Acute kidney injury and other factors associated with mortality in hiv-infected patients

SUMMARY OBJECTIVE: HIV-related mortality is still high, especially in developed countries. The aim of this study is to investigate factors associated to death in HIV-infected patients. METHODS: This is a cross-sectional study with all HIV adult patients admitted to a tertiary infectious diseases hospital in Fortaleza, Northeast Brazil, from January 2013 to December 2014. Patients were divided into two groups: survivors and non-survivors. Demo-graphical, clinical and laboratory data were compared and a logistic regression was performed in order to investigate risk factors for death. P values ≤0.05 were considered statistically significant. RESULTS: A total of 200 patients with mean age of 39 years were including in the study, 69.5% males. Fifteen patients (7.5%) died. Non-survivors presented a higher percentage of males (93.3 vs. 67.3%, p = 0.037). Non-survivors presented AKI (73.3 vs. 10.3%, p < 0.001), liver dysfunction (33.3 vs. 11.5, p = 0.031), dyspnea (73.3 vs. 33.0%, p = 0.002) and disorientation (33.3 vs. 12.4%, p = 0.025) more frequently. Non-survivors also had higher levels of urea (73.8 ± 52.7vs. 36.1 ± 29.1 mg/dL, p < 0.001), creatinine (1.98 ± 1.65 vs. 1.05 ± 1.07 mg/dL, p < 0.001), aspartate aminotransferase (130.8 vs. 84.8 U/L, p = 0.03), alanine aminotransferase (115.6 vs. 85.4 U/L, p = 0.045) and lactate dehydrogenase (LDH) (1208 vs. 608 U/L, p = 0.012), as well as lower levels of bicarbonate (18.0 ± 4.7 vs. 21.6 ± 4.6 mEq/L, p = 0.016) and PCO2 (27.8 ± 7.7 vs. 33.0 ± 9.3 mmHg, p = 0.05). In multivariate analysis, disorientation (p = 0.035, OR = 5.523, 95%CI = 1.130 - 26.998), dyspnoea (p = 0.046, OR = 4.064, 95%CI = 1.028 - 16.073), AKI (p < 0.001, OR = 18.045, 95%CI = 4.308 - 75.596) and disseminated histoplasmosis (p = 0.016, OR = 12.696, 95%CI = 1.618 - 99.646) and LDH > 1000 U/L (p = 0.038, OR = 4.854, 95%CI = 1.093 - 21.739) were risk factors for death.]CONCLUSION: AKI and disseminated histoplasmosis (DH) were the main risk factors for death in the studied population. Neurologic and respiratory impairment as well as higher levels of LDH also increased mortality in HIV-infected patients.

RESUMO INTRODUÇÃO: A mortalidade relacionada ao HIV ainda é alta, especialmente nos países em desenvolvimento. O objetivo deste estudo é investigar os fatores associados ao óbito em pacientes com HIV. MÉTODOS: Trata-se de um estudo transversal com todos os pacientes com HIV admitidos consecutivamente em um hospital terciário de doenças infecciosas em Fortaleza, Nordeste do Brasil, entre janeiro de 2013 e dezembro de 2014. Os pacientes foram divididos em dois grupos: sobreviventes e não sobreviventes. Dados demográficos, clínicos e laboratoriais foram comparados e análise de regressão logística foi feita para investigação dos fatores de risco para óbito. RESULTADOS: Um total de 200 pacientes, com média de idade de 39 anos, foi incluído no estudo, sendo 69,5% do sexo masculino. Óbito ocorreu em 15 pacientes (7,5%). Os não sobreviventes apresentaram maior percentual de homens (93,3 vs. 67,3%, p = 0,037) e um menor tempo de internação (8 ± 6 vs. 18 ± 15 dias, p = 0,005). Na análise multivariada, desorientação (p = 0,035, OR = 5,523), dispneia (p = 0,046, OR = 4,064), LRA (p < 0,001, OR = 18,045), histoplasmose disseminada (p = 0,016, OR = 12,696) e desidrogenase lática (LDH) > 1.000 U/L (p = 0,038, OR = 4,854) foram fatores de risco para óbito. CONCLUSÕES: LRA e histoplasmose disseminada foram os principais fatores de risco para óbito na população estudada. Distúrbios neurológicos e respiratórios, bem como níveis elevados de LDH, também estiveram associados com o aumento da mortalidade em pacientes com HIV.

