Undiagnosed HIV in Patients on Immunosuppressive Medications Presenting with HIV-Associated Kidney Disease.

Approximately 158,500 adults and adolescents in the United States live with undiagnosed human immunodeficiency virus (HIV). Missed or delayed diagnoses adversely affect disease management and outcomes. This is particularly salient for patients receiving immunosuppressive and immunomodulatory therapy for the management of chronic inflammatory conditions, in which additional immunosuppression may increase the risk and severity of opportunistic infections. Despite this risk, comprehensive HIV testing before the initiation of immunosuppressive therapy is not yet the norm. We describe a case series containing the narratives of three patients recently treated with immunosuppressive agents, who presented with signs concerning for HIV-associated kidney diseases and who were found to have undiagnosed HIV later in the treatment course, which, unfortunately, resulted in poor outcomes. Screening for HIV or related illnesses, such as viral hepatitis or mycobacterial co-infections including tuberculosis, is essential before initiating biologic immunosuppression.

Prosthetic fitting and mortality after major lower extremity amputation.

BACKGROUND: Studies suggest that ambulation after major lower extremity amputation (LEA) is low and mortality after LEA is high. Successful prosthetic fitting after LEA has a significant quality of life benefit; however, it is unclear if there are benefits in post-LEA mortality. Our objective was to examine a contemporary cohort of patients who underwent LEA and determine if there is an association between fitting for a prosthetic and mortality. METHODS: We reviewed all patients who underwent LEA between 2015 and 2022 at two academic health care systems in a large metropolitan city. The exposure of interest was prosthetic fitting after LEA. The primary outcomes were mortality within 1 and 3 years of follow-up. Ambulation after LEA was defined as being ambulatory with or without an assistive device. Patients with prior LEA were excluded. Extended Cox models with time-dependent exposure were used to evaluate the association between prosthetic fitting and mortality at 1 and 3 years of follow-up. RESULTS: Among 702 patients who underwent LEA, the mean (SD) age was 64.3 (12.6) years and 329 (46.6%) were fitted for prosthetic. The study population was mostly male (n = 488, 69.5%), predominantly non-Hispanic Black (n = 410, 58.4%), and nearly one-fifth were non-ambulatory before LEA (n = 139 [19.8%]). Of note, 14.3% of all subjects who were nonambulatory at some point after LEA, and 28.5% of patients not ambulatory preoperatively were eventually ambulatory after LEA. The rate of death among those fitted for a prosthetic was 12.0/100 person-years at 1 year and 5.8/100 person-years at 3 years of follow-up; among those not fitted for a prosthetic, the rate of death was 55.7/100 person-years and 50.7/100 person-years at 1 and 3 years of follow-up, respectively. After adjusting for several sociodemographic data points, comorbidities, pre- or post- coronavirus disease 2019 pandemic timeframe, and procedural factors, prosthetic fitting is associated with decreased likelihood of mortality within 1 year of follow-up (adjusted hazard ratio, 0.24; 95% confidence interval, 0.14-0.40) as well as within 3 years (adjusted hazard ratio, 0.40; 95% confidence interval, 0.29-0.55). CONCLUSIONS: Prosthetic fitting is associated with improved survival, and preoperative functional status does not always predict postoperative functional status. Characterizing patient, surgical, and rehabilitation factors associated with receipt of prosthetic after LEA may improve long-term survival in these patients. Process measures employed by the Department of Veterans Affairs, such as prosthetic department evaluation of all amputees, may represent a best practice.