Chronic kidney disease in the global adult HIV-infected population: A systematic review and meta-analysis

Renal function and associated mortality risk in adults commencing HIV antiretroviral therapy in Zimbabwe

BACKGROUND

People with HIV (PWH) in sub-Saharan Africa appear to have a higher incidence of renal disease than other global regions but data are limited. This renal impairment may be associated with an increased mortality risk.

AIMS

To define the prevalence of renal disease and explore its association with mortality risk in a cohort from Zimbabwe commencing antiretroviral therapy (ART) for HIV infection.

METHODS

A retrospective study of all patients aged at least 18 years, commenced on ART for HIV infection at the Newlands Clinic in Harare, Zimbabwe between January 2007 and September 2019 was conducted. Data were extracted from electronic medical records. Patients with no baseline creatinine measurement were excluded. Baseline characteristics were assessed as potential predictors for mortality by Cox proportional hazard regression.

RESULTS

Three thousand and thirty-nine patients were eligible for inclusion. Most were female (62.1%), with a median age of 36 years (IQR 30-43). At baseline, 7.3% had an estimated glomerular filtration rate (eGFR) 90 ml/min per 1.73 m2 or less and 11.4% had proteinuria. Over a median follow-up period of 4.6 years (IQR 2.5-6.9), the mortality rate was 8.7%. One half of deaths (49.2%) occurred within the first year. In multivariable analysis, a baseline eGFR between 60 and 90 ml/min per 1.73 m2 [hazard ratio 2.22, 95% confidence interval (CI) 1.46-3.33, P < 0.001] and proteinuria (hazard ratio 2.10, 95% CI 1.35-3.27, P < 0.001) were associated with increased mortality risk.

CONCLUSION

Baseline renal impairment was common. Both a reduced eGFR or proteinuria were independently associated with a doubling of mortality risk. These should serve as markers in the clinical setting of at-risk patients.

Incidence of impaired kidney function among people with HIV: a systematic review and meta-analysis

BACKGROUND

In the era of combination antiretroviral therapy (ART), the incidence, manifestations and severity of kidney diseases have dramatically changed in people living with HIV (PLWH). Little is known about the incidence of impaired kidney function (IKF) measured by serum creatine-based estimated glomerular filtration rate (eGFR) in PLWH.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Ovid, Medline, Embase and Web of Science for studies published before May 7th, 2021, with estimates of incidence of IKF among PLWH. We independently reviewed each study for quality by using the Newcastle-Ottawa scale. The incidence and 95% confidence intervals (CIs) were calculated using random-effects model.

RESULTS

Sixty out of 3797 identifiable studies were eligible for the meta-analysis. A total of 19 definitions of IKF were described and categorized into three types: the threshold of eGFR, an absolute or percent decrease in eGFR, and certain eGFR threshold combined with decrement in eGFR. The eGFR< 60 ml/min/1.73m2 was the most widely used definition or criterion for IKF, by which the pooled incidence rate of IKF was 12.50 (95%CI: 9.00-17.36) per 1000 person years (PYs). The second most-studied outcome was a > 25% decrease in eGFR, followed by eGFR< 90 ml/min/1.73m2, eGFR< 30 ml/min/1.73m2 and a combination of eGFR threshold plus decreased eGFR. The reported incidence rates of IKF differ widely by different definitions of IKF. The highest pooled incidence was observed for those with > 25% decrease in eGFR, while the lowest was observed in those with eGFR < 30 ml/min/1.73m2. Substantial heterogeneity was identified across most estimates.

CONCLUSION

Our study provides a comprehensive summary of eGFR-based definitions and incidence rates of IKF in PLWH, not only promoting our understanding of IKF, but also underscoring needs for a concerted action to unify definitions and outcomes of IKF and their applications in AIDS care.

Association Between CD4/CD8 Ratio Recovery and Chronic Kidney Disease Among Human Immunodeficiency Virus-Infected Patients Receiving Antiretroviral Therapy: A 17-Year Observational Cohort Study

BACKGROUND

CD4/CD8 ratio is considered as an emerging biomarker for human immunodeficiency virus (HIV)-related diseases. However, the relationship of CD4/CD8 ratio recovery and chronic kidney disease (CKD), and whether cumulative antiretroviral therapy (ART) is effective in the CD4/CD8 ratio recovery and in reducing CKD incidence among HIV patients remain unclear.

METHODS

A 17-year observational cohort study was conducted on all HIV-infected patients receiving ART in Guangxi, China. Kaplan-Meier analysis was used to investigate the cumulative CKD incidence. Cox regression and propensity score matching (PSM) were used to evaluate the association between CD4/CD8 ratio recovery and CKD incidence, and the effect of ART regimens on CD4/CD8 ratio recovery and CKD incidence.

RESULTS

A total of 59,268 eligible individuals contributing 285,143 person-years of follow-up, with an overall CKD incidence of 9.65%. After ART, patients who developed CKD showed higher mortality than those with normal kidney function (12.48 vs. 7.57%, p < 0.001). Patients whose CD4/CD8 ratio did not recover to 0.7 had a higher CKD incidence than the patients who recovered (aHR = 2.84, 95% CI 2.63-3.07), similar to the PSM analysis (aHR = 3.13, 95% CI 2.85-3.45). Compared with the PI-based and INSTI-based regimens, NNRTI-based regimen had a better CD4/CD8 ratio recovery rate (27.04, 16.16, and 29.66%, respectively) and a lower CKD incidence (17.43, 16.16, and 7.31%, respectively).

CONCLUSION

This large-scale real-world setting provide new evidence that the CD4/CD8 ratio recovery is associated with lower CKD incidence in HIV-infected patients receiving ART. NNRTI-based is a better choice for CD4/CD8 ratio recovery and reducing the risk of CKD.

APOL1 Renal Risk Variants and Kidney Function in HIV-1–Infected People From Sub-Saharan Africa

Introduction

APOL1 G1 and G2 alleles have been associated with kidney-related outcomes in people living with HIV (PLHIV) of Black African origin. No APOL1-related kidney risk data have yet been reported in PLHIV in West Africa, where high APOL1 allele frequencies have been observed.

Methods

We collected clinical data from PLHIV followed in Burkina Faso (N = 413) and in the ANRS-12169/2LADY trial (Cameroon, Senegal, Burkina Faso, N = 369). APOL1 G1 and G2 risk variants were genotyped using TaqMan assays, and APOL1 high-risk (HR) genotype was defined by the carriage of 2 risk alleles.

Results

In West Africa (Burkina Faso and Senegal), the G1 and G2 allele frequencies were 13.3% and 10.7%, respectively. In Cameroon (Central Africa), G1 and G2 frequencies were 8.7% and 8.9%, respectively. APOL1 HR prevalence was 4.9% in West Africa and 3.4% in Cameroon. We found no direct association between APOL1 HR and estimated glomerular filtration rate (eGFR) change over time. Nevertheless, among the 2LADY cohort participants, those with both APOL1 HR and high baseline viral load had a faster eGFR progression (β = −3.9[−7.7 to −0.1] ml/min per 1.73 m² per year, P < 0.05) than those with low-risk (LR) genotype and low viral load.

Conclusion

Overall, the APOL1 risk allele frequencies in PLHIV were higher in the West African countries than in Cameroon, but much lower than previously reported in some Nigeria ethnic groups, which strongly advocates for further investigation in the African continent. This study suggested that the virological status could modulate the APOL1 impact on kidney function, hence reinforcing the need for early therapeutic interventions.

Evaluation of a Clinic Dedicated to People Aging with HIV at Chelsea and Westminster Hospital: Results of a 10-Year Experience

Successful management of HIV infection as a chronic condition has resulted in a demographic shift where the proportion of people living with HIV (PLWH) older than 50 years is steadily increasing. A dedicated clinic to PLWH older than 50 years was established at Chelsea and Westminster Hospital in January 2009 and then extended to HIV services across the directorate. We report the results of a service evaluation reviewing 10 years of activities of this clinic between January 2009 and 2019. We aimed to estimate the prevalence of major noninfectious comorbidities, polypharmacy (≥5 medications), and multimorbidity (≥2 non-HIV-related comorbidities) and describe algorithms devised for use in HIV outpatient clinics across the directorate. A cohort of 744 PLWH older than 50 years attending this service were analyzed (93% male; mean age of 56 ± 5.5 years; 84% white ethnicity); 97.7% were on antiretroviral treatment and 95.9% had undetectable HIV-RNA at the time of evaluation. The most common comorbidities diagnosed were dyslipidemia (50.1%), hypertension (21.5%), mental health disorders (depression and/or anxiety disorders, 15.7%), osteoporosis (12.2%), obesity (11.9%), chronic kidney disease (7.5%), and diabetes (5.8%). Low vitamin D levels were found in 62% of patients [43% with vitamin D deficiency (<40 mmol/liter) and 57% with vitamin D insufficiency (40-70 mmol/liter)]. The overall prevalence of polypharmacy and multimorbidity was 46.6% and 69.3%, respectively. This study showed significant rates of non-HIV-related comorbidities and polypharmacy in PLWH older than 50 years, leading on to the implementation of clinical care pathways and new joint HIV/specialty clinics (cardiology, nephrology, neurology, metabolic, menopause, and geriatric) to improve prevention, diagnosis, and management of major comorbidities in people aging with HIV.

Prevalence, incidence and predictors of renal impairment in persons with HIV receiving protease-inhibitors in rural Tanzania

Objective

Ritonavir-boosted protease inhibitors (bPI) in people living with HIV (PLWH) have been associated with renal impairment. Limited data are available from rural sub-Saharan Africa.

