Prevalence and Risk Factors Associated to Chronic Kidney Disease in HIV-Infected Patients on HAART and Undetectable Viral Load in Brazil

BACKGROUND: To determine the prevalence and associated factors with chronic kidney disease (CKD) in a cohort of HIV-positive individuals with undetectable viral load on HAART. METHODS: From March, 2009 to September 2009, 213 individuals between 18-70 years, period on HAART ≥12 months, viral load < 50 copies/mm(3), and CD4 ≥ 200 cells/mm(3), were consecutively enrolled at the outpatient clinic of Hospital de Clínicas, Porto Alegre, Brazil. Exclusion criteria were obesity, malnourishment, amputee, paraplegic, previous history of renal disease, pregnancy and hepatic insufficiency. Renal function was determined by estimated glomerular filtration rate (eGFR) assessed by the modification of diet in renal disease. CKD was defined as an eGFR less or equal than 60 ml/min/1.73 m(2), for a period of at least 3 months. Poisson regression was used to determine factors associated with CKD. RESULTS: CKD was diagnosed in 8.4% of the population, and after adjustment, the risk factors were hypertension (RR = 3.88, 95%CI, 1.84-8.16), time on HAART (RR = 1.15, 95%CI,1.03-1.27) and tenofovir exposure (RR = 2.25, 95%CI, 1.04-4.95). Higher weight (RR = 0.88 95%CI, 0.82-0.96) was associated to normal function. CONCLUSIONS: CKD was a common finding in this cohort of patients and was related to hypertension, time on HAART and tenofovir exposure. We suggest a more frequent monitoring of renal function, especially for those with risk factors to early identify renal impairment

AVALIAÇÃO DE IMUNIZAÇÃO PRÉVIA PARA HEPATITE B ENTRE USUÁRIOS DO PREP EM UM SERVIÇO DE NATAL

Introdução/Objetivo: A Hepatite B é uma infecção sexualmente transmitida que leva à fibrose no fígado. A avaliação da imunização prévia para Hepatite B entre usuários da profilaxia pré-exposição (PrEP) é fundamental para a prevenção e para o controle dessa doença viral. A PrEP é uma estratégia de prevenção que envolve o uso diário de medicamentos antirretrovirais por pessoas que estão em um maior risco de exposição ao vírus da imunodeficiência humana. Assim, é importante garantir que os usuários do PrEP estejam devidamente imunizados contra a Hepatite B, uma vez que a coinfecção com esses dois vírus pode levar a complicações graves para a saúde do indivíduo. Métodos: Foram analisados 38 prontuários de pacientes em acompanhamento no serviço de referência para PrEP do Instituto de Medicina Tropical, em Natal-RN. Os itens escolhidos para a análise foram: idade, sexo, teste para hepatite B (HBsAg), histórico de vacinação para Hepatite B e o resultado da sorologia anti-HBs quantitativa. Resultados: A média das idades dos pacientes foi de 33,5 anos, dentre os quais haviam 4 mulheres cisgênero e 1 mulher transgênero, sendo o restante composto por homens cisgênero. Não houve resultado reagente para HBsAg na amostra. Na ficha de primeira consulta, 22 (57,89%) pacientes afirmaram ter 3 doses da vacina para hepatite B, destes haviam 19 (86,37%) com sorologia anti-HBs quantitativa igual ou acima de 10 UI/mL, enquanto para 2 (9,1%%) o resultado foi de não detectável ou abaixo de 10 UI/mL. Desse grupo, 1 paciente (4,54%) não realizou o exame sorológico quantitativo. Entre os 16 (42,11%) que não tinham o esquema completo ou que não souberam informar a situação vacinal, 6 (37,50%) tinham anti-HBs igual ou acima de 10 UI/mL, 3 (18,75%) o resultado do exame foi não detectável ou abaixo de 10 UI/mL e 7 (43,75%) não realizaram o exame. Para a amostra total, 25 (65,79%) tinham imunidade para hepatite B. Conclusão: A maioria dos pacientes analisados apresentaram imunidade adequada, indicando que a estratégia de imunização está sendo efetiva. Entretanto, ainda é necessário aumentar a conscientização sobre a vacinação completa nos usuários de PrEP, visto a taxa de usuários que não tinham esquema completo ou que não sabiam informar, a fim de evitar as complicações de uma coinfecção. Dessa forma, esses dados destacam a importância de campanhas de vacinação e monitoramento sorológico

Prevalence of alteration in the renal function according to Kidney Disease Outcomes Quality Initiative – KDOQI [12], assessed by the modification of diet in renal disease.

a<p>Estimated Glomerular filtration rate</p

Bland-Altman graph comparing MDRD and CKD-epi in individuals with chronic kidney disease.