Clinical outcomes and risk factors for death from disseminated histoplasmosis in patients with AIDS who visited a high-complexity hospital in Campo Grande, MS, Brazil

Abstract INTRODUCTION: Disseminated histoplasmosis (DH) is a systemic mycosis caused by Histoplasma capsulatum (H. capsulatum) and is characterized by progressive and fatal evolution in immunocompromised patients. Moreover, it is considered an AIDS-defining disease. METHODS: We performed an observational, analytical, retrospective study to identify the clinical outcomes and risk factors for death from DH in patients with AIDS at an infectious diseases service facility in Brazil between September 2011 and July 2016. Patients with a positive serology for HIV and DH were diagnosed via direct examination and/or positive cultures for H. capsulatum. RESULTS: Twenty-three patients were included in this study. Approximately, 82.6% were men, with a mean age of 41.0±11.5 years, and 52.2% had a concomitant diagnosis of AIDS and DH. The median CD4+ T cell count was 19 cells/mm3, and 56.5% of the patients died. The most frequently observed symptoms were fever, dyspnea, and skin lesions. On the basis of a comparative analysis of those who died and survived, the absence of splenomegaly and hepatomegaly and the presence of H. capsulatum in the peripheral blood were considered as risk factors for death. Those who died had a higher leukocyte count; CRP, urea, and lactate dehydrogenase levels; AST index; and international normalized ratio prothrombin time. The serum total protein and albumin levels of the patients were lower. CONCLUSIONS: The mortality rate for DH is high among severely immunocompromised patients with AIDS. The risk factors for death were those traditionally associated with blood dyscrasia, inflammatory activity, as well as increased renal and nutritional impairment.

Características clínico-evolutivas de 134 pacientes com histoplasmose disseminada associada a SIDA no Estado do Ceará / Clinical and evolutionary characteristics of 134 patients with disseminated histoplasmosis associated with AIDS in the State of Ceará

INTRODUÇÃO: Desde o início da epidemia de HIV no Ceará, histoplasmose disseminada tem sido detectada com frequência em pacientes com aids. MÉTODOS: De modo a conhecer características clínico-laboratoriais, evolução e sobrevida da co-infecção HD/AIDS, analisou-se retrospectivamente 134 prontuários casos de HD internados de 1999 a 2005 no hospital referência para HIV no Ceará. RESULTADOS: Pacientes com HD apresentaram maior frequência de febre diária, tosse, perda de peso, hepatoesplenomegalia e insuficiência renal aguda. Diagnóstico foi dado por pesquisa e/ou cultura. À admissão, foram fatores de risco relacionados ao óbito de pacientes com HD: vômitos, dispnéia, insuficiência respiratória e IRA, hemoglobina<8g/L, uréia>40mg/dL e creatinina >1,5mg/dL. CONCLUSÕES: pacientes com HD apresentaram caracteristicamente febre mais elevada, internamentos anteriores por infecção respiratória, mais complicações clínicas e como fatores independentes para óbito, anemia importante e elevação de uréia.

INTRODUCTION: Since the beginning of the HIV epidemic in Ceará, disseminated histoplasmosis (DH) has often been detected among AIDS patients. METHODS: In order to investigate the clinical and laboratory characteristics, evolution and survival of cases of DH/AIDS coinfection, the medical records on 134 cases of DH admitted to a reference hospital in Ceará between 1999 and 2005 were analyzed. RESULTS: Patients with DH presented higher frequency of daily fever, coughing, weight loss, enlarged liver and spleen and acute kidney failure. The diagnosis was made using investigation and/or cultures. At admission, the following were risk factors for death among DH patients: vomiting, dyspnea, respiratory failure, acute kidney failure, hemoglobin < 8g/l, urea > 40mg/dl and creatinine >1.5 mg/dl. CONCLUSIONS: Patients with DH characteristically presented higher fever, previous hospitalization due to respiratory infection and more clinical complications. Significant anemia and elevated urea were independent risk factors for death among DH patients.