Methods

Using data from the Kilombero and Ulanga Antiretroviral Cohort Study (KIULARCO) in rural Tanzania from 2005-01/2020, we assessed the prevalence of renal impairment (estimated glomerular filtration rate <60 mL/min/1.73m2) at the time of switch from first-line antiretroviral treatment (ART) to bPI-regimen and the incidence of renal impairment on bPI. We assessed risk factors for renal impairment using logistic and Cox regression models.

Results

Renal impairment was present in 52/687 PLWH (7.6%) at the switch to bPI. Among 556 participants with normal kidney function at switch, 41 (7.4%) developed renal impairment after a median time of 3.5 (IQR 1.6–5.1) years (incidence 22/1,000 person-years (95%CI 16.1–29.8)). Factors associated with renal impairment at switch were older age (adjusted odds ratio (aOR) 1.55 per 10 years; 95%CI 1.15–2.11), body mass index (BMI) <18.5 kg/m² (aOR 2.80 versus ≥18kg/m²; 95%CI 1.28–6.14) and arterial hypertension (aOR 2.33; 95%CI 1.03–5.28). The risk of renal impairment was lower with increased duration of ART use (aOR 0.78 per one-year increase; 95%CI 0.67–0.91). The renal impairment incidence under bPI was associated with older age (adjusted hazard ratio 2.01 per 10 years; 95%CI 1.46–2.78).

Conclusions

In PLWH in rural sub-Saharan Africa, prevalence and incidence of renal impairment among those who were switched from first-line to bPI-regimens were high. We found associations between renal impairment and older age, arterial hypertension, low BMI and time on ART.

The Use of 'Omics for Diagnosing and Predicting Progression of Chronic Kidney Disease: A Scoping Review

Globally, chronic kidney disease (CKD) contributes substantial morbidity and mortality. Recently, various 'omics platforms have provided insight into the molecular basis of kidney dysfunction. This scoping review is a synthesis of the current literature on the use of different 'omics platforms to identify biomarkers that could be used to detect early-stage CKD, predict disease progression, and identify pathways leading to CKD. This review includes 123 articles published from January 2007 to May 2021, following a structured selection process. The most common type of 'omic platform was proteomics, appearing in 55 of the studies and two of these included a metabolomics component. Most studies (n = 91) reported on CKD associated with diabetes mellitus. Thirteen studies that provided information on the biomarkers associated with CKD and explored potential pathways involved in CKD are discussed. The biomarkers that are associated with risk or early detection of CKD are SNPs in the MYH9/APOL1 and UMOD genes, the proteomic CKD273 biomarker panel and metabolite pantothenic acid. Pantothenic acid and the CKD273 biomarker panel were also involved in predicting CKD progression. Retinoic acid pathway genes, UMOD, and pantothenic acid provided insight into potential pathways leading to CKD. The biomarkers were mainly used to detect CKD and predict progression in high-income, European ancestry populations, highlighting the need for representative 'omics research in other populations with disparate socio-economic strata, including Africans, since disease etiologies may differ across ethnic groups. To assess the transferability of findings, it is essential to do research in diverse populations.

Risk factors associated with albuminuria in Rwanda: results from a STEPS survey

BACKGROUND

Non-communicable diseases (NCDs) are a growing burden which affects every part of the world, including developing countries. Chronic kidney disease (CKD) has varied etiology which can result from or complicate other NCDs such as diabetes and cardiovascular diseases. The growing prevalence of NCDs coupled with the increasing age in most developing countries, has seen a marked increase of CKD in these settings. CKD has been described as "the most neglected NCD" and greatly affects the quality of life of patients. It also places a huge economic burden on societies. However, few epidemiological data exist, particularly in sub-Saharan Africa. Assessment of the prevalence of albuminuria as a marker of kidney damage and CKD progression and its main risk factors was thus needed in Rwanda.

METHODS

This study analyzed data collected during the first STEPwise approach to NCD risk factor Surveillance (STEPS) survey in Rwanda, conducted from 2012 to 2013, to assess the prevalence of albuminuria. A multistage cluster sampling allowed to select a representative sample of the general population. Furthermore, descriptive, as well as univariable analyses and multiple logistic regression were performed to respond to the research question.

RESULTS

This survey brought a representative sample of 6,998 participants, among which 4,384 (62.65%) were female. Median age was 33 years (interquartile range, IQR 26-44), and over three quarters (78.45%) lived in rural areas. The albuminuria prevalence was 105.9 per 1,000 population. Overall, semi-urban and urban residency were associated with lower odds of CKD (odds ratio, OR 0.36, CI 0.23-0.56, p<0.001 and OR 0.34, CI 0.23-0.50, p<0.001, respectively) than rural status. Being married or living with a partner had higher odds (OR 1.44 (CI 1.03-2.02, p=0.031) and OR 1.62 (CI 1.06-2.48, p=0.026), respectively) of CKD than being single. Odds of positive albuminuria were also greater among participants living with human immunodeficiency virus (HIV) (OR 1.64, CI 1.09- 2.47, p=0.018). Gender, age group, smoking status and vegetable consumption, body mass index (BMI) and hypertension were not associated with albuminuria.

CONCLUSION

The albuminuria prevalence was estimated at 105.9 per 1,000 in Rwanda. Rural residence, partnered status and HIV positivity were identified as main risk factors for albuminuria. Increased early screening of albuminuria to prevent CKD among high-risk groups, especially HIV patients, is therefore recommended.

Renal adverse drug reactions

PURPOSE OF REVIEW

Chronic kidney disease (CKD) is common in people living with HIV (PLWH) and is related to a multitude of factors. The aim of this review is to provide an overview of the most recent evidence of renal adverse effects of antiretroviral drugs, predictors of CKD risk and areas for future research.

RECENT FINDINGS

Advancing age, cardiometabolic risk factors and adverse effects of antiretroviral drugs contribute to the higher prevalence of CKD in PLWH. Genetic factors and baseline clinical CKD risk are strongly correlated to risk of incident CKD, although it is unclear to what extent gene polymorphisms explain renal adverse effects related to tenofovir disoproxil fumarate (TDF). Switching from TDF to tenofovir alafenamide (TAF) in people with baseline renal dysfunction improves renal parameters; however, the long-term safety and benefit of TAF in individuals at low risk of CKD is an area of ongoing research.

SUMMARY

Several factors contribute to estimated glomerular function decline and CKD in PLWH. Clinical risk scores for CKD may be useful to inform selection of ART in an ageing population. In people with baseline renal dysfunction, potentially nephrotoxic antiretroviral drugs should be avoided.

Paediatric Nephrology in Africa

PURPOSE OF REVIEW

We highlight the unique facets of paediatric nephrology in Africa in terms of the spectrum of kidney diseases, available diagnostic and treatment modalities, kidney healthcare financing options, paediatric nephrology manpower and the contribution of geography and demographics.

RECENT FINDINGS

Paediatric acute kidney injury in Africa is now commonly due to sepsis rather than gastroenteritis. Steroid-sensitive form of nephrotic syndrome is far more common than was two decades ago.

SUMMARY

The hot arid climate in North Africa and the tropical climate in most of sub-Saharan Africa, and the high rate of consanguinity, sickle cell disease and HIV drive the spectrum of paediatric kidney diseases in the continent. Kidney diseases are often precipitated by infectious triggers associated with poor living conditions and little access to medical care thus resulting in late presentation and often end-stage kidney disease. Although accessibility to kidney care has improved in the continent due to training opportunities provided by international professional organisations, most children still face significant barriers to kidney care because they live in rural areas, governments spend the least on healthcare and the continent has the least density of healthcare practitioners and nephrology trainees.

Preoperative versus Postoperative Compensation of the Contralateral Normal Kidney in Patients Treated with Radical Nephrectomy for Renal Cell Carcinoma

BACKGROUND

We sought to identify the factors affecting renal compensatory processes that occur preoperatively as well as postoperatively in patients treated with radical nephrectomy (RNx) for renal cell carcinoma (RCC).

METHODS

We retrospectively reviewed the records of 906 patients treated with RNx for RCC. We defined the early compensatory process (process 1) as compensatory adaptation of the contralateral normal kidney (CNK) before RNx. We defined the late compensatory process (process 2) as compensatory adaptation of the CNK after RNx. Total compensation was defined as the combination of these two processes. Multivariable logistic regression analyses were used to identify significant factors associated with processes 1, 2 and total compensation.

RESULTS

Mean preoperative, 1-week, and 5-year postoperative estimated glomerular filtration rates (eGFR) were 84.5, 57.6 and 63.7 mL/min/1.73 m2, respectively. Female sex (p < 0.001), lower body mass index (BMI) (p < 0.001), absence of hypertension (p = 0.019), lower preoperative eGFR (p < 0.001), larger tumor volume (p < 0.001), and larger CNK volume (p < 0.001) were significantly associated with process 1. Younger age (p = 0.019), higher BMI (p < 0.001), and absence of diabetes mellitus (DM) (p = 0.033) were significantly associated with process 2. Female sex (p < 0.001), younger age (p < 0.001), absence of DM (p = 0.002), lower preoperative eGFR (p < 0.001), and larger tumor (p = 0.001) and CNK volumes (p < 0.001) were significantly associated with total compensation.

CONCLUSIONS

Different factors affected each compensatory process. Process 1 made a greater contribution to the entire renal compensatory process than process 2.

Prevalence of Chronic Kidney Disease as a Marker of Hypertension Target Organ Damage in Africa: A Systematic Review and Meta-Analysis

Introduction

Hypertension is a major global cause of cardiovascular disease and death with rising worldwide prevalence, particularly in low-income countries. With low awareness, poor treatment, and low control of hypertension in Africans, there is an increased number of patients with target organ damage (TOD), especially chronic kidney disease (CKD), as a consequence of hypertension. The aim of our study is to assess the prevalence of CKD from studies in Africa reporting TOD related to hypertension.