<p>There was a concordance in eGFR between the MDRD and CKD-epi equations in individuals with chronic kidney disease (the mean difference was 0.41±1.90 ml). eGFR  =  estimated glomerular filtration rate; MDRD  =  modified diet in renal disease; CKD-epi  =  chronic kidney disease epidemiology.</p

Main demographic characteristics (data are presented as mean ± standard deviation or percentage).

a<p>Estimated glomerular filtration rate,</p>b<p>Antiretroviral therapy</p

Risk factors associated to alteration in the renal function (eGFR < 60 ml/min per 1.73 m² by MDRD); univariate and multivariate analysis.

<p>CKD defined as confirmed (persisting for ≤ 3 months) decrease in eGFR to 60 ml/min per 1.73m² by MDRD or the presence of proteinuria independent of eGFR. CI, confidence interval; RR, risk ratio; eGFR, estimated glomerular filtration rate. All variables significant in univariate analyses (P<0.05) were included in multivariate model. All variables with P<0.1 in the multivariate analysis (data not shown) were included in the final model</p

Loop-mediated Isothermal Amplification and nested PCR of the Internal Transcribed Spacer (ITS) for Histoplasma capsulatum detection.

BackgroundHistoplasmosis is a neglected disease that affects mainly immunocompromised patients, presenting a progressive dissemination pattern and a high mortality rate, mainly due to delayed diagnosis, caused by slow fungal growth in culture. Therefore, a fast, suitable and cost-effective assay is required for the diagnosis of histoplasmosis in resource-limited laboratories. This study aimed to develop and evaluate two new molecular approaches for a more cost-effective diagnosis of histoplasmosis.MethodologySeeking a fast, suitable, sensitive, specific and low-cost molecular detection technique, we developed a new Loop-mediated Isothermal Amplification (LAMP) assay and nested PCR, both targeting the Internal Transcribed Spacer (ITS) multicopy region of Histoplasma capsulatum. The sensitivity was evaluated using 26 bone marrow and 1 whole blood specimens from patients suspected to have histoplasmosis and 5 whole blood samples from healthy subjects. All specimens were evaluated in culture, as a reference standard test, and Hcp100 nPCR, as a molecular reference test. A heparin-containing whole blood sample from a heathy subject was spiked with H. capsulatum cells and directly assayed with no previous DNA extraction.ResultsBoth assays were able to detect down to 1 fg/μL of H. capsulatum DNA, and ITS LAMP results could also be revealed to the naked-eye by adding SYBR green to the reaction tube. In addition, both assays were able to detect all clades of Histoplasma capsulatum cryptic species complex. No cross-reaction with other fungal pathogens was presented. In comparison with Hcp100 nPCR, both assays reached 83% sensitivity and 92% specificity. Furthermore, ITS LAMP assay showed no need for DNA extraction, since it could be directly applied to crude whole blood specimens, with a limit of detection of 10 yeasts/μL.ConclusionITS LAMP and nPCR assays have the potential to be used in conjunction with culture for early diagnosis of progressive disseminated histoplasmosis, allowing earlier, appropriate treatment of the patient. The possibility of applying ITS LAMP, as a direct assay, with no DNA extraction and purification steps, makes it suitable for resource-limited laboratories. However, more studies are necessary to validate ITS LAMP and nPCR as direct assay in other types of clinical specimens

Invasive fungal infection by Cryptococcus neoformans var. grubii with bone marrow and meningeal involvement in a HIV-infected patient: a case report

