Postnatal HIV transmission in breastfed infants of HIV‐infected women on ART: a systematic review and meta‐analysis

Introduction : To systematically review the literature on mother‐to‐child transmission in breastfed infants whose mothers received antiretroviral therapy and support the process of updating the World Health Organization infant feeding guidelines in the context of HIV and ART. Methods : We reviewed experimental and observational studies; exposure was maternal HIV antiretroviral therapy (and duration) and infant feeding modality; outcomes were overall and postnatal HIV transmission rates in the infant at 6, 9, 12 and 18 months. English literature from 2005 to 2015 was systematically searched in multiple electronic databases. Papers were analysed by narrative synthesis; data were pooled in random effects meta‐analyses. Postnatal transmission was assessed from four to six weeks of life. Study quality was assessed using a modified Newcastle‐Ottawa Scale (NOS) and GRADE. Results and discussion : Eleven studies were identified, from 1439 citations and review of 72 abstracts. Heterogeneity in study methodology and pooled estimates was considerable. Overall pooled transmission rates at 6 months for breastfed infants with mothers on antiretroviral treatment (ART) was 3.54% (95% CI: 1.15–5.93%) and at 12 months 4.23% (95% CI: 2.97–5.49%). Postnatal transmission rates were 1.08 (95% CI: 0.32–1.85) at six and 2.93 (95% CI: 0.68–5.18) at 12 months. ART was mostly provided for PMTCT only and did not continue beyond six months postpartum. No study provided data on mixed feeding and transmission risk. Conclusions : There is evidence of substantially reduced postnatal HIV transmission risk under the cover of maternal ART. However, transmission risk increased once PMTCT ART stopped at six months, which supports the current World Health Organization recommendations of life‐long ART for all.     

Use of perioperative cardiac medical therapy among patients undergoing coronary artery bypass graft surgery

BACKGROUND: Previous studies have demonstrated that cardiac medical therapy is associated with improved clinical outcomes in noncardiac surgery. However, the use of these agents among patients undergoing coronary artery bypass graft (CABG) remains poorly understood. METHODS: We described the in-hospital medication use among 2,389 consecutive patients who underwent CABG at three North American hospitals. Demographic, clinical, and medication use information was extracted from resource and cost accounting systems at each hospital. We examined use of aspirin, angiotensin-converting-enzyme (ACE) inhibitors, beta blockers, and statins during the following seven in-hospital periods: admission, presurgery, the day before surgery, the day of surgery, the day after surgery, postsurgery, and discharge. RESULTS: Medication use throughout hospitalization was low among patients undergoing CABG. Use of ACE inhibitors and statins on the day of surgery was <10%, while aspirin and beta blocker use on the day of surgery was 43.0% and 42.9%, respectively. The use of cardiac medical therapy at hospital discharge was also low (ACE inhibitors: 23.0%; aspirin: 74.9%; beta blockers: 58.9%; and statins: 28.2%). The use of cardiac medical therapy at discharge appeared to increase over time. CONCLUSION: In-hospital cardiac medical therapies are underused among patients undergoing CABG. This is particularly true at discharge, where the benefits of these agents for secondary prevention are well established.     

Results of inferior vena caval interruption by greenfield filter, ligation or resection during radical nephrectomy and tumor thrombectomy

PURPOSE: Surgical resection for patients with renal cell carcinoma and venous tumor thrombus may require interruption of the inferior vena cava using a Greenfield filter, ligation or resection. We describe the indications, technique, complications and outcomes of vena caval interruption during nephrectomy with tumor thrombectomy. MATERIALS AND METHODS: We identified 160 patients treated for level II-IV tumor thrombus at our institution between 1970 and 2004. Operative reports were reviewed to establish vena caval interruption. All patients who underwent interruption were assessed for postoperative disability according to the American Venous Forum International Consensus Committee. RESULTS: Vena caval interruption was performed in 40 of 160 cases (25%), including 14 level II, 10 level III and 16 level IV thrombi. A total of 34 patients (85%) were symptomatic at presentation. A Greenfield filter was deployed before cavotomy closure in 4 of 160 patients (2.5%) for bland thrombus of the infrarenal vena cava. Vena caval ligation was used for bland thrombus that completely occluded the infrarenal vena cava in 23 of 160 patients (14.4%), while segmental vena caval resection was performed for tumor thrombus growing into the wall of the vena cava or for tumor thrombus that interfaced with bland thrombus in 13 of 160 (8.1%). Postoperatively no case was class 3 disability, 12 of 40 (30%) were class 2, 12 of 40 (30%) were class 1 and 16 of 40 (40%) showed no disability. CONCLUSIONS: The need to interrupt the inferior vena cava is not infrequent in patients undergoing radical nephrectomy and tumor thrombectomy, and it may be well tolerated postoperatively. Management should be based on the degree of venous occlusion and the presence of bland thrombus.     

