ABSTRACT
BACKGROUND: Chronic kidney disease (CKD) is age-dependent and has a high prevalence in the general population. Most patients are managed in ambulatory care. This systematic review provides an updated overview of quality and content of international clinical practice guidelines for diagnosis and management of non-dialysis CKD relevant to patients in ambulatory care. METHODS: We identified guidelines published from 2012-to March 2018 in guideline portals, databases and by manual search. Methodological quality was assessed with the Appraisal of Guidelines for Research and Evaluation II instrument. Recommendations were extracted and evaluated. RESULTS: Eight hundred fifty-two publications were identified, 9 of which were eligible guidelines. Methodological quality ranged from 34 to 77%, with domains "scope and purpose" and "clarity of presentation" attaining highest and "applicability" lowest scores. Guidelines were similar in recommendations on CKD definition, screening of patients with diabetes and hypertension, blood pressure targets and referral of patients with progressive or stage G4 CKD. Definition of high risk groups and recommended tests in newly diagnosed CKD varied. CONCLUSIONS: Guidelines quality ranged from moderate to high. Guidelines generally agreed on management of patients with high risk or advanced CKD, but varied in regarding the range of recommended measurements, the need for referrals to nephrology, monitoring intervals and comprehensiveness. More research is needed on efficient management of patients with low risk of CKD progression to end stage renal disease.
Subject(s)
Ambulatory Care , Practice Guidelines as Topic/standards , Renal Insufficiency, Chronic/diagnosis , Renal Insufficiency, Chronic/therapy , Disease Progression , Humans , Monitoring, Physiologic , Quality Assurance, Health Care , Referral and Consultation , Risk FactorsABSTRACT
BACKGROUND: Maraviroc represents the first licensed CCR5 co-receptor antagonist from the new antiretroviral (ARV) drug-class of entry inhibitors. RESULTS: Results of Phase III clinical trials in three-drug-class experienced patients have presented maraviroc as a promising new agent for treatment of HIV-1-infection. Maraviroc (b.i.d./q.d.) + optimised background therapy (OBT) provided significantly superior virological control and CD4+ increases compared with placebo + OBT at 48 weeks, with no clinically relevant differences in the safety profile between the maraviroc and the placebo groups. CONCLUSION: Its proven efficacy in cases of virological failure and three-class ARV-drug resistance is a major benefit of maraviroc compared to the so far commercially available drugs from existing (non-) nucleoside reverse transcriptase inhibitors ([N]NRTI) and protease inhibitors drug-classes, particularly in times of increasing ARV drug resistance. Moreover, the tolerability profile of the drug makes maraviroc particularly appealing as a combination partner in ARV therapy. As maraviroc however is only effective against CCR5-tropic HIV-1, tropism testing is required before initiation of treatment. Tropism-testing possibilities are still limited, and presently only possible at high costs. The main constraints to be considered in the clinical use of maraviroc are the declining number of CCR5-tropic patients with advanced HIV-1 disease owing to tropism-shifting and the occurrence of drug-drug interactions, requiring regular dose adaptations. The true clinical value of this new substance and its future role in the treatment of HIV-1-infection remains to be defined by further data from clinical studies and by future experiences of practitioners.
Subject(s)
Cyclohexanes/administration & dosage , HIV Fusion Inhibitors/administration & dosage , HIV Infections/drug therapy , Triazoles/administration & dosage , CCR5 Receptor Antagonists , Clinical Trials, Phase III as Topic , Cyclohexanes/adverse effects , Drug Resistance, Multiple, Viral , HIV Fusion Inhibitors/adverse effects , HIV-1/drug effects , Humans , Maraviroc , Triazoles/adverse effectsABSTRACT
BACKGROUND: Primary HIV drug resistance (PDR) is associated with poor treatment outcome of first-line highly active antiretroviral therapy (HAART). The aim of the study was to observe the trend of prevalence of PDR between 2001 and 2005. METHODS: In a prospective multicentre study in the state of Nordrhein-Westfalen, Germany, 831 treatment-naive chronically HIV-infected patients underwent genotypic resistance testing. RESULTS: Six hundred and forty (77%) of them were male. Two-thirds of the patients (558, 67%) were infected with HIV subtype B. PDR was found in 75 of 831 [9%; 95% confidence interval (CI) 7.1-10.9] cases entering the study between January 2001 and December 2005. An increasing trend of PDR was found from 2001 (4.8%; CI 2.1-9.4) to 2005 (9.0%; CI 5.4-12.6; P = 0.08). A significant tendency to higher PDR was observed for ethnicity other than Caucasian (P = 0.04), HIV subtypes other than B (P = 0.02) and transmission routes other than homosexual (P = 0.03). CONCLUSIONS: A non-significant increase in prevalence of PDR was observed from 2001 to 2005. A significant trend to higher PDR rate was detected in non-Caucasian patients, patients infected with non-B subtypes, and in patients with risk factors for acquisition of HIV other than homosexual transmission. Based on the fact that there is a trend to higher PDR rate, resistance testing in untreated HIV-infected patients starting HAART becomes more important in clinical routine. The identification of patient subgroups with a remarkable risk of PDR makes continuous monitoring of PDR mandatory.