Abstract Background Cryptococcosis is a common opportunistic infection in patients infected by Human Immunodeficiency Virus (HIV) and is the second leading cause of mortality in Acquired Immunodeficiency Syndrome (AIDS) patients worldwide. The most frequent presentation of cryptococcal infection is subacute meningitis, especially in patients with a CD4+ T Lymphocytes count below 100 cells/μL. However, in severely immunosuppressed individuals Cryptococcus neoformans can infect virtually any human organ, including the bone marrow, which is a rare presentation of cryptococcosis. Case presentation A 45-year-old HIV-infected male patient with a CD4+ T lymphocyte count of 26 cells/μL who presented to the emergency department with fever and pancytopenia. Throughout the diagnostic evaluation, the bone marrow aspirate culture yielded encapsulated yeasts in budding, identified as Cryptococcus sp. The bone marrow biopsy revealed a hypocellularity for age and absence of fibrosis. It was observed presence of loosely formed granuloma composed of multinucleated giant cells encompassing rounded yeast like organisms stained with mucicarmine, compatible with Cryptococcus sp. Then, the patient underwent a lumbar puncture to investigate meningitis, although he had no neurological symptoms and neurological examination was normal. The cerebrospinal fluid culture yielded Cryptococcus sp. The species and genotype identification step showed the infection was caused by Cryptococcus neoformans var. grubii (genotype VNI). The patient was initially treated with amphotericin B deoxycholate plus fluconazole for disseminated cryptococcosis, according to guideline recommendations. However, the patient developed acute kidney injury and the treatment was switched for fluconazole monotherapy. The symptoms disappeared completely with recovery of white blood cells and platelets counts. Cerebrospinal fluid cultures for fungi at one and two-weeks of treatment were negative. Conclusions Bone marrow infection caused by Cryptococcus neoformans is a rare presentation of cryptococcosis. The cryptococcal infection should be included for differential diagnosis in HIV-infected patients with fever and cytopenias, especially when CD4+ T lymphocytes count is below 100 cells/μL

IMUNIDADE CONTRA O VÍRUS DA HEPATITE A ENTRE GAYS E OUTROS HOMENS QUE FAZEM SEXO COM HOMENS USUÁRIOS DE PROFILAXIA PRÉ-EXPOSIÇÃO AO HIV

Introdução/Objetivo: A hepatite A é uma doença infectocontagiosa causada pelo vírus da hepatite A (HAV), que é transmitido mormente via fecal-oral, incluindo sexo oral-anal. Entre usuários de profilaxia pré-exposição ao HIV (PrEP HIV) no Brasil, dos quais 83% são gays e HSH, recomenda-se avaliar a susceptibilidade ao HAV por sorologia para fins de prevenção. Este estudo teve por objetivo avaliar a prevalência de anticorpos Anti-HAV IgG/total entre gays e HSH em uso de PrEP HIV e caracterizar suas práticas sexuais. Métodos: Estudo transversal, realizado entre agosto/2021 e junho/2023, envolvendo gays e HSH ≥ 18 anos, usuários de PrEP HIV, atendidos no principal Serviço de Atendimento Especializado (SAE) do Rio Grande do Norte. Através de um instrumento de coleta padronizado, coletaram-se dados do prontuário sobre aspectos socioeconômicos, práticas sexuais e o resultado da sorologia Anti-HAV IgG/total. O tamanho amostral foi calculado em 185 participantes, com base em prevalência prévia de 62,3% de Anti-HAV IgG/total entre HSH, limite de confiança de ± 7%, erro tipo-α = 5% e erro tipo-β = 20%. Os resultados foram apresentados em proporções e seus intervalos de confiança de 95%. O estudo foi aprovado no comitê de ética sob CAAE n° 31650520.0.2005.5292. Resultados: Participaram do estudo 287 usuários (49,5% daqueles atualmente atendidos no SAE). A mediana de idade foi de 31 anos [IQ = 27-36). Declararam-se negros em 53,7% [43,9-62,7%] e brancos em 45,3% [39,7-50,9%]. Em sua maioria, eram solteiros (82,6% [78,4-86,8%]), residentes em Natal (76,7% [71,8-81,5%]) e homens cis (98,6% [97,2-100%]), tinham > 11 anos de estudo (87,8% [84,0-91,6%]) e renda ≤ 3 salários mínimos (59,9% [54,0-65,5%]). Na inclusão do estudo 64,5% [54,0-75,3%] já usavam PrEP HIV há, pelo menos, 6 meses. Em 62,4% [56,4-68,4%] dos participantes, os anticorpos Anti-HAV IgG/total foram reagentes. Sexo anal desprotegido foi relatado por 83,9% [79,0-88,0%] dos usuários. Em algum momento da vida, frequentar sauna foi relatado por 39,0% [33,1-45,3%], usar sex toys com parcerias em 22,3% [17,4-27,9%] e praticar fisting em 19,9% [15,3-25,1%] dos usuários. Práticas de fingering e sexo oral-anal em algum momento da vida foram relatados por 59,9% [54,0-65,2%] e 92,7% [89,2-95,5%], respectivamente. Conclusão: A prevalência de imunidade contra o HAV entre a população de gays e HSH em uso de PrEP HIV está abaixo dos níveis estimados (> 70%) necessários para impedir transmissão viral sustentada e futuros surtos