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The objective of this study was to identify the factors associated with important clinical outcomes in a case-control study of 213 patients with lupus nephritis. Included were 47% Hispanics, 44% African Americans and 9% Caucasians with a mean age of 28 years. Fifty-four (25%) patients reached the primary composite outcome of doubling serum creatinine, end-stage renal disease or death during a mean follow-up of 37 months. Thirty-four percent African Americans, 20% Hispanics and 10% Caucasians reached the primary composite outcome ( P < 0.05). Patients reaching the composite outcome had predominantly proliferative lupus nephritis (WHO classes: 30% III, 32% IV, 18% V and 5% II, P < 0.025) with higher activity index score (7 ± 6 versus 5 ± 5, P

Resume Le pronostic des malades neutropeniques en reanimation est extremement sombre, en particulier lorsque le recours a la ventilation mecanique (VM) s'avere necessaire. La tracheotomie, realisee precocement apres le debut de la VM, pourrait permettre d'ameliorer le pronostic de ces patients. L'objectif de ce travail etait d'evaluer, chez les malades neutropeniques ventiles, l'innocuite de la tracheotomie en termes de complications infectieuses et hemorragiques, ainsi que son efficacite sur la mortalite en reanimation et la survenue de pneumopathies nosocomiales. L'etude de l'innocuite de la tracheotomie repose sur l'analyse retrospective des dossiers de 26 patients tracheotomises en aplasie, sur une periode consecutive de 4 ans. Les caracteristiques et la duree de la VM et de la neutropenie ont ete recueillies. Le saignement et l'infection de l'orifice stomal, ainsi que les pneumopathies infectieuses et les hemorragies alveolaires ont ete notes. Des transfusions plaquettaires ont ete effectuees chez 23 des 26 patients au moment de la procedure ; aucune hemorragie locale n'est survenue. Aucune infection pulmonaire ou stomale secondaire a la tracheotomie n'a ete retrouvee. La tracheotomie n'a jamais ete consideree comme responsable d'une aggravation respiratoire. Dix-neuf patients (73 p. 100) sont decedes en reanimation, sans lien direct entre la tracheotomie et le deces. Le benefice lie a la tracheotomie a ete ensuite etudie par analyse des dossiers de 53 patients neutropeniques (ou destines a le devenir tres rapidement) ventiles pendant la meme periode (en excluant les malades ventiles moins de 48 heures, ou seulement ventiles en postoperatoire immediat). Vingt patients ont ete tracheotomises precocement, avant la 48 e heure de VM (groupe TP), alors que 33 patients ont ete tracheotomises plus tard ou sont restes intubes (groupe INT). Les deux groupes sont comparables vis-a-vis de la maladie sous-jacente, la defaillance respiratoire, la VM et les scores de gravite, mais la neutropenie est plus profonde dans le groupe TP. La mortalite est similaire (TP : 70 p. 100 ; INT : 78,8 p. 100). Il existe cependant une tendance (quoique non significative) pour une prolongation de la survie en reanimation dans le groupe TP, y compris apres ajustement sur le degre de neutropenie (test du Log-Rank : p = 0,07). L'incidence des pneumopathies est similaire dans les deux groupes. Ces resultats suggerent non seulement l'innocuite de la tracheotomie chez les patients neutropeniques necessitant la VM, mais aussi que cette procedure pourrait prolonger la survie dans l'attente de la sortie d'aplasie. Seule une etude prospective permettra de confirmer ou non cette hypothese.

An RNA virus designated hepatitis G virus (HGV) has been recently identified in patients with acute and chronic liver disease. HGV is transfusion transmissible, it has global distribution, and it is present in the volunteer blood donor population in the United States. One hundred sixty patients undergoing maintenance hemodialysis at the University of Miami-affiliated unit were evaluated. There were 99 men and 61 women ranging in age from 22 to 80 years. Sixty percent had a history of blood transfusion, 6% had a history of drug abuse, and 9% were infected with the human immunodeficiency virus. HGV-RNA was detected by reverse-transcriptase polymerase chain reaction with amplification of two independent regions (5'-nontranslated region and NS5a coding region). Detection of digoxigenin-labeled amplification products with specific capture probes to the coding and noncoding regions was performed with the Enzymun-test DNA on an ES-300 Immunoassay System (Boehringer-Mannheim, Mannheim, Germany). Hepatitis C antibodies were measured with anti-hepatitis C virus enzyme-linked immunosorbent third-generation assays and hepatitis C virus RNA by reverse-transcriptase polymerase chain reaction. There were 32 (20%) patients with detectable HGV RNA with both primer pairs. Because of possible mutations, the HGV virus may be detectable only with one primer pair. We considered the latter as indeterminate: 12 had detectable levels to the NS5a region only, seven to the 5'-nontranslated region, and six had borderline results. Detectable and indeterminate samples were confirmed by repeat measurements in a new blood sample. Seven of 24 (29%) patients with detectable hepatitis C virus RNA had coexisting HGV with one or both HGV primer pairs (four with both and three with one). Five patients were hepatitis B surface antigen positive and HGV negative. We conclude that HGV infection is prevalent in our dialysis patients. The clinical significance of HGV infection remains to be established.

Hepatitis C virus (HCV) infection is endemic in long-term dialysis units. We assessed the performance of a recently developed HCV 3.0 assay for the detection of HCV antibodies in patients undergoing dialysis. The study evaluated 128 patients undergoing long-term maintenance hemodialysis. Anti-HCV was detected by 2.0 and 3.0 enzyme immunoassay (EIA). Results were confirmed with recombinant immunoblot assays (RIBA 2.0 and RIBA 3.0). HCV RNA was detected by using reverse transcriptase-polymerase chain reaction (RT-PCR). Thirty-two patients (25%) were HCV EIA 2.0 positive. Of these, 1 was RIBA 2.0 negative (PCR positive), 3 were indeterminate (3 PCR positive), and 28 were positive (23 PCR positive). Thirty-five (27%) were HCV EIA 3.0 positive. One was RIBA 3.0 negative (PCR positive), 1 was indeterminate (c33c, PCR positive), and 33 were positive (27 PCR positive) by RIBA 3.0. Thus only 1 PCR-positive patient was negative with RIBA 2.0 and 3.0 assays. Two of the 3 RIBA 2.0 indeterminate samples were positive with RIBA 3.0. One remained indeterminate but was HCV RNA positive. In summary, HCV 3.0 EIA detected 4 additional viremic patients but was positive in 6 PCR-negative subjects. A high correlation of the presence of antibody to c33c with HCV RNA (28 of 34, 82%) was found, and it was found in all anti-HCV positive samples and in 1 indeterminate sample. We conclude that the HCV EIA 3.0 test with the supplemental confirmatory RIBA 3.0 test may improve the sensitivity for the detection of anti-HCV. Nevertheless, in potentially immunocompromised patients undergoing dialysis, PCR continues to be the only reliable test for detecting viremia.