Methods

We performed a search of PubMed/MEDLINE, Web of Science, EBSCOhost, and African Journals Online (AJOL) for studies reporting on CKD as TOD in patients with hypertension. The pooled estimate of CKD was then presented by subregions, age group, eGFR equations, and urban or rural location.

Results

We identified 1,334 articles from which 12 studies were included for quantitative analysis. The studies included 5297 participants from 6 countries (Ghana, Nigeria, Uganda, Tanzania, Democratic Republic of Congo, and South Africa). The pooled prevalence of CKD was 17.8% (95% CI 13.0-23.3%), and CKD was significantly more prevalent in West Africa (21.3% (95% CI: 16.1-27.0); p < 0.0001) and in studies conducted in urban settings (p < 0.001). CKD prevalence was not significantly different by type of GFR equation or age.

Conclusion

This study reports a high prevalence of CKD related to hypertension with a higher prevalence in urban than rural areas. This emphasizes the role of hypertension in causing kidney damage, and the need for strategies to improve awareness, treatment, and control of hypertension in Africans. This study is registered with PROSPERO registration number CRD42018089263.

Experience of chronic noncommunicable disease in people living with HIV: a systematic review and meta-aggregation of qualitative studies

Background

An increasing number of people living with HIV (PLWH) have had chronic noncommunicable diseases (NCDs) over the last 5 years. However, robust evidence regarding the perception and challenges of having NCDs among PLWH is limited. Therefore, this study aimed to synthesize qualitative evidence regarding the experiences of PLWH with NCDs.

Methods

We used a meta-aggregation approach to synthesize qualitative studies. Peer-reviewed and gray literature published in English and Chinese from 1996 to November 2020 was searched using electronic databases. Two reviewers independently appraised the methodological quality and extracted data from the included studies. The Joanna Briggs Institute (JBI) meta-aggregation approach was used to synthesize the findings.

Results

In total, 10,594 studies were identified in the initial database search. Fourteen eligible studies were included in the meta-synthesis. Among these studies, nine synthesized findings regarding the following topics were identified: fragmented healthcare systems, care continuity, manifestations of multiple conditions, financial hardship, stigma and discrimination, polypharmacy burden and adherence, reciprocal relationships between HIV and NCDs, and coping strategies.

Conclusions

In recent years, attempts have been made to institutionalize NCD preventive and control services in HIV long-term care. However, considering the growing problem of HIV and NCD comorbidity globally, integrated primary health care systems are needed to address the problems of PLWH with NCDs. Healthcare professionals should help PLWH develop strategies to better monitor their polypharmacy burden and adherence, stigma and discrimination, financial hardship, and manifestations of multiple conditions to achieve high levels of care continuity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11698-5.

The epidemiology of kidney disease in people of African ancestry with HIV in the UK

BACKGROUND

Chronic kidney disease (CKD) is a leading cause of morbidity and mortality globally. The risk of CKD is increased in people of African ancestry and with Human Immunodeficiency Virus (HIV) infection.

METHODS

We conducted a cross-sectional study investigating the relationship between region of ancestry (East, Central, South or West Africa) and kidney disease in people of sub-Saharan African ancestry with HIV in the UK between May 2018 and February 2020. The primary outcome was renal impairment (estimated glomerular filtration rate [eGFR] of <60 mL/min/1.73 m2). Secondary outcomes were stage 5 CKD (eGFR <15 ml/min/1.73 m2, on dialysis for over 3 months or who had received a kidney transplant), proteinuria (urine protein/creatinine ratio >50 mg/mmol), and biopsy-confirmed HIV-associated nephropathy (HIVAN), focal segmental glomerulosclerosis (FSGS) or arterionephrosclerosis. Multivariable robust Poisson regression estimated the effect of region of African ancestry on kidney disease outcomes.

FINDINGS

Of the 2468 participants (mean age 48.1 [SD 9.8] years, 62% female), 193 had renal impairment, 87 stage 5 CKD, 126 proteinuria, and 43 HIVAN/FSGS or arterionephrosclerosis. After adjusting for demographic characteristics, HIV and several CKD risk factors and with East African ancestry as referent, West African ancestry was associated with renal impairment (prevalence ratio [PR] 2.06 [95% CI 1.40-3.04]) and stage 5 CKD (PR 2.23 [1.23-4.04]), but not with proteinuria (PR 1.27 [0.78-2.05]). West African ancestry (as compared to East/South African ancestry) was also strongly associated with a diagnosis of HIVAN/FSGS or arterionephrosclerosis on kidney biopsy (PR 6.44 [2.42-17.14]).

INTERPRETATION

Our results indicate that people of West African ancestry with HIV are at increased risk of kidney disease. Although we cannot rule out the possibility of residual confounding, geographical region of origin appears to be a strong independent risk factor for CKD as the association did not appear to be explained by several demographic, HIV or renal risk factors.

Apolipoprotein-1 risk variants and associated kidney phenotypes in an adult HIV cohort in Nigeria

HIV-positive adults are at risk for various kidney diseases, and apolipoprotein 1 (APOL1) high-risk genotypes increase this risk. This study aimed to determine the prevalence and ethnic distribution of APOL1 risk genotypes among a cohort of HIV-positive Nigerian adults and explore the relationship between APOL1 risk variant status with albuminuria and estimated glomerular filtration rate (eGFR). We conducted a cross-sectional study among 2 458 persons living with HIV who attended an HIV clinic in northern Nigeria and had received antiretroviral therapy for a minimum of six months. We collected two urine samples four-eight weeks apart to measure albumin excretion, and blood samples to measure eGFR and determine APOL1 genotype. The frequency of APOL1 high-risk genotype was 6.2%, which varied by ethnic group: Hausa/Fulani (2.1%), Igbo (49.1%), and Yoruba (14.5%). The prevalence of microalbuminuria (urine/albumin creatinine ratio 30- 300 mg/g) was 37%, and prevalence of macroalbuminuria (urine/albumin creatinine ratio over 300 mg/g) was 3%. The odds of microalbuminuria and macroalbuminuria were higher for participants with the APOL1 high-risk genotype compared to those carrying the low-risk genotype ([adjusted odds ratio 1.97, 95% confidence interval 1.37-2.82] and [3.96, 1.95-8.02] respectively). APOL1 high-risk genotype participants were at higher risk of having both an eGFR under 60 ml/min/1.73m2 and urine/albumin creatinine ratio over 300 mg/g (5.56, 1.57-19.69). Thus, we found a high proportion of HIV-positive, antiretroviral therapy-experienced, and largely virologically suppressed adults had microalbuminuria. Hence, although the high-risk APOL1 genotype was less prevalent than expected, it was strongly associated with some level of albuminuria.

Renal Function Impairment and Associated Factors Among Adult HIV-Positive Patients Attending Antiretroviral Therapy Clinic in Mettu Karl Referral Hospital: Cross-Sectional Study

BACKGROUND

Human immunodeficiency virus (HIV) affects every organ system in the body through impairment or by rendering the patient vulnerable to opportunistic infections. The kidney is the vital organ in the excretion of waste products and toxins (urea, creatinine and uric acid), and regulation of extracellular fluid volume, serum osmolality and electrolyte concentrations. The risk of kidney disease is greater in HIV-infected individuals than in the general population. This study aimed to assess the magnitude of renal function impairment and its associated factors among adult HIV-positive patients attending an ART clinic in Mettu Karl Referral Hospital, Mettu town, south-west Ethiopia.

METHODS

The institution-based, cross-sectional quantitative study was conducted from March 8 to May 30, 2020. A total of 352 clients participated and a systematic sampling technique was used to allocate study participants. Data were entered into Epi data and exported to SPSS version 22 for analysis. Bivariate analysis was conducted to identify candidate variables for multivariate analysis at P <0.25. Multivariable logistic regression analysis was conducted to determine the predictors of renal function impairment with ART. P value < 0.05 was considered to indicate statistical significance.

RESULTS

A total of 352 HIV-infected patients participated in this study with a response rate of 98.1%. Out of 352 HIV patients on ART, 73 (20.7%) were found to have renal function impairment. Cigarette smoking [AOR = 9.60, 95% CI: 4.73-19.48], diabetes mellitus [AOR = 6.16, 95% CI: 2.79-13.59], hypertension [AOR = 4.71, 95% CI: 1.98-11.17] and low CD4 count [AOR = 6.47, 95% CI: 3.31-12.64] were found to be independent predictors of renal function impairment among adult HIV positive patients.

CONCLUSION

The prevalence of renal function impairment among HIV patients on ART is high. Hypertension, diabetes, cigarette smoking and low CD4 count were associated factors of renal function impairment. HIV patients on ART should be regularly screened for early diagnosis and management of renal function impairment.

Histopathological Pattern of Kidney Diseases Among HIV-Infected Treatment-Naïve Patients in Kano, Nigeria

Introduction

Kidney biopsy in patients with HIV-associated kidney diseases allows for histopathologic diagnosis and institution of appropriate treatment as well as proper prognostication. There is a paucity of data on the histopathological pattern of HIV-associated kidney diseases in most sub-Saharan African countries. This study was aimed at evaluating the histopathologic patterns of kidney diseases seen among HIV-infected treatment-naive patients in our center as this will allow for proper diagnosis and institution of appropriate treatment.

Methods

In this cross-sectional study, consecutive patients who satisfied inclusion criteria and consented to participate were recruited. Percutaneous kidney biopsies were carried out as day procedures under real-time ultrasound guidance using an automatic spring-loaded biopsy gun as per our unit protocols. Baseline investigations including urea, creatinine, electrolytes, CD4 count, complete blood count, and glomerular filtration rate (eGFR) calculations, urinalysis and urine protein creatinine ratios were done on all the participants.

