81.4%), respectively (p=0.92). Re-admission rates for patients with and without weight loss were 52.7% (95% CI: 42.9-62.43%) and 50.0% (95% CI: 45.3-54.7%), respectively (p=0.34). CONCLUSIONS Significant weight loss occurred in 20.8% of patients with HF. Weight loss was not associated with mortality or readmission.

Precipitating factors of heart failure admission: Differences related to age and left ventricular ejection fraction

AIM To evaluate precipitating factors (PF) of exacerbation in heart failure (HF) and their relationship with age, preserved vs. reduced left ventricular ejection fraction (LVEF) and short-term prognosis. METHODS We included and followed 2962 patients admitted with acute HF to Internal Medicine Units. Several PF were identified. Differences in PF according to preserved vs. reduced LVEF and age (patients≥80years vs. younger) were analyzed. Primary endpoints were readmission due to worsening HF and all-cause mortality at 3months follow-up. Multivariable Cox models were conducted to identify the independent predictors of 3-months mortality and readmission. RESULTS More than half of the patients were 80years and over, 47% were women and 61% had preserved LVEF. Atrial fibrillation (AF) and myocardial ischemia were the more common cause of decompensation among octogenarians. It was more frequent to find myocardial ischemia or non-adherence to treatment as precipitants in patients with systolic dysfunction. However, respiratory infections, AF and poor control of blood pressure were more usual in patients with preserved LVEF compared to those with LVEF <50%. Patients admitted for HF precipitated by myocardial ischemia had a higher risk of readmission at 3months (HR 1.49; CI 95%: 1.12-1.99, p=0.006) and the longest hospital stay (12days). PF showed no predictive value for mortality. CONCLUSION Myocardial ischemia as a PF was an independent marker for HF readmissions at 3-months follow-up. Precipitants are different depending on the age and LVEF of patients. Their identification could improve risk stratification and prevention strategies.

Documento de consenso sobre el manejo de la patología renal en pacientes con infección por VIH

OBJECTIVE To update the 2010 recommendations on the evaluation and management of renal disease in HIV-infected patients. METHODS This document was approved by a panel of experts from the AIDS Working Group (GESIDA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Nephrology (S.E.N.), and the Spanish Society of Clinical Chemistry and Molecular Pathology (SEQC). The quality of evidence and the level of recommendation were evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS The basic renal work-up should include measurements of serum creatinine, estimated glomerular filtration rate by CKD-EPI, Urine protein-to-creatinine ratio, and urinary sediment. Tubular function tests should include determination of serum phosphate levels and urine dipstick for glucosuria. In the absence of abnormal values, renal screening should be performed annually. In patients treated with tenofovir or with risk factors for chronic kidney disease (CKD), more frequent renal screening is recommended. In order to prevent disease progression, potentially nephrotoxic antiretroviral drugs are not recommended in patients with CKD or risk factors for CKD. The document advises on the optimal time for referral of a patient to the nephrologist and provides indications for renal biopsy. The indications for and evaluation and management of dialysis and renal transplantation are also addressed. CONCLUSIONS Renal function should be monitored in all HIV-infected patients. The information provided in this document should enable clinicians to optimize the evaluation and management of HIV-infected patients with renal disease.

Anemia en la insuficiencia cardiaca, su utilidad como marcador de pronóstico o de comorbilidad, estudio GESAIC-2

BACKGROUND AND OBJECTIVE To assess the prognosis and etiology of anemia in heart failure (HF). PATIENTS AND METHODS Prospective multicenter cohort of HF after one year of hospitalization. RESULTS A total of 57 (27%) of the 211 patients died and 115 (67.8%) were readmitted. Mortality was higher in the group with anemia (31.8%) without statistical significance (P=.09), except for refractory HF mortality (P=.013). Predictors of HF mortality included Barthel index (hazard ratio [HR] 0.97, CI 95% 0.96 to 0.98) and serum creatinine at discharge (HR 2.28, 95% CI 1.51 to 3.45). For reentry, the Charlson index (OR 1.16, CI 95% 0.98 to 1.38), treatment with calcium channel blockers (OR 0.29, 95% CI 0.1 to 0.84) and not being treated with digoxin (OR 2.33, CI 95% 1.09 to 4.97), the latter with the greatest influence on readmission for HF (OR 3.07, CI 95% 1.39 to 6.79), along with not being a HF debut (OR 2.8, CI 95% 1.45 to 5.39). CONCLUSIONS Anemia is an increased risk of mortality due to refractory HF, but not for readmission within the first year after an acute event.

The utility of heart failure registries: a descriptive and comparative study of two heart failure registries

Background and aim Registries are useful to address questions that are difficult to answer in clinical trials. The objective of this study was to describe and compare two heart failure (HF) cohorts from two Spanish HF registries. Methods We compared the RICA and EAHFE registries, both of which are prospective multicentre cohort studies including patients with decompensated HF consecutively admitted to internal medicine wards (RICA) or attending the emergency department (EAHFE). From the latter registry we only included patients who were admitted to internal medicine wards. Results A total of 5137 patients admitted to internal medicine wards were analysed (RICA: 3287 patients; EAHFE: 1850 patients). Both registries included elderly patients (RICA: mean (SD) age 79 (9) years; EAHFE: mean (SD) age 81 (9) years), with a slight predominance of female gender (52% and 58%, respectively, in the RICA and EAHFE registries) and with a high proportion of patients with preserved ejection fraction (58% and 62%, respectively). Some differences in comorbidities were noted, with diabetes mellitus, dyslipidaemia, chronic renal failure and atrial fibrillation being more frequent in the RICA registry while cognitive and functional impairment predominated in the EAHFE registry. The 30-day mortality after discharge was 3.4% in the RICA registry and 4.8% in the EAHFE registry (p<0.05) and the 30-day readmission rate was 7.5% in the RICA registry (readmission to hospital) and 24.0% in the EAHFE registry (readmission to emergency department) (p<0.001). Conclusions We found differences in the clinical characteristics of patients admitted to Spanish internal medicine wards for decompensated HF depending on inclusion in either the RICA or EAHFE registry.