Micoses sistêmicas: fatores associados ao óbito em pacientes com infecção pelo vírus da imunodeficiência humana, Cuiabá, Estado de Mato Grosso, 2005-2008 / Systemic mycosis: factors associated with death among patients infected with the human immunodeficiency virus, Cuiabá, State of Mato Grosso, Brazil, 2005-2008

A prevalência de micose sistêmica entre 1.300 pacientes portadores de HIV/Aids de Cuiabá, Mato Grosso foi de 4,6 por cento, no período de 2005-2008. As espécies de fungos isoladas foram o Cryptococcus neoformans (50 por cento), Cryptococcus gattii (1,6 por cento), Cryptococcus spp (6,6 por cento), Histoplasma capsulatum (38,3 por cento) e Paracoccidioides brasiliensis (3,3 por cento). Óbito foi registrado em 32 (53,3 por cento) pacientes, sendo a criptococose a principal causa. A contagem de linfócitos T CD4+ foi baixa e semelhante entre os pacientes que sobreviveram ou faleceram por micose sistêmica. O etilismo (OR:8,2; IC95 por cento: 1,4-62,1; p=0,005) e o nível médio de desidrogenase lática [758 (182) U/L vs 416 (268) U/L; p<0,001] foram as características independentemente associadas ao óbito dos pacientes do estudo. Os resultados mostram alta letalidade por micoses sistêmicas em pacientes portadores de HIV/Aids de Cuiabá e sugerem que características clínico-laboratoriais tais como o etilismo e a elevação precoce da desidrogenase lática podem ser fatores relacionados ao pior prognóstico nessas condições.

Between 2005 and 2008, the prevalence of systemic mycosis among 1,300 HIV/AIDS patients in Cuiabá, Mato Grosso, was 4.6 percent. The fungus species isolated were Cryptococcus neoformans in 50 percent, Cryptococcus gattii in 1.6 percent, Cryptococcus spp in 6.6 percent, Histoplasma capsulatum in 38.3 percent and Paracoccidioides brasiliensis in 3.3 percent. Death was recorded in the cases of 32 patients (53.3 percent), and cryptococcosis was the main cause. The CD4+ T lymphocyte count was low and similar among patients who survived or died due to systemic mycosis. The factors independently associated with the deaths of these patients were alcoholism (OR: 8.2; 95 percent CI: 1.4-62.1; p = 0005) and the mean level of lactate dehydrogenase [758 (182) U/l vs. 416 (268) U/l; p < 0001]. The findings showed that systemic mycosis was highly lethal among the patients with HIV/AIDS in Cuiabá and suggested that clinical-laboratory characteristics such as alcoholism and early elevation of lactate dehydrogenase may be factors relating to worse prognosis under these conditions.

Study of 30 cases of histoplasmosis observed in the Mato Grosso do Sul State, Brazil

Thirty cases of histoplasmosis observed at the University Hospital of the Federal University of Mato Grosso do Sul (HU-UFMS) from January 1998 to December 2005 are reported. Most (83.3 percent) of the patients were men, average 33.4 years old, 63.3 percent of them were born and living in Mato Grosso do Sul and 83.3 percent presented AIDS as an underlying disease. In almost all cases (96.7 percent) the disease occurred in its disseminated form and the most frequent clinical manifestations were: fever (83.3 percent), weight loss (70.0 percent), cough (63.3 percent), hepatomegaly and splenomegaly (40.0 percent), and lymph node enlargement (36.7 percent). The laboratory diagnosis was obtained in 29 patients by isolation of Histoplasma capsulatum from various clinical specimens cultivated in Sabouraud dextrose and brain heart infusion agar and in 16 patients the fungus was observed by direct microscopy of Giemsa-stained smears. The observed mortality was 40 percent. This is the first report in the literature of the occurrence of histoplasmosis in Mato Grosso do Sul State.