Results

Fifty-five patients who satisfied the inclusion criteria were studied. The mean age of the study population was 38.34± 9.26 years, with 32% females. Mean serum creatinine was 249.6±164.6 μmol/L, and mean CD4 count was 238 ±210 cells/mL. The commonest histological type was FSGS seen in 20 patients (37.7%), followed by HIVAN seen in 17 (32.1%) patients; chronic interstitial nephritis in 7 patients (13.2%) and 6 (11%) had no significant pathological finding. Compared to non-HIVAN, HIVAN patients tended to have higher systolic BP (p= 0.05); higher serum creatinine levels (p= 0.05); lower eGFR (0.03) and higher urine protein to creatinine ratio [uPCR; p= 0.02].

Conclusion

Kidney involvement is still a form of presentation among HIV-infected treatment-naïve patients and though a wide range of glomerular and tubulointerstitial lesions may be seen, FSGS and HIVAN are still the most common. We recommend assessment of kidney function, including urinalysis, as part of the routine evaluation of newly diagnosed HIV patients and biopsy where indicated to prognosticate and institute appropriate early treatment.

A Review of Chronic Comorbidities in Adults Living With HIV: State of the Science

ABSTRACT

People living with HIV are living longer, high-quality lives; however, as they age, this population is at increased risk for developing chronic comorbidities, including cardiovascular disease, certain types of cancer (e.g., lung, anal, and liver), and diabetes mellitus. The purpose of this state-of-the-science review is to provide an evidence-based summary on common physical comorbidities experienced by people living and aging with HIV. We focus on those chronic conditions that are prevalent and growing and share behavioral risk factors that are common in people living with HIV. We will discuss the current evidence on the epidemiology, physiology, prevention strategies, screening, and treatment options for people living with HIV across resource settings.

Chronic Kidney Disease and Associated Factors Among HIV Infected Patients Taking Tenofovir Disoproxil Fumarate Based Regimen in Ethiopia: A Hospital-Based Cross-Sectional Study

Background

Life expectancy of HIV patients has increased by the extensive use of antiretroviral therapies (ART), but ART predisposes patients to chronic non-communicable diseases including chronic kidney disease (CKD). Tenofovir disoproxil fumarate is one of the commonly used drugs in ART and is found to have more risk for developing CKD. In the study areas, there was no previous study addressing the prevalence of CKD, so the purpose of this study was to pinpoint the prevalence of CKD, and its associated factors.

Methods

A hospital-based cross-sectional study was employed at Tikur Anbessa Specialized Hospital (TASH) and Zewuditu Memorial Hospital (ZMH) from April 1 to June 30, 2019. The study participants were proportionally allocated to each hospital and a total of 243 eligible participants were selected conveniently from the two hospitals in the study period. Structured questionnaire and checklist were used to collect socio-demographic and clinical data of the participants. Blood samples (3–5 ml) were used to determine serum creatinine using calibrated fully automated Mind ray BS-200E, and glomerular filtration rate (GFR) was estimated using a chronic kidney disease epidemiology equation. Multivariate logistic regression was employed to identify factors associated with CKD, and a P-value of less than 0.05 was considered significant.

Results

In the present study, the prevalence of CKD (GFR <60 ml/min/1.73 m²) was 4.53% (95% CI = 2.3–8%). GFR was classified into stages, stage 5 (GFR <15), stage 4 (15–29.9), stage 3 (30–59.9), stage 2 (60–89.9), and stage 1 (≥90) were 0%, 0.4%, 4.1%, 38.3%, and 57.2%, respectively. In the multivariate logistic regression, age greater than 50 years old, and having cancer were significantly associated with CKD (AOR: 0.22, 95% CI = 0.05–0.88, P = 0.033, and AOR: 18.20, 95% CI = 122–271.77, P = 0.035, respectively).

Conclusion

Chronic kidney disease in HIV-infected patients receiving a TDF-based regimen requires attention. Age >50 years old, and having cancer as comorbidity were significantly associated with chronic kidney disease. Patients should be regularly monitored for early diagnosis and management of chronic kidney disease in a TDF-based regimen.

COVID/HIV Co-Infection: A Syndemic Perspective on What to Ask and How to Answer

The present commentary explored the intersecting nature of the COVID-19 and HIV pandemics to identify a shared research agenda using a syndemic approach. The research agenda posits the following questions. Questions around HIV infection, transmission, and diagnosis include: (i) molecular, genetic, clinical, and environmental assessments of COVID-19 in people living with HIV, (ii) alternative options for facility-based HIV testing services such as self- and home-based HIV testing, and (iii) COVID-19 related sexual violence and mental health on HIV transmission and early diagnosis. These and related questions could be assessed using Biopsychosocial and socio-ecological models. Questions around HIV treatment include: (i) the effect of COVID-19 on HIV treatment services, (ii) alternative options for facility-based treatment provision such as community-based antiretroviral therapy groups, and (iii) equitable distribution of treatment and vaccines for COVID-19, if successful. Bickman's logic model and the social determinants of health framework could guide these issues. The impact of stigma, the role of leveraging lessons on sustained intra-behavioral change, the role of medical mistrust and conspiracy beliefs, and the role of digital health on integrated management of HIV care and spectrum of care of COVID-19 need assessment using several frameworks including Goffman's stigma framework, Luhmann's Trust theory, and Gidden's theory of structuration. In conclusion, the potential research agenda of this commentary encompasses a variety of research fields and disciplinary areas-clinicians, laboratory scientists, public health practitioners, health economists, and psychologists-, and suggests several theoretical frameworks to guide examination of complex issues comprehensively.

The burden of non-communicable diseases and mortality in people living with HIV (PLHIV) in the pre-, early- and late-HAART era

Objectives

To estimate the burden of non‐communicable diseases (NCDs) and mortality among PLHIV in the pre‐, early‐ and late‐HAART (highly active antiretroviral therapy) era.

Methods

We conducted a cohort study using population‐based Danish medical registries including all adult HIV‐infected residents of the Central Denmark Region during 1985–2017. For each HIV patient, we selected 10 comparisons from the background population matched by age, sex and municipality of residence. Based on hospital‐related diagnoses we estimated the prevalence and incidence of specific NCD at diagnosis and at 5 and 10 years.

Results

We identified 1043 PLHIV and 10 430 matched comparisons. PLHIV had lower socioeconomic status and more were born outside western Europe. At HIV diagnosis, 21.9% of PHLIV vs. 18.2% of non‐HIV individuals had at least one NCD, increasing to 42.2% vs. 25.9% after 10 years. PLHIV had higher prevalence and cumulative incidence of alcohol abuse, chronic obstructive pulmonary disease (COPD), ischaemic heart disease, mental disorders, renal and liver disease, but no increased risk of diabetes mellitus. Only PLHIV in the age groups 41–50 and > 51 years had an increased incidence of osteoporosis. From the pre‐ to the late‐HAART era, 10‐year mortality among PLHIV decreased from 45.5% to 9.4% but continued at more than twice that of uninfected comparisons. However, in the late‐HAART era, the mortality of PLHIV who were alive 2 years after HIV diagnosis was approaching that of comparisons.

Conclusions

Even in the late‐HAART era, PLHIV have an excess mortality, which may be attributable to several NCDs being more prevalent among PLHIV. The prevalence rates of ischaemic heart disease, diabetes, osteoporosis and renal disease tend to increase over calendar time. Therefore, improvement of survival and quality of life of PLHIV neets strategies to reduce the risk of developing NCDs, including avoiding toxic antiretroviral therapy and lifestyle changes.

Validation of the D: A: D Chronic Kidney Disease Risk Score Model Among People Living With HIV in the Asia-Pacific

BACKGROUND

We validated the Data collection on Adverse events of anti-HIV Drugs (D:A:D) full-risk and short-risk score models for chronic kidney disease (CKD) in the Asian HIV cohorts.

SETTINGS

A validation study among people living with HIV (PLHIV) aged ≥18 years among the cohorts in the Asia-Pacific region.

METHODS

PLHIV with a baseline estimated glomerular filtration rate > 60 mL/min/1.73 m were included for validation of the D:A:D CKD full version and short version without cardiovascular risk factors. Those with <3 estimated glomerular filtration rate measurements from baseline or previous exposure to potentially nephrotoxic antiretrovirals were excluded. Kaplan-Meier methods were used to estimate the probability of CKD development. The area under the receiver operating characteristics was also used to validate the risk score.

RESULTS

We included 5701 participants in full model {median 8.1 [interquartile range (IQR) 4.8-10.9] years follow-up} and 9791 in short model validation [median 4.9 (IQR 2.5-7.3) years follow-up]. The crude incidence rate of CKD was 8.1 [95% confidence interval (CI): 7.3 to 8.9] per 1000 person-years in the full model cohort and 10.5 (95% CI: 9.6 to 11.4) per 1000 person-years in the short model cohort. The progression rates for CKD at 10 years in the full model cohort were 2.7%, 8.9%, and 26.1% for low-risk, medium-risk, and high-risk groups, and 3.5%, 11.7%, and 32.4% in the short model cohort. The area under the receiver operating characteristics for the full-risk and short-risk score was 0.81 (95% CI: 0.79 to 0.83) and 0.83 (95% CI: 0.81 to 0.85), respectively.

CONCLUSION

The D:A:D CKD full-risk and short-risk score performed well in predicting CKD events among Asian PLHIV. These risk prediction models may be useful to assist clinicians in identifying individuals at high risk of developing CKD.

