Acute renal impairment in coronavirus-associated severe acute respiratory syndrome

Acute renal impairment in coronavirus-associated severe acute respiratory syndrome.BackgroundSevere acute respiratory syndrome (SARS) is a newly emerged infection from a novel coronavirus (SARS-CoV). Apart from fever and respiratory complications, acute renal impairment has been observed in some patients with SARS. Herein, we describe the clinical, pathologic, and laboratory features of the acute renal impairment complicating this new viral infection.MethodsWe conducted a retrospective analysis of the plasma creatinine concentration and other clinical parameters of the 536 SARS patients with normal plasma creatinine at first clinical presentation, admitted to two regional hospitals following a major outbreak in Hong Kong in March 2003. Kidney tissues from seven other patients with postmortem examinations were studied by light microscopy and electron microscopy.ResultsAmong these 536 patients with SARS, 36 (6.7%) developed acute renal impairment occurring at a median duration of 20 days (range 5–48 days) after the onset of viral infection despite a normal plasma creatinine level at first clinical presentation. The acute renal impairment reflected the different prerenal and renal factors that exerted renal insult occurring in the context of multiorgan failure. Eventually, 33 SARS patients (91.7%) with acute renal impairment died. The mortality rate was significantly higher among patients with SARS and acute renal impairment compared with those with SARS and no renal impairment (91.7% vs. 8.8%) (P < 0.0001). Renal tissues revealed predominantly acute tubular necrosis with no evidence of glomerular pathology. The adjusted relative risk of mortality associated with the development of acute renal impairment was 4.057 (P < 0.001). By multivariate analysis, acute respiratory distress syndrome and age were the most significant independent risk factors predicting the development of acute renal impairment in SARS.ConclusionAcute renal impairment is uncommon in SARS but carries a high mortality. The acute renal impairment is likely to be related to multi-organ failure rather than the kidney tropism of the virus. The development of acute renal impairment is an important negative prognostic indicator for survival with SARS

The use of transient elastography in the management of chronic hepatitis B

There has been increasing interest in noninvasive methods of assessing liver fibrosis over the last decade. The use of transient elastography in measuring liver stiffness has become the forefront of a wide range of noninvasive tools. Most of the other methods are based on measurements of biomarkers associated with fibrosis. There are several reasons for its wide acceptance, including the ease of performing a scan, the short procedure time, the results being immediately available on completion of the examination, and its reproducibility. For chronic hepatitis B (CHB), the cut-off values for F3 and F4 fibrosis range between 7.5–12.0 and 11.0–13.4 kPa, respectively, although the cut-offs may be slightly lower in those with normal ALT. In addition to measuring liver fibrosis, recent studies have demonstrated several other roles for transient elastography, including selecting patients who will benefit from antiviral therapy, monitoring response to antiviral therapy, and predicting long-term outcomes. However, there are limitations associated with transient elastography, including the confounding effects of inflammatory activity, and to a lesser extent, steatosis, on liver stiffness. There is also reduced accuracy observed in lower fibrosis stages (F0–F2). Furthermore, the incidences of failed and unreliable scan have been reported to be ~ 3 and 16%, respectively. Although liver biopsy can be avoided in an estimated 50–60% using transient elastography, in situations where liver stiffness measurement is nondiagnostic or inconsistent with the clinical picture, a biopsy is still recommended. Further studies are needed to consolidate the role of transient elastography in the management of CHB, and for incorporation of this method into current treatment guidelines

On-line hemodiafiltration and high-flux hemodialysis: comparison of efficiency and cost analysis

AbstractWith on-line hemodiafiltration (HDF), low molecular weight substances are predominantly cleared by diffusion while middle molecules such as ß2-microglobulin (ß2M), an amyloidogenic factor, are removed mainly by convection. The objectives of this study are to evaluate the cost-effectiveness and safety of on-line HDF with dialyzer reuse, and to compare HDF and high-flux hemodialysis (HD) with respect to ß2M removal, urea kinetics (Kt/V) and symptom relief in those patients having dialysis-related amyloidosis. Ten chronic HD patients were put on post-dilution HDF for a period of 14.2 ±7.1 months. The AK 100 ULTRA system was used for on-line preparation of substitution fluid. These patients were then switched over to high-flux HD for a period of 4.6 ±3 months. Dialyzers were reused up to 30 times to reduce the cost of HDF. All the patients were hemodynamically stable during both HDF and high-flux HD treatments. No febrile reactions were reported. The percentage reduction of ß2M during HDF was significantly higher when compared with high-flux HD (75 ±4% vs 51 ±7%, p < 0.001). After 14.2 ±7.1 months of HDF, the patients had significant reduction of both the pre-dialysis ß2M level (47.4 ±7.9 μg/mL vs 28.2 ±4.9 μg/mL, p < 0.01) and post-dialysis ß2M level (11.4 ±2.8 μg/mL vs 6.8 ±1.0 μg/mL, p < 0.01). eKt/V achieved by HDF was significantly higher than that achieved by high-flux HD (1.94 ±0.26 vs 1.75 ±0.23, p < 0.01). Those patients with dialysis arthropathy and carpal tunnel syndrome had decreased joint pain and hand numbness respectively after putting on HDF but symptoms recurred while on high-flux HD. There were no statistical significant differences in the percentage reduction of ß2M, ß2M clearance, urea clearance and eKt/V with dialyzer reuse, and no adverse patient reactions had been recorded.ConclusionOn-line HDF has been proven to be a safe and reliable treatment. The clearance of ß2M and urea are significantly increased by HDF when compared with high-flux HD, and the increase in clearance of ß2M is sustained throughout the HDF treatment period. Symptoms of dialysis-related amyloidosis are improved by HDF. Dialyzer reuse, which reduces the cost of HDF by 30%, is feasible and safe