Foram estudados 30 casos de histoplasmose observados no estado de Mato Grosso do Sul - HU-UFMS, no período de janeiro de 1998 a dezembro de 2005. Os pacientes eram, na maioria, homens (83,3 por cento) jovens (média de 33,4 anos de idade), naturais e procedentes de Mato Grosso do Sul (63,3 por cento) e tinham AIDS como principal doença subjacente (83,3 por cento). Houve predomínio da forma disseminada (96,7 por cento) e as manifestações clínicas mais freqüentes foram: febre (83,3 por cento), emagrecimento (70,0 por cento) tosse (63,3 por cento), hepatoesplenomegalia (40,0 por cento) e linfonodomegalia (36,7 por cento). O diagnóstico laboratorial foi obtido por exame microscópio direto de esfregaços corados pela técnica de Giemsa, em 16 pacientes, e isolamento de H. capsulatum em cultivo nos meios de agar Sabouraud dextrose e agar infusão de cérebro e coração, de materiais diversos, em 29 pacientes. A letalidade observada foi de 40 por cento. O trabalho apresenta, pela primeira vez na literatura, a ocorrência de histoplasmose-doença no Estado de Mato Grosso do Sul.

Histoplasmosis diseminada / Disseminated histoplasmosis. A case report

Introducción. La histoplasmosis en general es una de las infecciones micóticas más frecuentes en el mundo. El diagnóstico puede ser difícil y comúnmente es realizado durante la autopsia. En nuestro país se desconoce la frecuencia de esta enfermedad y dada la gravedad se considera conveniente comunicar el presente caso. Caso clínico. Se presenta el caso de una niña de 2 años y 4 meses de edad con padecimiento de 4 meses de evolución, caracterizado por ataque al estado general, síndrome infiltrativo en diferentes aparatos y sistemas y fiebre de 2 meses de evolución. El diagnóstico de histoplasmosis diseminada se estableció por la presencia del hongo en ganglios cervicales. Conclusión. Se hace énfasis en sospechar la enfermedad en todo paciente con síndrome febril e infiltrativo; y tenerse presente en el manejo de pacientes con gran nódulo linfático cervical

Micoses profundas em transplantados renais: indicaçäo de alerta clínico / Deep mycosis in kidney transplantation: indication of alert clinic

A imunossupressao dada a receptores de transplantes renais torna-os suscetíveis a infecçoes oportunísticas. Os autores estudaram o impacto das micoses profundas numa populaçao de 502 transplantados renais (525 transplantes) num período de 20 anos.Vinte e quatro receptores (4,6 por cento) desenvolveram micose profunda. Histoplasmose e criptococose foram as micoses mais prevalentes e as maiores responsáveis pela relativamente alta percentagem de óbitos observada (5O por cento). Revisao sobre métodos diagnósticos e de tratamento das mesmas é apresentada.Transplantados renais com micose profunda representam possivelmente um grupo imunossuprimido em excesso que deve ser seguido de perto para se tentar evitar mortalidade excessiva.

Manifestaciones perianales de la histoplasmosis generalizada / Perianal manifestations of the generalized hystoplasmosis

Se presenta un paciente portador de histoplasmosis generalizada que cursa la forma clínica sistémica rápida ampliamente diseminada. En el cuadro clínico prima la afectación del sistema nervioso central acompañado de hepatoesplenomegalia, linfadenopatía generalizada y lesiones tegumentarias expresadas como úlceras múltiples en cavidad oral, pie y región perianal. Se describen las caraterísticas de estas lesiones periorificiales y se evalúa su frecuencia.