Current Management Strategies of Chronic Kidney Disease in Resource-Limited Countries

The incidence and prevalence of chronic kidney disease (CKD) and kidney failure continues to increase worldwide, especially in resource-limited countries. Many countries in this category already have a massive burden of communicable diseases, as well as socio-economic and socio-demographic challenges. The rising CKD burden and exorbitant economic cost associated with treatment are mainly responsible for the alarming mortality rate associated with kidney disease in these regions. There is often poor risk factor (diabetes and hypertension) and CKD awareness in these countries and limited availability and affordability of treatment options. Given these observations, early disease detection and preventive measures remain the best options for disease management in resource-limited settings. Primary, secondary and tertiary preventive strategies need to be enhanced and should particularly include measures to increase awareness, regular assessment to detect hypertension, diabetes and albuminuria, options for early referral of identified patients to a nephrologist and options for conservative kidney management where kidney replacement therapies may not be available or indicated. Much is still needed to be done by governments in these regions, especially regarding healthcare funding, improving the primary healthcare systems and enhancing non-communicable disease detection and treatment programs as these will have effects on kidney care in these regions.

Pharmacotherapeutic options for kidney disease in HIV positive patients

INTRODUCTION

Since the developmentof combined antiretroviral therapy (cART), HIV-associated mortality and the incidence of HIV-associated end-stage kidney disease (ESKD) has decreased. However, in the United States, an increase in non-HIV-associated kidney diseases within the HIV-positive population is expected.

AREAS COVERED

In this review, the authors highlight the risk factors for kidney disease within an HIV-positive population and provide the current recommendations for risk stratification and for the monitoring of its progression to chronic kidney disease (CKD), as well as, treatment. The article is based on literature searches using PubMed, Medline and SCOPUS.

EXPERT OPINION

The authors recommend clinicians (1) be aware of early cART initiation to prevent and treat HIV-associated kidney diseases, (2) be aware of cART side effects and discriminate those that may become more nephrotoxic than others and require dose-adjustment in the setting of eGFR ≤ 30ml/min/1.73m², (3) follow KDIGO guidelines regarding screening and monitoring for CKD with a multidisciplinary team of health professionals, (4) manage other co-infections and comorbidities, (5) consider changing cART if drug induced toxicity is established with apparent eGFR decline of ≥ 10ml/min/1.73m² or rising creatinine (≥0.5mg/dl) during drug-drug interactions, and (6) strongly consider kidney transplant in appropriately selected individuals with end stage kidney failure.

Podocytopathies

Podocytopathies are kidney diseases in which direct or indirect podocyte injury drives proteinuria or nephrotic syndrome. In children and young adults, genetic variants in >50 podocyte-expressed genes, syndromal non-podocyte-specific genes and phenocopies with other underlying genetic abnormalities cause podocytopathies associated with steroid-resistant nephrotic syndrome or severe proteinuria. A variety of genetic variants likely contribute to disease development. Among genes with non-Mendelian inheritance, variants in APOL1 have the largest effect size. In addition to genetic variants, environmental triggers such as immune-related, infection-related, toxic and haemodynamic factors and obesity are also important causes of podocyte injury and frequently combine to cause various degrees of proteinuria in children and adults. Typical manifestations on kidney biopsy are minimal change lesions and focal segmental glomerulosclerosis lesions. Standard treatment for primary podocytopathies manifesting with focal segmental glomerulosclerosis lesions includes glucocorticoids and other immunosuppressive drugs; individuals not responding with a resolution of proteinuria have a poor renal prognosis. Renin-angiotensin system antagonists help to control proteinuria and slow the progression of fibrosis. Symptomatic management may include the use of diuretics, statins, infection prophylaxis and anticoagulation. This Primer discusses a shift in paradigm from patient stratification based on kidney biopsy findings towards personalized management based on clinical, morphological and genetic data as well as pathophysiological understanding.

Renal function in Ethiopian HIV-positive adults on antiretroviral treatment with and without tenofovir

Background

Limited data are available on the effect of antiretroviral treatment (ART) or Tenofovir disoproxil fumarate (TDF) on renal function in Ethiopians. We aimed to assess factors associated with renal function changes during the first year of ART with special focus on TDF.

Methods

HIV positive persons who were ≥ 18 years of age and eligible for ART initiation were recruited. Creatinine measurement to estimate glomerular filtration rate (eGFR) and spot urine analyses were performed at baseline and after 3, 6 and 12 months of ART. Univariate and multivariate linear regression and univariate logistic regression were used to determine factors associated with eGFR as continuous and categorical variable respectively. A linear mixed model was used to assess 12 month eGFR difference in TDF and non-TDF based regimen.

Result

Of 340 ART-naïve HIV patients with baseline renal function tests, 82.3% (279/339) were initiated on a TDF based ART regimen. All patients were on non-nucleoside reverse transcriptase inhibitors (NNRTI) based ART regimen. The median (IQR) change in eGFR with 12 months of ART was 0.8 (− 11.1; 10.0) ml/min/1.73m². About 41 and 26.9% of HIV patients had a drop of greater than 3 and 10 mL/min/1.73 m² in eGFR at 12 month, respectively. However, none of the HIV patients declined to < 60 ml/min/1.73m² within 12 months. Moreover, none of the HIV patients had persistent proteinuria or glycosuria. Older HIV patients especially age > 45 years and those with unsuppressed viral load at 6 month of ART had a significantly lower eGFR at 12 months of ART initiation. However, there was no difference in 12 month eGFR between HIV patients initiated on TDF based regimen and non-TDF based regimen.

Conclusion

Renal function remained stable with no difference between HIV patients treated with TDF or non-TDF NNRTI based ART regimen over 12 months. However, older HIV patients and those with unsuppressed viral load deserve special focus on renal monitoring. Data on long-term safety of TDF (> 1 year) is still warranted in this population.

Factors associated to chronic kidney disease in people living with HIV/AIDS

OBJECTIVE

to analyze the factors associated to chronic kidney disease in people living with HIV (PLHIV).

METHOD

a paired case-control study (4 controls for each case) carried out in a specialized care service in the Southeastern of Brazil, by analyzing PLHIV medical records. The sample consisted of 85 participants, corresponding to 17 cases and 68 controls. Pearson's chi-square test (Χ2) and Fisher's exact test, logistic regression, Odds Ratio (OR), 95% Confidence Interval (CI) and p<0.05 were used. SPSS version 25.0 and R Core Team, 2018 version 3.5.1 were used.

RESULTS

the factors associated with chronic kidney disease identified in this study were the following: presence of Systemic Arterial Hypertension [OR=5.8, CI (95%)=1.84-18.42, p=0.001] and use of nephrotoxic anti-retrovirals in the previous therapeutic regimen [OR=3.3, CI (95%)=1.105-10.221, p=0.028]. On the other hand, age below 40 years old [OR: 0.122, CI (95%)=0.015-0.981, p=0.022] was identified as a protective factor.

CONCLUSION

the PLHIV under study have multi-factorial exposure associated with chronic kidney disease. However, knowing these factors helps to identify the existing risks and/or renal dysfunction, in addition to supporting the clinical decision of the health professionals who directly assist them.

Concurrent administration with multivalent metal cation preparations or polycationic polymer preparations inhibits the absorption of raltegravir via its chelation

OBJECTIVES

Raltegravir (RAL) that can form chelates with multivalent metal cations shows lateral interactions with multivalent metal cation and polycationic polymer. We investigated the interactions of RAL with multivalent metal cation preparations, Al(OH)₃ and LaCO₃ , and polycationic polymer preparations, bixalomer (Bxl) and sevelamer (Svl).

METHODS

Immediately before the oral administration of 40 mg/kg RAL, the rats were administered orally with the vehicle, Al(OH)₃ , LaCO₃ , Bxl, or Svl, and the time course of RAL serum concentration was followed. The in vitro binding affinity of RAL with multivalent metal cation and polycationic polymer was also evaluated using isothermal titration calorimetry (ITC).

RESULTS

When Al(OH)₃ , LaCO₃ , Bxl, or Svl was concomitantly administered with RAL, the maximum concentration and area under the curve were significantly lower than those when RAL was administered alone. ITC showed the interaction of RAL with Al(OH)₃ as an enthalpy-driven reaction and its interactions with LaCO₃ and Bxl as entropy-enthalpy mixed reactions.

CONCLUSIONS

The interaction of RAL with Al(OH)₃ , LaCO_3, Bxl, or Svl can inhibit RAL absorption into the gastrointestinal tract, and thus, the multivalent metal cation and polycationic polymer are the modifying factors that can affect RAL pharmacokinetics.

Association of Genetic Polymorphisms of TGF-β1, HMOX1, and APOL1 With CKD in Nigerian Patients With and Without HIV

RATIONALE & OBJECTIVE

Recent studies in the human immunodeficiency virus (HIV)-infected population have suggested that there are genetic predispositions to the development of chronic kidney disease (CKD) in this context. We investigated the association of genetic polymorphisms of the genes encoding apolipoprotein L1 (APOL1), transforming growth factor β1 (TGF-β1; a profibrotic cytokine), and heme oxygenase 1 (HMOX1) with prevalent CKD among adults with and without HIV infection.

STUDY DESIGN

Case-control study.

SETTING & PARTICIPANTS

West African adults including 217 HIV-infected patients with CKD (HIV⁺/CKD⁺ group), 595 HIV-infected patients without CKD (HIV⁺/CKD^- group), 269 with CKD and no HIV infection (HIV^-/CKD⁺ group), and 114 with neither CKD nor HIV (HIV^-/CKD^- group).