Age affects outcomes in chronic kidney disease

Chronic kidney disease (CKD) is common among the elderly. However, little is known about how the clinical implications of CKD vary with age. We examined the age-specific incidence of death, treated end-stage renal disease (ESRD), and change in estimated glomerular filtration rate (eGFR) among 209,622 US veterans with CKD stages 3 to 5 followed for a mean of 3.2 years. Patients aged 75 years or older at baseline comprised 47% of the overall cohort and accounted for 28% of the 9227 cases of ESRD that occurred during follow-up. Among patients of all ages, rates of both death and ESRD were inversely related to eGFR at baseline. However, among those with comparable levels of eGFR, older patients had higher rates of death and lower rates of ESRD than younger patients. Consequently, the level of eGFR below which the risk of ESRD exceeded the risk of death varied by age, ranging from 45 ml/min per 1.73 m(2) for 18 to 44 year old patients to 15 ml/min per 1.73 m(2) for 65 to 84 year old patients. Among those 85 years or older, the risk of death always exceeded the risk of ESRD in this cohort. Among patients with eGFR levels <45 ml/min per 1.73 m(2) at baseline, older patients were less likely than their younger counterparts to experience an annual decline in eGFR of >3 ml/min per 1.73 m(2). In conclusion, age is a major effect modifier among patients with an eGFR of <60 ml/min per 1.73 m(2), challenging us to move beyond a uniform stage-based approach to managing CKD.     

Predicting Renal Function Outcomes After Partial and Radical Nephrectomy

Background

Partial nephrectomy (PN) is generally favored for cT1 tumors over radical nephrectomy (RN) when technically feasible. However, it can be unclear whether the additional risks of PN are worth the magnitude of renal function benefit.

Adiponectin in renal disease: relationship to phenotype and genetic variation in the gene encoding adiponectin

BACKGROUND: The prevalence of cardiovascular disease (CVD) and inflammation is high in patients with end-stage renal disease (ESRD). Adiponectin is an adipocytokine that may have significant anti-inflammatory and anti-atherosclerotic effects. Low adiponectin levels have previously been found in patients with high risk for CVD. METHODS: In a cohort of 204 (62% males) ESRD patients aged 52 +/- 1 years the following parameters were studied: presence of CVD, body composition, plasma adiponectin (N= 107), cholesterol, triglycerides, HDL-cholesterol, serum leptin, high-sensitivity C-reactive protein (hs-CRP), urinary albumin excretion (UAE), and single-nucleotide polymorphisms (SNPs) in the apM1 gene at positions -11391, -11377, 45, and 276. Thirty-six age- (52 +/- 2 years) and gender-matched (64% males) healthy subjects served as control subjects. RESULTS: Markedly (P < 0.0001) elevated median plasma adiponectin levels were observed in ESRD patients (22.2 microg/mL), especially type 1 diabetic patients (36.8 microg/mL), compared to control subjects (12.2 microg/mL). Log plasma adiponectin correlated to visceral fat mass (R=-0.29; P < 0.01) and Log hs-CRP (R=-0.26; P < 0.01). In a stepwise (forward followed by backward) multiple regression model only type-1 diabetes (P < 0.001) and visceral fat mass (P < 0.05) were independently associated with plasma adiponectin levels. The adiponectin gene -11377 C/C genotype was associated with a lower prevalence of CVD (25 vs. 42%) compared to the G/C genotype. CONCLUSION: The present cross-sectional study demonstrates that, whereas genetic variations seem to have a minor impact on circulating adiponectin levels, lower visceral fat mass and type 1 diabetes mellitus are associated with elevated plasma adiponectin levels in ESRD patients. Furthermore, low levels of adiponectin are associated with inflammation in ESRD.     

Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy

PURPOSE: We compared outcomes between patients treated with nephron sparing surgery (NSS) without imperative indications for renal preservation and radical nephrectomy (RN) for 4 to 7 cm renal cell carcinoma (RCC). MATERIALS AND METHODS: We identified 91 patients treated with NSS and 841 patients treated with RN for 4 to 7 cm RCC between 1970 and 2000. Cancer specific, distant metastases-free and recurrence-free survivals were estimated using the Kaplan-Meier method. RESULTS: Cancer specific survival rates at 5 years for patients treated with NSS and RN for 4 to 7 cm RCC were 98% and 86%, respectively. On univariate analysis patients treated with RN for 4 to 7 cm RCC were more likely to die of RCC compared to patients treated with NSS. However, after adjusting for features associated with death from RCC including stage, grade, histological tumor necrosis and histological subtype, this difference was no longer statistically significant (risk ratio 1.60, 95% CI 0.50-5.12, p = 0.430). Distant metastases-free survival rates at 5 years for patients treated with NSS and RN were 94% and 83%, respectively. On univariate analysis patients treated with RN were more likely to have tumors that metastasized compared to patients treated with NSS, although this difference was no longer significant after adjusting for the features listed previously (risk ratio 1.76, 95% CI 0.64-4.83, p = 0.273). Recurrence-free survival rates at 5 years for patients treated with NSS and RN were 94% and 98%, respectively. On univariate analysis patients treated with RN were less likely to have recurrence compared to patients treated with NSS (risk ratio 0.32, 95% CI 0.12-0.85, p = 0.022). CONCLUSIONS: There were no statistically significant differences in cancer specific survival and distant metastases-free survival between patients treated with NSS and RN for 4 to 7 cm RCC after adjusting for important pathological features. NSS for 4 to 7 cm RCC results in excellent outcome in appropriately selected patients.     

Low sodium haemodialysis reduces interdialytic fluid consumption but paradoxically increases post-dialysis thirst.

BACKGROUND: Interdialytic weight gain (IDWG) can be reduced by lowering the dialysate sodium concentration ([Na]) in haemodialysis patients. It has been assumed that this is because thirst is reduced, although this has been difficult to prove. We compared thirst patterns in stable haemodialysis patients with high and low IDWG using a novel technique and compared the effect of low sodium dialysis (LSD) with normal sodium dialysis (NSD). METHODS: Eight patients with initial high IDWG and seven with low IDWG completed hourly visual analogue ratings of thirst using a modified palmtop computer during the dialysis day and the interdialytic day. The dialysate [Na] was progressively reduced by up to 5 mmol/l over five treatments. Dialysis continued at the lowest attained [Na] for 2 weeks and the measurements were repeated. The dialysate [Na] then returned to baseline and the process was repeated. RESULTS: Baseline interdialytic day mean thirst was higher than the dialysis day mean for the high IDWG group (49.9+/-14.0 vs 36.2+/-16.6) and higher than the low weight gain group (49.9+/-14.0 vs 34.1+/-14.6). This trend persisted on LSD, but there was a pronounced increase in post-dialysis thirst scores for both groups (high IDWG: 46+/-13 vs 30+/-21; low IDWG: 48+/-24 vs 33+/-18). The high IDWG group demonstrated lower IDWG during LSD than NSD (2.23+/-0.98 vs 2.86+/-0.38 kg; P<0.05). CONCLUSIONS: Our results indicate that patients with high IDWG experience more intense feelings of thirst on the interdialytic day. LSD reduces their IDWG, but paradoxically increases thirst in the immediate post-dialysis period.     

Acute interstitial nephritis: clinical features and response to corticosteroid therapy.

BACKGROUND: Acute interstitial nephritis (AIN) is a recognized cause of reversible acute renal failure characterized by the presence of an interstitial inflammatory cell infiltrate. METHODS: In order to evaluate the clinical characteristics and management of this disorder, we performed a retrospective study of all cases of AIN found by reviewing 2598 native renal biopsies received at our institution over a 12 year period. Presenting clinical, laboratory and histological features were identified, as was clinical outcome with specific regard to corticosteroid therapy response. RESULTS: AIN was found in 2.6% of native biopsies, and 10.3% of all biopsies performed in the setting of acute renal failure during the period analysed (n = 60). The incidence of AIN increased progressively over the period observed from 1 to 4% per annum. AIN was drug related in 92% of cases and appeared to be idiopathic in the remainder. The presenting symptoms included oliguria (51%), arthralgia (45%), fever (30%), rash (21%) and loin pain (21%). Median serum creatinine at presentation was 670 micromol/l [interquartile range (IQR) 431-1031] and 58% of cases required acute renal replacement therapy. Corticosteroid therapy was administered in 60% of cases. Serum creatinine at baseline was similar in the corticosteroid-treated and conservatively managed groups; 700 micromol/l (IQR 449-1031) vs 545 micromol/l (IQR 339-1110) P = 0.4. In this, the largest retrospective series to date, we did not detect a statistically significant difference in outcome, as determined by serum creatinine, between those patients who received corticosteroid therapy and those who did not, at 1, 6 and 12 months following presentation. CONCLUSION: The results of this study do not support the routine administration of corticosteroid therapy in the management of AIN.