Optimal gender-specific age for cost-effective vaccination with adjuvanted herpes zoster subunit vaccine in Chinese adults.

BackgroundAdjuvanted herpes zoster (HZ) subunit (HZ/su) vaccine is recommended for healthy adults aged ≥50 years, yet vaccine efficacy is expected to wane over time. Age-sex specific cost-effectiveness analyses of HZ/su vaccine are warranted to inform decision-making on vaccine policy. We aimed to determine the optimal gender-specific age for cost-effective HZ/su vaccination in Hong Kong.MethodsA Markov model was used to compare outcomes with and without HZ/su in healthy males and females at age 50-80 years. Model outcome measures were total cost, HZ cases, and HZ-associated quality-adjusted life-years (QALYs) loss. Incremental cost per QALY saved (ICER) by HZ/su was estimated for each age-sex group. Sensitivity analyses were performed to examine robustness of model results.ResultsHZ/su reduced incidence of HZ in both males and females aged 50-80 years and the numbers needed to vaccinate to avoid one HZ case were lowest at age 60 years for males (6.05) and females (5.50). The highest QALY-saved occurred in females (0.00396 QALYs) and males (0.00379 QALYs) who were vaccinated at 60 years old. The ICERs were lowest at age 60-70 years for both genders. Using 1× gross domestic product per capita of Hong Kong (USD46,153) as willingness-to-pay threshold, HZ/su vaccine was accepted to be cost-effective for all female and male age groups at vaccine cost = USD160, for female aged 50-79 years and male aged 54-74 years at vaccine cost = USD200, and for female aged 59-71 years at vaccine cost = USD240.ConclusionsHZ/su vaccine is more likely to be cost-effective for males and females aged between 60-70 years than the extreme age groups (less than 60 years and older than 70 years) in Hong Kong. The age range for cost-effective acceptance of HZ/su vaccine appears to be broader in females than males given the same vaccine cost and willingness-to-pay threshold

The pharmacokinetics and bioequivalence of Gengraf and Neoral in stable renal transplant recipients

AbstractObjectiveGengraf capsule, an AB-rated generic cyclosporine for Neoral, has been shown to be bioequivalent in previous studies. The objective of this study was to evaluate the pharmacokinetics and bioequivalence of Gengraf and Neoral in stable Chinese renal allograft recipientsMethodsIn a prospective, open-label, two-period design study, 20 renal allograft recipients receiving stable doses of Neoral were recruited. Subjects continued their Neoral regimen during period I (days 1-14). They were then switched from Neoral on a milligram-for-milligram basis to Gengraf during period II (days 15-28). Four-hour pharmacokinetic parameters (concentration before dosing [Ctrough], maximum blood concentration [Cmax], time to maximum concentration [Tmax], and area under the blood concentration-versus-time curve [AUC0-4]) were taken on days 1, 8, 21, and 28. Biochemical parameters were also evaluated.ResultsThere was no significant difference in the pharmacokinetics of Gengraf (Ctrough, Tmax, Cmax, and AUC0-4) as compared with that of Neoral in stable renal transplant recipients. The bioequivalent capsules were interchangeable with respect to Ctrough, Cmax and AUC0-4. The 90% confidence intervals of the ratio of Ctrough, Cmax, Tmax, and AUC0-4 of Gengraf and Neoral were 0.94 to 1.21 for Ctrough, 0.97 to 1.20 for Cmax, and 0.97 to 1.20 for AUC0-4. Ctrough and C2 remained stable throughout the study without any dosage adjustments. Gengraf was well tolerated, and had a comparable safety profile as Neoral.ConclusionGengraf are bioequivalent to Neoral. Gengraf is well tolerated and interchangeable with Neoral in stable Chinese renal allograft recipients