EXPOSURE

The genetic polymorphisms with reference single-nucleotide polymorphism (rs) identification numbers rs1800469 (TGF-β1), rs1800470 (TGF-β1), rs121918282 (TGF-β1); rs60910145 (APOL1 G1 risk allele), rs73885319 (APOL1 G1 risk allele), rs71785313 (APOL1 G2 risk allele), and rs743811 (HMOX1); HIV.

OUTCOME

CKD.

ANALYTICAL APPROACH

Single-nucleotide polymorphism (SNP) genotyping of rs1800469 (TGF-β1), rs1800470 (TGF-β1), rs121918282 (TGF-β1); rs60910145 (APOL1), rs73885319 (APOL1), rs71785313 (APOL1), and rs743811 (HMOX1) was performed. Hardy-Weinberg equilibrium was evaluated for all SNPs, and minor allele frequencies were reported. A case-control analysis was performed, and multivariable logistic regression was used to control for potential confounders.

RESULTS

Minor allele frequencies for TGF-β1 (rs1800469, rs1800470, and rs1800471), APOL1 (rs60910145, rs73885319, and rs71785313), and HMOX1 (rs743811) were 0.25, 0.46, 0.46, 0.44, 0.45, 0.17, and 0.14, respectively. Among HIV-positive individuals, only TGF-β1 rs1800470 (GG vs AA), APOL1 (in the recessive model), and hypertension were associated with prevalent CKD (adjusted ORs of 0.44 [95% CI, 0.20-0.97], 2.54 [95% CI, 1.44-4.51], and 2.17 [95% CI, 1.35-3.48], respectively). No SNP polymorphisms were associated with prevalent CKD among HIV-negative individuals.

LIMITATIONS

The lack of histopathology data for proper categorization of the type of HIV-related nephropathy.

CONCLUSIONS

APOL1 polymorphisms were highly prevalent in this population and among adult patients infected with HIV and were associated with increased CKD risk. The TGF-β1 (rs1800470) polymorphism was associated with reduced risk, and HMOX1 polymorphisms were unassociated with CKD.

Prevalence of renal dysfunction and associated risk factors among HIV patients on ART at the Bamenda Regional Hospital, Cameroon

Since the advent of the management of HIV/AIDS using combination antiretroviral therapy (ART), the leading causes of morbidity and mortality in people living with HIV (PLWH) have changed from infectious to non-infectious causes with kidney disease increasingly emerging as being significant. Despite the introduction of the ‘test and treat’ strategy in Cameroon, there are still few data available on the effect of ART on renal function. Thus, this study aimed to determine the prevalence of renal dysfunction among PLWH on ART and its associated risk factors. We conducted a hospital-based comparative cross-sectional study involving PLWH naïve to ART and those on ART. Spectrophotometry was used to quantify renal markers. Glomerular filtration rate was estimated by the creatinine clearance (CrCl) method. Participants with CrCl <60 ml/min/1.73 m2 were considered to have renal dysfunction. A total of 136 participants were recruited of which 97 (71.3%) were females. The mean age was 39.5 ± 9.2 years. Each study category had the same number of participants (68 each). Both had a prevalence of proteinuria of 50%. Of the total study population, 26 (19.1%) had CrCl <60 ml/min/1.73 m2. About 82.4% of the participants on ART were on tenofovir-based regimens with a mean duration of treatment of 6.95 ± 3.74 years. The ART-experienced group had a prevalence of renal dysfunction of 26.5% and the ART-naïve group 11.8%. The difference in mean CrCl between the study groups was not statistically significant. There was no association between renal dysfunction and the ART regimen, duration on treatment, or adherence to treatment. Our study demonstrated a high prevalence of renal dysfunction among PLWH that was associated with increasing age. Decreased CD4 cell count increased the risk of proteinuria.

Contemporary issues and new challenges in chronic kidney disease amongst people living with HIV

Chronic kidney disease (CKD) is a comorbidity of major clinical significance amongst people living with HIV (PLWHIV) and is associated with significant morbidity and mortality. The prevalence of CKD is rising, despite the widespread use of antiretroviral therapy (ART) and is increasingly related to prevalent non-infectious comorbidities (NICMs) and antiretroviral toxicity. There are great disparities evident, with the highest prevalence of CKD among PLWHIV seen in the African continent. The aetiology of kidney disease amongst PLWHIV includes HIV-related diseases, such as classic HIV-associated nephropathy or immune complex disease, CKD related to NICMs and CKD from antiretroviral toxicity. CKD, once established, is often relentlessly progressive and can lead to end-stage renal disease (ESRD). Identifying patients with risk factors for CKD, and appropriate screening for the early detection of CKD are vital to improve patient outcomes. Adherence to screening guidelines is variable, and often poor. The progression of CKD may be slowed with certain clinical interventions; however, data derived from studies involving PLWHIV with CKD are sparse and this represent an important area for future research. The control of blood pressure using angiotensin converting enzyme inhibitors and angiotensin receptor blockers, in particular, in the setting of proteinuria, likely slows the progression of CKD among PLWHIV. The cohort of PLWHIV is facing new challenges in regards to polypharmacy, drug-drug interactions and adverse drug reactions. The potential nephrotoxicity of ART is important, particularly as cumulative ART exposure increases as the cohort of PLWHIV ages. The number of PLWHIV with ESRD is increasing. PLWHIV should not be denied access to renal replacement therapy, either dialysis or kidney transplantation, based on their HIV status. Kidney transplantation amongst PLWHIV is successful and associated with an improved prognosis compared to remaining on dialysis. As the cohort of PLWHIV ages, comorbidity increases and CKD becomes more prevalent; models of care need to evolve to meet the new and changing chronic healthcare needs of these patients.

Global, regional, and national burden of chronic kidney disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Health system planning requires careful assessment of chronic kidney disease (CKD) epidemiology, but data for morbidity and mortality of this disease are scarce or non-existent in many countries. We estimated the global, regional, and national burden of CKD, as well as the burden of cardiovascular disease and gout attributable to impaired kidney function, for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017. We use the term CKD to refer to the morbidity and mortality that can be directly attributed to all stages of CKD, and we use the term impaired kidney function to refer to the additional risk of CKD from cardiovascular disease and gout.

METHODS

The main data sources we used were published literature, vital registration systems, end-stage kidney disease registries, and household surveys. Estimates of CKD burden were produced using a Cause of Death Ensemble model and a Bayesian meta-regression analytical tool, and included incidence, prevalence, years lived with disability, mortality, years of life lost, and disability-adjusted life-years (DALYs). A comparative risk assessment approach was used to estimate the proportion of cardiovascular diseases and gout burden attributable to impaired kidney function.

FINDINGS

Globally, in 2017, 1·2 million (95% uncertainty interval [UI] 1·2 to 1·3) people died from CKD. The global all-age mortality rate from CKD increased 41·5% (95% UI 35·2 to 46·5) between 1990 and 2017, although there was no significant change in the age-standardised mortality rate (2·8%, -1·5 to 6·3). In 2017, 697·5 million (95% UI 649·2 to 752·0) cases of all-stage CKD were recorded, for a global prevalence of 9·1% (8·5 to 9·8). The global all-age prevalence of CKD increased 29·3% (95% UI 26·4 to 32·6) since 1990, whereas the age-standardised prevalence remained stable (1·2%, -1·1 to 3·5). CKD resulted in 35·8 million (95% UI 33·7 to 38·0) DALYs in 2017, with diabetic nephropathy accounting for almost a third of DALYs. Most of the burden of CKD was concentrated in the three lowest quintiles of Socio-demographic Index (SDI). In several regions, particularly Oceania, sub-Saharan Africa, and Latin America, the burden of CKD was much higher than expected for the level of development, whereas the disease burden in western, eastern, and central sub-Saharan Africa, east Asia, south Asia, central and eastern Europe, Australasia, and western Europe was lower than expected. 1·4 million (95% UI 1·2 to 1·6) cardiovascular disease-related deaths and 25·3 million (22·2 to 28·9) cardiovascular disease DALYs were attributable to impaired kidney function.

INTERPRETATION

Kidney disease has a major effect on global health, both as a direct cause of global morbidity and mortality and as an important risk factor for cardiovascular disease. CKD is largely preventable and treatable and deserves greater attention in global health policy decision making, particularly in locations with low and middle SDI.

FUNDING

Bill & Melinda Gates Foundation.

Therapeutic management of HIV-infected patients with chronic kidney disease

CKD and HIV infection are two chronic diseases impacting heavily on the survival of the affected patients. The interplay between HIV infection and chronic kidney disease (CKD) is complex and interactions occur at multiple levels. Approach to the management of HIV-infected patients requires special attention to face the numerous therapeutic difficulties ranging from drug-drug interactions to drug-toxicity. The most effective strategy is targeted to suppression of HIV viral load, as it dramatically changes the prognosis of the patients as well as prevents the development of HIV-associated kidney disease. As shown in this review, the approach to the therapeutic management of CKD in the setting of HIV infection varies in relation to the degree of renal impairment.

Optimizing antiretroviral regimens in chronic kidney disease

PURPOSE OF REVIEW

To identify recent data that inform the management of individuals with HIV and chronic kidney disease.

RECENT FINDINGS

Several nonnucleoside reverse transcriptase, protease, and integrase strand transfer inhibitors inhibit tubular creatinine secretion resulting in stable reductions in creatinine clearance of 5-20 ml/min in the absence of other manifestations of kidney injury. Progressive renal tubular dysfunction is observed with tenofovir disoproxil fumarate in clinical trials, and more rapid decline in estimated glomerular filtration rate in cohort studies of tenofovir disoproxil fumarate and atazanavir, with stabilization, improvement or recovery of kidney function upon discontinuation. Results from clinical trials of tenofovir alafenamide (TAF) in individuals with chronic kidney disease suggest that TAF is well tolerated in those with mild to moderate renal impairment (creatinine clearance >30 ml/min) but results in very high tenofovir exposures in those on haemodialysis.

