Outcome of HIV positive patients presenting with renal failure at Charlotte Maxeke Johannesburg Academic Hospital

Outcome of HIV positive patients presenting with renal failure at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) Background The majority of the 33.4 million people infected with HIV worldwide reside in sub-Saharan Africa. The HIV prevalence amongst young South Africans (ages 15- 49) is 16%. HIV is the third leading cause of ESRD in African - Americans aged 20-64 in the United States. There is a paucity of data regarding the prevalence of acute kidney injury (AKI) in HIV patients in sub-Saharan Africa. Methods A retrospective review of 101 HIV positive patients presenting with renal failure at the CMJAH from 1st October 2005 until 31st October 2006 was undertaken. There were 50 HIV positive patients with presumed AKI that were compared to 90 HIV negative patients with AKI. Results A total of 684 patients presented with renal failure, 101(14.8%) of whom were HIV positive. Ninetynine of the HIV positive patients were black and 56 were male. The mean age of HIV positive patients with renal failure was 38 years. Fifty-seven patients presented with AKI (seven patients were excluded due to lack of records), 21 with acute on chronic renal failure and 23 with chronic renal failure. The causes of AKI in the HIV positive group included sepsis (62%), haemodynamic instability (20%), toxins (10%), urological obstruction (8%) and miscellaneous (10%). The common underlying aetiologies of the 90 HIV negative patients studied presenting with AKI were sepsis (43%), haemodynamic instability (17%), toxins (7%), urological obstruction (8%) and miscellaneous (23%). Forty-seven (52%) of these HIV negative patients recovered. Forty-two (47%) patients died, compared with 22 (44%) patients in the HIV positive group. Hyponatraemia, hyperkalaemia, hypochloraemia and acidosis were more common in the HIV positive patients. Dialysis was initiated in 36% of HIV positive patients with AKI. There were more HIV positive patients that recovered with supportive care, including fluid therapy when compared to HIV negative patients. Recovery was noted to be more rapid in the HIV positive group. Using survival and death as the outcome there was no difference between the HIV positive and the HIV negative group presenting with AKI (p<0.7173). Discussion HIV positive patients presented with renal failure at a younger age – a mean age of 38 years in this study. Previous studies have shown mean ages ranging from 35 years to 46.7 years. The majority of the HIV positive patients presenting with renal failure were black (98%). The racial predominance is different to that of other countries which might be due to epidemiological factors. The gender differences were similar when compared to other studies. Sepsis was the more common aetiological factor of AKI (62% of HIV positive patients compared to 43% of HIV negative patients). HIV positive patients with AKI presented at an advanced stage of immunosuppression (more than 50% had CD4<100cells/μl). Electrolyte disturbances were common in HIV positive patients with AKI. Conclusion HIV positive patients with AKI presented with advanced immunosuppression. Sepsis was the most common aetiology of AKI. Supportive management or renal replacement therapy resulted in recovery in a large number of patients.HIV positive patients should be treated acutely just as HIV negative patients and should not be excluded on the basis of their HIV status. Dialysis should be offered when indicated and aggressive fluid resuscitation should be emphasized. Outcomes were similar in HIV positive and HIV negative patients presenting with AKI

Reduced glomerular filtration rate is associated with ascending aortic dilatation in South African chronic kidney disease patients

Background: Ascending aortic dilatation (AAD) is an adverse prognostic cardiovascular marker in the general population. There are few data reporting its presence or clinical significance in chronic kidney disease (CKD) patients. The aim of this study was to evaluate ascending aorta dimensions and their correlates in a population of South African CKD patients.Methods: A total of 124 CKD patients and 40 healthy controls were enrolled. Cardiac dimensions, systolic and diastolic function indices, and aortic root diameters were assessed by transthoracic echocardiography. The ascending aorta was measured at four levels (aortic annulus, sinuses of Valsalva, sino-tubular junction, and ascending aorta) and was normalised for body surface area. The prevalence of AAD was assessed in CKD patients compared with the control group.Results: In CKD patients, the ascending aorta dimension was significantly larger than in controls at all four sites of the aorta that were measured. The prevalence of AAD was 6.5% at the annulus, 12.9% at the sinuses, 15.3% at the sino-tubular junction, and 8.9% at the ascending aorta. Overall, 29 patients (23%) had AAD. On multivariate analyses, eGFR was independently associated with AAD (odds ratio 0.980; 95% confidence interval 0.965–0.996; P = 0.014).Conclusion: AAD is a common cardiovascular phenotype in South African CKD patients. Low eGFR was independently associated with AAD, suggesting a direct link between CKD and the development of AAD in South African CKD patients

