Development and Validation of a Risk Score for Chronic Kidney Disease in HIV Infection Using Prospective Cohort Data from the D:A:D Study

Ristola M. on työryhmien DAD Study Grp ; Royal Free Hosp Clin Cohort ; INSIGHT Study Grp ; SMART Study Grp ; ESPRIT Study Grp jäsen.Background Chronic kidney disease (CKD) is a major health issue for HIV-positive individuals, associated with increased morbidity and mortality. Development and implementation of a risk score model for CKD would allow comparison of the risks and benefits of adding potentially nephrotoxic antiretrovirals to a treatment regimen and would identify those at greatest risk of CKD. The aims of this study were to develop a simple, externally validated, and widely applicable long-term risk score model for CKD in HIV-positive individuals that can guide decision making in clinical practice. Methods and Findings A total of 17,954 HIV-positive individuals from the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study with >= 3 estimated glomerular filtration rate (eGFR) values after 1 January 2004 were included. Baseline was defined as the first eGFR > 60 ml/min/1.73 m2 after 1 January 2004; individuals with exposure to tenofovir, atazanavir, atazanavir/ritonavir, lopinavir/ritonavir, other boosted protease inhibitors before baseline were excluded. CKD was defined as confirmed (>3 mo apart) eGFR In the D:A:D study, 641 individuals developed CKD during 103,185 person-years of follow-up (PYFU; incidence 6.2/1,000 PYFU, 95% CI 5.7-6.7; median follow-up 6.1 y, range 0.3-9.1 y). Older age, intravenous drug use, hepatitis C coinfection, lower baseline eGFR, female gender, lower CD4 count nadir, hypertension, diabetes, and cardiovascular disease (CVD) predicted CKD. The adjusted incidence rate ratios of these nine categorical variables were scaled and summed to create the risk score. The median risk score at baseline was -2 (interquartile range -4 to 2). There was a 1: 393 chance of developing CKD in the next 5 y in the low risk group (risk score = 5, 505 events), respectively. Number needed to harm (NNTH) at 5 y when starting unboosted atazanavir or lopinavir/ritonavir among those with a low risk score was 1,702 (95% CI 1,166-3,367); NNTH was 202 (95% CI 159-278) and 21 (95% CI 19-23), respectively, for those with a medium and high risk score. NNTH was 739 (95% CI 506-1462), 88 (95% CI 69-121), and 9 (95% CI 8-10) for those with a low, medium, and high risk score, respectively, starting tenofovir, atazanavir/ritonavir, or another boosted protease inhibitor. The Royal Free Hospital Clinic Cohort included 2,548 individuals, of whom 94 individuals developed CKD (3.7%) during 18,376 PYFU (median follow-up 7.4 y, range 0.3-12.7 y). Of 2,013 individuals included from the SMART/ESPRIT control arms, 32 individuals developed CKD (1.6%) during 8,452 PYFU (median follow-up 4.1 y, range 0.6-8.1 y). External validation showed that the risk score predicted well in these cohorts. Limitations of this study included limited data on race and no information on proteinuria. Conclusions Both traditional and HIV-related risk factors were predictive of CKD. These factors were used to develop a risk score for CKD in HIV infection, externally validated, that has direct clinical relevance for patients and clinicians to weigh the benefits of certain antiretrovirals against the risk of CKD and to identify those at greatest risk of CKD.Peer reviewe

Evaluatie van de diagnostiek en behandeling van bacteriëmie door Staphylococcus aureus. Minimale behandelduur van 2 weken vaak niet gehaald

Bacteraemia caused by Staphylococcus aureus (SA bacteraemia) can run a relatively mild course, but can also be complicated by focal infections in bones, joints, soft tissue and the heart. The Infectious Disease Society of America (IDSA) advises a transoesophageal echocardiogram (TOE) be taken in each case of SA bacteraemia in order to rule out endocarditis, in addition to sampling blood for culture 2-3 days after the start of treatment. Both the IDSA and the Dutch Stichting Werkgroep Antibiotica Beleid (SWAB - Foundation for Antibiotic Policy Work Groups) recommend that patients with SA bacteraemia be treated intravenously for at least 14 days; longer if a complicated course is expected. We investigated whether SA bacteraemia was diagnosed and treated according to current guidelines. Retrospective cohort study A case series of consecutive patients ≥ 18 years of age with SA bacteraemia was identified using the electronic microbiology registration system. A total of 93 patients were identified. Median follow-up duration was ≥ 3 months. Of the 81 patients who had survived one week after admission to the hospital, 41(60%) did not undergo TOE. Blood cultures on day 3 were performed in only 6 (6%) patients. Of the 79 (85%) patients who had survived the first two weeks of infection, 26 (33%) had been treated with intravenous antibiotics for less than 14 days. Recurrent SA bacteraemia occurred in 4 patients. In the majority of patients with SA bacteraemia, diagnostic work-up and duration of therapy did not comply with ISDA and SWAB guideline

Spatial clustering and livestock exposure as risk factor for community-acquired Clostridium difficile infection.

Clostridium difficile infections (CDI) account for 1.5% of diarrhoeic episodes in patients attending a general practitioner in the Netherlands, but its sources are unknown. We searched for community clusters to recognise localised point sources of CDI