SUMMARY

Standard antiretroviral regimens remain appropriate for individuals with normal and/or stable, mildly impaired kidney function. In those with chronic kidney disease or progressive decline in estimated glomerular filtration rate, antiretrovirals with nephrotoxic potential should be avoided or discontinued. Although TAF provides a tenofovir formulation for individuals with impaired kidney function, TAF is best avoided in those with severe or end-stage kidney disease.

The agreement between fasting glucose and markers of chronic glycaemic exposure in individuals with and without chronic kidney disease: a cross-sectional study

Background

To assess whether the agreement between fasting glucose and glycated proteins is affected by chronic kidney disease (CKD) in a community-based sample of 1621 mixed-ancestry South Africans.

Methods

CKD was defined as an estimated glomerular filtration rate < 60 ml/min/1.73 m². Fasting plasma glucose and haemoglobin A1c (HbA1c) concentrations were measured by enzymatic hexokinase method and high-performance liquid chromatography, respectively, with fructosamine and glycated albumin measured by immunoturbidimetry and enzymatic method, respectively.

Results

Of those with CKD (n = 96), 79, 16 and 5% where in stages 3, 4 and 5, respectively. Those with CKD had higher levels of HbA1c (6.2 vs. 5.7%; p < 0.0001), glycated albumin (15.0 vs. 13.0%; p < 0.0001) and fructosamine levels (269.7 vs. 236.4 μmol/l; p < 0.0001), compared to those without CKD. Higher fasting glucose levels were associated with higher HbA1c, glycated albumin and fructosamine, independent of age, gender, and CKD. However, the association with HbA1c and glycated albumin differed by CKD status, at the upper concentrations of the respective markers (interaction term for both: p ≤ 0.095).

Conclusion

Our results suggest that although HbA1c and glycated albumin perform acceptably under conditions of normoglycaemia, these markers correlate less well with blood glucose levels in people with CKD who are not on dialysis.

Validation of the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) chronic kidney disease risk score in HIV-infected patients in the USA

Objectives

The aim of the study was to assess the validity of an easy‐to‐calculate chronic kidney disease (CKD) risk score developed by the Data Collection on Adverse Events of Anti‐HIV Drugs (D:A:D) group in a longitudinal observational study of people living with HIV (PLWH) in the USA.

Methods

PLWH (2002–2016) without prior exposure to potentially nephrotoxic antiretroviral agents and with at least three estimated glomerular filtration rate (eGFR) test results were identified in the Observational Pharmaco‐Epidemiology Research and Analysis (OPERA^®) cohort. Three samples were drawn independently using the same eligibility criteria but each using a different eGFR equation, specifically the Cockcroft–Gault (C‐G), Modification of Diet in Renal Disease (MDRD) or Chronic Kidney Disease Epidemiology Collaboration (CKD‐EPI) eGFR estimation method. Full and short D:A:D risk scores were applied. CKD was defined as a confirmed decrease in eGFR to < 60 mL/min/1.73 m² (stages 3–5). Poisson models estimated the association between CKD incidence and a one‐point increase in the continuous risk score. The incidence rate ratio (IRR), adjusted IRR (aIRR), and Harrell's discrimination statistic were used to assess validity.

Results

There were 19 444, 22 727 and 22 748 PLWH in the OPERA C‐G, CKD‐EPI and MDRD samples, respectively. The median (minimum–maximum) follow‐up duration was 6.1 (0.3–9.1) years in the D:A:D cohort and ranged from 3.2 to 3.5 (0.2–15.5) years in the OPERA validation samples. The observation time for the majority of PLWH in the D:A:D cohort began prior to 2006, in stark contrast to the OPERA validation samples, where the majority of PLWH were observed after 2011. The CKD incidence ranged from 7.3 per 1000 person‐years [95% confidence interval (CI) 6.8, 7.9 per 1000 person‐years] in OPERA C‐G to 11.0 (95% CI 10.4, 11.6 per 1000 person‐years) in OPERA MDRD. In OPERA samples, IRRs by risk group and adjusted IRRs (full risk score) were similar to those in the D:A:D derivation cohort (adjusted IRR 1.3; 95% CI 1.3, 1.3). Harrell's c‐statistic ranged from 0.87 to 0.92 in the OPERA samples, comparable to that in the derivation cohort (0.92). Results for short scores were similar.

Conclusions

The findings support the validity of the D:A:D risk scoring method for assessing CKD (stages 3–5) probability in an exclusively USA‐based sample regardless of eGFR method.

Preventing CKD in Low- and Middle-Income Countries: A Call for Urgent Action

The epidemiologic transition occurring in low- and middle-income countries (LMICs) has led to a surge in chronic kidney disease (CKD) prevalence because of a combination of highly prevalent chronic noncommunicable diseases (NCDs) and communicable diseases (CDs). The progressive rise in CKD prevalence in LMICs threatens the existing weak health systems in these countries as care for advanced CKD remains largely unavailable and unaffordable. An interplay of low literacy levels, poor health-seeking behavior, inadequate health care funding, weak health systems, and lack of skilled nephrology workforce has made it difficult for adequate CKD preventive measures to be implemented. Primary, secondary, and tertiary prevention measures need to be instituted in LMICs by a collaboration of governmental and nongovernmental organizations to stem this tide and help prevent deaths from other NCDs that share similar risk factors with CKD. For these to be effective, locally relevant knowledge is needed to contextualize existing prevention and control solutions, or to develop novel and more appropriate solutions for LMICs.

Chronic Kidney Disease Risk in African and Caribbean Populations With HIV

We conducted an observational cohort study of end-stage kidney disease (ESKD) in >7000 African and Caribbean people with HIV in the UK. Using Poisson regression and East Africans as the reference group, the adjusted incidence rate ratio (95% confidence interval) of ESKD was 3.14 (1.26–7.84) in Southern Africans, 6.35 (2.53–15.96) in West Africans, and 5.26 (1.91–14.43) in Caribbeans. Higher CD4 cell count and suppressed HIV replication were associated with reduced risk of ESKD. The risk of ESKD varied among HIV-positive people of African heritage, with the highest rates observed in those of West African descent.

Kidney Disease in HIV Infection

Antiretroviral therapy (ART) has significantly improved life expectancy of infected subjects, generating a new epidemiological setting of people aging withHuman Immunodeficiency Virus (HIV). People living with HIV (PLWH), having longer life expectancy, now face several age-related conditions as well as side effects of long-term exposure of ART. Chronic kidney disease (CKD) is a common comorbidity in this population. CKD is a relentlessly progressive disease that may evolve toward end-stage renal disease (ESRD) and significantly affect quality of life and risk of death. Herein, we review current understanding of renal involvement in PLWH, mechanisms and risk factors for CKD as well as strategies for early recognition of renal dysfunction and best care of CKD.

Prevalence of chronic kidney disease among HIV-1-infected patients receiving a combination antiretroviral therapy

BACKGROUND

Chronic kidney disease (CKD) has become one of the most frequent non-infectious comorbidities in the aging HIV-infected population on long-standing combination antiretroviral therapy (cART).

METHODS

We conducted a retrospective, cross-sectional study including HIV-infected adult patients attending our HIV outpatient clinic during the years 2017 and 2018 to assess prevalence and associated risk factors of CKD. Estimated glomerular filtration rate (eGFR) was measured by Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation. CKD was diagnosed and classified according to the National Kidney Foundation guidelines. Logistic regression was employed to identify factors associated with CKD.

RESULTS

We enrolled 2339 HIV-infected patients (91% were Caucasian) with a mean age of 45.3 years and a mean current CD4 lymphocyte count of 531 cells/mm³. CKD was diagnosed in 311 subjects (13.3%). Overall, 294 (12.6%) patients had albuminuria, 108 (4.6%) had eGFR < 60 mL/min/1.73 m², and 78 (3.3%) had albuminuria plus eGFR < 60 mL/min/1.73 m². Stages 4-5 of CKD were documented in 23 (1%) cases. Age greater than 50 years, male gender, hypertension, diabetes mellitus, high triglycerides, nadir CD4 cell count < 200 cells/mm³, current use of tenofovir disoproxyl fumarate (TDF) and of TDF plus a ritonavir-boosted protease inhibitors were independently associated with CKD, while current use of abacavir plus one integrase inhibitor was associated with a reduced risk of CKD.

CONCLUSION

There is a significant prevalence of CKD among HIV-infected persons in association with both traditional and HIV-specific risk factors, requiring a careful periodic monitoring of renal function in these patients.

Clinical characteristics and outcome of HIV infected patients with chronic kidney disease in Sub Saharan Africa: an example from in Cameroon

BACKGROUND

Chronic kidney disease (CKD) is one of the major complications of Human immune deficiency Virus (HIV) and a risk factor for poor outcome of these patients. We aimed to describe the profile and outcome of HIV positive patients with CKD in Douala general hospital in Cameroon.

METHODS

HIV positive patients with CKD referred to the nephrologist from January 2007 to March 2013 were included. Socio demographic, clinical (history and stage of HIV, comorbidities, baseline nephropathy, used of c-ART), para clinical data at referral (serum urea, creatinine, full blood count, CD4 count, serum calcium, phosphorus, albumin), dialysis initiation and outcome at 1 year were collected from medical records. GFR was estimated using Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. CKD was defined and classified according to the Kidney Disease Improving Global Outcomes (KDIGO 2012).