Interventional cardiology during the COVID-19 epidemic

The impact of the COVID-19 pandemic on our lives is unprecedented and major adjustments to our practices as physicians are required. Although our comments are applicable at the time of writing, the situation changes daily and the content of this article should be adjusted accordingly.Cath lab: An unambiguous cath lab protocol should be drawn up for each facility, appropriate to local circumstances. This should include standard procedures in preparation for arrival at the lab, in the performance of procedures, and, importantly, in maintaining due diligence when removing protective gear. All team members should be well trained in these procedures.Acute coronary syndromes: Standard timing for the invasive management of patients should not change during the pandemic. Due to delays often unavoidable during the pandemic, alternative strategies such as thrombolysis may be more readily available and therefore more appropriate.Drugs: The sick COVID-19 patient often represents a pro-thrombotic state and operators should ensure adequate anti-thrombotic therapy. Knowledge of interactions between cardiac drugs and investigational antiviral treatments is important.Elective procedures: Patients with chronic cardiac conditions are at high risk and may require non-urgent procedures to avert major complications. Selecting these cases requires consideration of multiple risks and benefits

Transforming Growth Factor-β Protects against Inflammation-Related Atherosclerosis in South African CKD Patients

Background. Transforming growth factor-β (TGF-β) may inhibit the development of atherosclerosis. We evaluated serum levels of TGF-β isoforms concurrently with serum levels of endotoxin and various inflammatory markers. In addition, we determined if any association exists between polymorphisms in the TGF-β1 gene and atherosclerosis in South African CKD patients. Methods. We studied 120 CKD patients and 40 healthy controls. Serum TGF-β1, TGF-β2, TGF-β3, endotoxin, and inflammatory markers were measured. Functional polymorphisms in the TGF-β1 genes were genotyped using a polymerase chain reaction-sequence specific primer method and carotid intima media thickness (CIMT) was assessed by B-mode ultrasonography. Results. TGF-β isoforms levels were significantly lower in the patients with atherosclerosis compared to patients without atherosclerosis (p<0.001). Overall, TGF-β isoforms had inverse relationships with CIMT. TGF-β1 and TGF-β2 levels were significantly lower in patients with carotid plaque compared to those without carotid plaque [TGF-β1: 31.9 (17.2 – 42.2) versus 45.9 (35.4 – 58.1) ng/ml, p=0.016; and TGF-β2: 1.46 (1.30 – 1.57) versus 1.70 (1.50 – 1.87) ng/ml, p=0.013]. In multiple logistic regression, age, TGF-β2, and TGF-β3 were the only independent predictors of subclinical atherosclerosis in CKD patients [age: odds ratio (OR), 1.054; 95% confidence interval (CI): 1.003 – 1.109, p=0.039; TGF-β2: OR, 0.996; 95% CI: 0.994–0.999, p=0.018; TGF-β3: OR, 0.992; 95% CI: 0.985–0.999, p=0.029). TGF-β1 genotypes did not influence serum levels of TGF-β1 and no association was found between the TGF-β1 gene polymorphisms and atherosclerosis risk. Conclusion. TGF-β isoforms seem to offer protection against the development of atherosclerosis among South African CKD patients

Evaluation of coronary features of HIV patients presenting with ACS. the CUORE, a multicenter study

Background and aims: The risk of recurrence of myocardial infarction (MI) in HIV patients presenting with acute coronary syndrome (ACS) is well known, but there is limited evidence about potential differences in coronary plaques compared to non-HIV patients. Methods: In this multicenter case-control study, HIV patients presenting with ACS, with intravascular-ultrasound (IVUS) data, enrolled between February 2015 and June 2017, and undergoing highly active antiretroviral therapy (HAART), were retrospectively compared to non-HIV patients presenting with ACS, before and after propensity score with matching, randomly selected from included centers. Primary end-point was the prevalence of multivessel disease. Secondary end-points were the prevalence of abnormal features at IVUS, the incidence of major-acute-cardiovascular-events (MACE), a composite end point of cardiovascular death, MI, target lesion revascularization (TLR), stent thrombosis (ST), non-cardiac death and target vessel revascularization (TVR). For each end-point, a subgroup analysis was conducted in HIV patients with CD4 cell count <200/mm3. Results: Before propensity score, 66 HIV patients and 120 non-HIV patients were selected, resulting in 20 and 40 after propensity score. Patients with multivessel disease were 11 and 17, respectively (p = 0.56). IVUS showed a lower plaque burden (71% vs. 75%, p < 0.001) and a higher prevalence of hyperechoic non-calcified plaques (100% vs. 35%, p < 0.05) in HIV patients; a higher prevalence of hypoechoic plaques (7% vs. 0%, p < 0.05), a higher incidence of MACE (17.4% vs. 9.1% vs. l’8.0%, p < 0.05), MI recurrence (17.2% vs. 0.0% vs. 2.3%, p < 0.05), and ST (6.7% vs. 0.3% vs. 03%, p < 0.05) in HIV patients with CD4 < 200/mm3. Conclusions: Our study may provide a part of the pathophysiological basis of the differences in coronary arteries between HIV-positive and HIV-negative patients, suggesting that the former present with peculiar morphological features at IVUS, even after adjustment for clinical variables. Furthermore, we confirmed that an advanced HIV infection is associated with a high risk of non-calcific plaques and with a worse prognosis, including cardiovascular events and ACS recurrence