RESULTS

We included 156 patients (51.3% men) with a mean age of 45.4 ± 12.1 years. Hypertension (36.5%), diabetes (17.9%) and Hepatitis C (7.7%) were the main comorbidities. HIV associated nephropathy (27.6%), chronic glomerulonephritis (15.4%) diabetes (14.1%) and hypertension (13.5%) were the leading causes of kidney disease. Before referral HIV status was known by 109 (69.9%) patients, with 76 (69.7%) being on c-ART. Median CD4 count was 241 (117-438) cells/mm3. Prevalence of anemia (93.9%), hypocalcemia (68.6%) and Proteinuria (77.6%) was high, 94 (60.3%) patients were at CKD stage 5 at referral and 37 (23.7%) underwent emergency dialysis. After 1 year, 64 (41.0%) patients were lost to follow up. The mortality rate was 49% and 25 (28.7%) were maintenance hemodialysis, and being on c-ART was associated with a lower risk of death (HR: 0.45; 95% CI: 0.23-0.89; p = 0.021).

CONCLUSION

HIV patients with CKD were referred late with high morbidity and need for urgent hemodialysis. HIVAN was the main etiology of CKD and mortality rate was high mainly due to the absence of c-ART at referral.

Chronic kidney disease and HIV in the era of antiretroviral treatment: findings from a 10-year cohort study in a west African setting

Background

It has been reported that people living with HIV in West Africa exhibited the highest risks for chronic kidney disease (CKD) in the world. Here, we aimed at determining the CKD frequency and changes in kidney function during antiretroviral treatment (ART) in a large cohort of HIV-patients followed in Burkina Faso.

Methods

We included ART-naive adults who initiated ART at the Day Care Unit of the Souro Sanou University Hospital between 01/01/2007 and 12/31/2016. We assessed the estimated glomerular filtration rate (eGFR) by serum creatinine using the Modification of Diet in Renal Disease (MDRD) equation. Following the K/DOQI recommendations, CKD was defined as eGFR < 60 ml/min/1.73m² at two consecutive measurements at least 3 months apart. The factors associated with eGFR decline or CKD were identified by mixed linear regression and Cox regression, respectively.

Results

Three thousand, one hundred and thirty-eight patients (72% women) were followed for a median (IQR) of 4.5(2.2–6.9) years. At baseline, median eGFR (IQR) was 110.7(94.4–128.4) ml/min/1.73m² and 93 (3%) patients exhibited eGFR < 60 ml/min/1.73m². The lowest-performing progressions of eGFR during the first year of ART were observed in patients with 40-49 yr. age range (− 8.3[− 11.7;-5.0] ml/min/1.73m², p < 0.001), age ≥ 50 yr. (− 6.2[− 10.7;-1.8] ml/min/1.73m², p = 0.006) and high blood pressure (HBP) (− 28.4[− 46.9;-9.9] ml/min/1.73m², p = 0.003) at ART initiation. Regarding the ART exposure in patients with normal baseline eGFR, zidovudine (AZT) with protease inhibitor (PI) (− 4.7[− 7.7;-1.6] ml/min/1.73m², p = 0.002), tenofovir (TDF) + PI (− 13.1[− 17.4;-8.7] ml/min/1.73m², p < 0.001), TDF without PI (− 3.2[− 5.0;-1.4] ml/min/1.73m², p < 0.001), stavudine (d4T) + PI (− 8.5[− 14.6–2.4] ml/min/1.73m², p = 0.006) and d4T without PI (− 5.0[− 7.6–2.4] ml/min/1.73m², p < 0.001) were associated with poorer eGFR progression. The prevalence of CKD was 0.5% and the incidence was 1.9 [1.3; 2.7] cases/1000 person-years. The risk of CKD was higher in patients with HBP (4.3[1.8;9.9], p = 0.001), 40-49 yr. patients (4.2[1.6;11.2], p = 0.004), ≥50 yr. patients (4.5[1.5;14.1], p = 0.009) and patients exposed to abacavir (ABC) or didanosine (ddI) based ART (13.1[4.0;42.9], p < 0.001).

Conclusions

Our findings do not confirm the high risk of CKD reported in previous studies of West Africans with HIV, but support the recommendations for early initiation of ART and close kidney function monitoring in patients with HBP or aged ≥40 yr.

Clinical spectrum of renal disease in hospitalized HIV/AIDS patients: A teaching hospital experience

Background:

Renal involvement in HIV patients is relatively common and quite broad. However, despite an increasingly large number of HIV patients in Asia, systematic studies of renal involvement are lacking.

Objectives:

The study was carried out to delineate the clinical spectrum of renal disease in HIV/AIDS patients hospitalised in a tertiary care centre.

Patients and Methods:

A total of 510 consecutive hospitalised HIV/AIDS with age >18years were included in the study. Detailed demographic, clinical and laboratory data including urinalysis was obtained from all participants.

Results:

Electrolyte disorders were seen in 71% of patients, with the most frequent being hyponatremia (61%). Acute renal failure was seen in 15.8% and CKD was found in 13% of HIV patients. Dipstick proteinuria of grade ≥1+ was seen in 147 patients (29% of total). CD4 count had a significant positive correlation with creatinine clearance, hyponatremia and total leukocyte count, and significant negative correlation with duration of disease and proteinuria.

Conclusion:

Electrolyte disorders and renal involvement are quite common in HIV/AIDS patients from India. Prompt diagnosis and management is required as their presence carry higher morbidity and mortality.

Chronic kidney disease in patients infected with human immunodeficiency virus (HIV) in an urban cohort

BACKGROUND AND OBJECTIVES

HIV-infected patients are at risk for developing chronic kidney disease (CKD), defined by estimated glomerular filtration rate (eGFR) <60 ml/min/1.73m2. Our purpose was to understand the genesis of CKD in HIV patients from a large urban clinic in Houston, Texas, USA, and to characterize progression of CKD in the cohort.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

A retrospective cohort study (2012-2016) was conducted in all HIV-infected patients seen in a federally qualified community health center in Houston, Texas. CKD prevalence and its association with HIV viral load and CD4 count were determined. The association of the change in eGFR over time and comorbidities was assessed using linear mixed models.

RESULTS

Of 3714 HIV-infected patients analyzed, 153 (4.1%) had CKD. The prevalence of CKD in the different racial groups was 5.4% White, 4.0% African American, 2.8% Hispanic/Latino and 3.2% Asian. There was no difference in the rate of decline in kidney function in White vs. African American HIV infected patients with CKD. Compared with non-CKD patients, CKD patients were older, had lived longer with HIV infection, had lower CD4 cell counts, higher proportions of hypertension, hyperlipidemia, and cerebrovascular disease, and had significantly higher rates of eGFR deterioration represented by a median decrease of 26.5% from first to last follow-up eGFR (versus 0% change). Linear mixed modeling identified older age, male gender, White race, longer time with HIV infection, hypertension, history of kidney stones, cerebrovascular disease, autoimmune disease, increased potassium and total cholesterol levels, and being treated with combination ART as associated with a worsening eGFR over time.

CONCLUSION

This study demonstrates a prevalence of CKD in HIV-infected patients of 4.1% and points to an important role for HIV medications and other common comorbidities in the genesis and progression of kidney disease. Importantly, CKD was not more prevalent in African Americans than in Whites, perhaps due to a low prevalence of IV drug abuse as inferred from the lower prevalence of HCV infection in this cohort.

Patient Selection for Kidney Transplant

The incidence of end-stage renal disease has continued to increase. Similarly, the number of patients living with a functioning renal allograft has also increased. Transplantation has improved with advances in surgical techniques, immunosuppression, and better control of comorbid conditions. Transplantation is transformative and offers the greatest potential for restoring a healthy, productive, and durable life to appropriately selected patients. This article describes factors to address in selection of renal transplant candidates and discusses commonly encountered perioperative events. Paramount to selecting appropriate candidates is the collaboration between a multidisciplinary team focused on a systematic process guided by protocols and common practices.

Metabolic and Cardiovascular Comorbidities Among Clinically Stable HIV Patients on Long-Term ARV Therapy in Five Ambulatory Clinics in Lima-Callao, Peru

Background:

There is scarcity of data about the prevalence of non-AIDS defining comorbidities among stable HIV-infected patients in Peru.

Objective:

We aimed to describe the most frequent cardiometabolic comorbidities found among ambulatory adults on ARV in Peru.

Methods:

A review of records for patients attending regular visits at 5 clinics in Lima-Callao in January-February 2016 is presented. Patients were adults on ARV for >6 months, with no recent AIDS-defining condition.

Results:

Three hundred and five medical charts were reviewed. Most patients were male (73.1%, n=223) with a mean age of 46.0 years. Mean time from HIV diagnosis was 9.41 yrs. and mean duration of ARV was 7.78 yrs. Most patients were on an NNRTI-based first line regimen (76.4%, n=233), and 12.1% (n=37) were on rescue regimens. Median CD4 count was 614.2 cells/µL and the proportion of patients with viral load <40 c/mL was 90.8% (n=277). Most frequent metabolic diagnoses were dyslipidemia (51.5%, n=157), obesity (11.1%, n=34), and diabetes mellitus (7.2%, n=22). Hypertension was diagnosed in 8.9% (n=27). Other diagnoses of cardiovascular disease were documented in 3.3% (n=10). Pharmacologic treatment was prescribed in 91.3% of patients with diabetes or hypertension, but in only 29.3% of patients with dyslipidemia.

Conclusion:

A high proportion of metabolic comorbidities was found, with dyslipidemia being the most frequent, followed by obesity and diabetes. In contrast, cardiovascular disease was documented less frequently. Medical treatment was started for only a third of dyslipidemia patients. HIV care policies need to consider proper management of chronic comorbidities to optimize long-term outcomes.