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de Seigneux S, Lucas GM. Renal injury and human immunodeficiency virus: what remains after 30 years? Nephrol Dial Transplant 2020; 35:555-557. [PMID: 31407789 PMCID: PMC7139202 DOI: 10.1093/ndt/gfz162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/10/2019] [Indexed: 12/21/2022] Open
Affiliation(s)
- Sophie de Seigneux
- Service and Laboratory of Nephrology, PHYME and Medicine Department, University Hospital of Geneva, Geneva, Switzerland
| | - Gregory M Lucas
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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102
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Heron JE, Bagnis CI, Gracey DM. Contemporary issues and new challenges in chronic kidney disease amongst people living with HIV. AIDS Res Ther 2020; 17:11. [PMID: 32178687 PMCID: PMC7075008 DOI: 10.1186/s12981-020-00266-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/22/2020] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Jack Edward Heron
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Corinne Isnard Bagnis
- Nephrology Department, Groupe Hospitalier Pitié-Salpêtrière, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - David M Gracey
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
- Central Clinical School, The University of Sydney, Sydney, NSW, Australia.
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103
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Wearne N, Davidson B, Blockman M, Swart A, Jones ES. HIV, drugs and the kidney. Drugs Context 2020; 9:dic-2019-11-1. [PMID: 32256631 PMCID: PMC7104683 DOI: 10.7573/dic.2019-11-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/18/2020] [Accepted: 02/11/2020] [Indexed: 12/20/2022] Open
Abstract
Human immunodeficiency virus (HIV) affects over 36 million people worldwide. Antiretroviral therapy (ART) is expanding and improving HIV viral suppression, resulting in increasing exposure to drugs and drug interactions. Polypharmacy is a common complication as people are living longer on ART, increasing the risk of drug toxicities. Polypharmacy is related not only to ART exposure and medication for opportunistic infections, but also to treatment of chronic lifestyle diseases. Acute kidney injury (AKI) is frequent in HIV and is commonly the result of sepsis, dehydration and drug toxicities. Furthermore, HIV itself increases the risk of chronic kidney disease (CKD). Drug treatment is often complicated in people living with HIV because of a greater incidence of AKI and/or CKD compared to the HIV-negative population. Impaired renal function affects drug interactions, drug toxicities and importantly drug dosing, requiring dose adjustment. This review discusses ART and its nephrotoxic effects, including drug–drug interactions. It aims to guide the clinician on dose adjustment in the setting of renal impairment and dialysis, for the commonly used drugs in patients with HIV.
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Affiliation(s)
- Nicola Wearne
- Groote Schuur Hospital Department of Medicine, Division of Nephrology and Hypertension, Nephrology and Hypertension Research Unit, University of Cape Town, South Africa
| | - Bianca Davidson
- Groote Schuur Hospital Department of Medicine, Division of Nephrology and Hypertension, Nephrology and Hypertension Research Unit, University of Cape Town, South Africa
| | - Marc Blockman
- Groote Schuur Hospital Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, South Africa
| | - Annoesjka Swart
- Groote Schuur Hospital Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, South Africa
| | - Erika Sw Jones
- Groote Schuur Hospital Department of Medicine, Division of Nephrology and Hypertension, Nephrology and Hypertension Research Unit, University of Cape Town, South Africa
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104
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Wyatt CM, Chaudhari J, Miao S, Krishnasami Z, Hellinger J, Levey AS, Ross M, Ryom L, Mocroft A, Brunet L, Fusco J, Inker LA. Ritonavir-Boosted Protease Inhibitors Do Not Significantly Affect the Performance of Creatinine-Based Estimates of GFR. Kidney Int Rep 2020; 5:734-737. [PMID: 32405595 PMCID: PMC7210603 DOI: 10.1016/j.ekir.2020.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/27/2019] [Accepted: 01/27/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Christina M. Wyatt
- Department of Medicine and Nephrology, Duke University School of Medicine, Durham, North Carolina, USA
- Correspondence: Christina M. Wyatt, Nephrology, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina 27705, USA.
| | - Juhi Chaudhari
- Department of Medicine and Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Shiyuan Miao
- Department of Medicine and Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Zipporah Krishnasami
- Department of Medicine and Nephrology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - James Hellinger
- Department of Medicine and Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Andrew S. Levey
- Department of Medicine and Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Michael Ross
- Department of Medicine and Nephrology, Albert Einstein School of Medicine, Bronx, New York, USA
| | - Lene Ryom
- Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Amanda Mocroft
- Department of Epidemiology and Medical Statistics, University College London, London, UK
| | | | | | - Lesley A. Inker
- Department of Medicine and Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
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105
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The spectrum of kidney biopsy findings in HIV-infected patients in the modern era. Kidney Int 2020; 97:1006-1016. [PMID: 32278618 DOI: 10.1016/j.kint.2020.01.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/27/2019] [Accepted: 01/03/2020] [Indexed: 02/08/2023]
Abstract
HIV-associated kidney disease is evolving rapidly. Few North American studies have addressed modern trends and none has applied the 2018 Kidney Disease Improving Global Outcomes (KDIGO) pathologic classification. Therefore we performed a retrospective clinical-pathologic analysis of all HIV-positive patients with kidney biopsy interpreted at Columbia University from 2010-2018 using the KDIGO classification. The biopsy cohort of 437 HIV-positive patients had median age 53 years, including 66% males, 80% on anti-retroviral therapy, 57% with hypertension, 31% with diabetes, 27% with hepatitis C and 6% with hepatitis B co-infections. Race, known in 308 patients, included 58% black, 25% white and 17% Hispanic. Pathologic diagnoses were surprisingly diverse. Immune complex glomerulonephritis (ICGN) and diabetic nephropathy each outnumbered HIV-associated nephropathy, followed by tenofovir nephrotoxicity, FSGS- not otherwise specified (NOS) and global sclerosis (NOS). HIV-associated nephropathy was the most common disease in patients not on anti-retroviral therapy, and 94% were black. The association of FSGS (NOS) with black race (68%) and anti-retroviral therapy use (77%) suggests some cases may represent attenuated HIV-associated nephropathy. The most common ICGNs were IgA nephropathy and membranous glomerulopathy, both associating with anti-retroviral therapy (over 90%), followed by hepatitis C-associated proliferative ICGN. Among the 16 cases of uncharacterized ICGN lacking identifiable etiology, 69% were not on anti-retroviral therapy, possibly representing true HIV-associated immune complex kidney disease. Dual diseases occurred in 17% of patients, underscoring lesion complexity. Thus, anti-retroviral therapy has shifted the landscape of HIV-associated kidney disease toward diverse ICGN, diabetic nephropathy, and non-collapsing glomerulosclerosis, but has not eradicated HIV-associated nephropathy.
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106
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Therapeutic management of HIV-infected patients with chronic kidney disease. J Nephrol 2020; 33:699-713. [PMID: 32020538 DOI: 10.1007/s40620-020-00701-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 01/02/2020] [Indexed: 02/06/2023]
Abstract
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.
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107
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Abstract
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.
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108
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Reghine ÉL, Foresto RD, Kirsztajn GM. HIV-related nephropathy: new aspects of an old paradigm. ACTA ACUST UNITED AC 2020; 66Suppl 1:s75-s81. [PMID: 31939539 DOI: 10.1590/1806-9282.66.s1.75] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The scenario of infection by the human immunodeficiency virus (HIV) has been undergoing changes in recent years, both in relation to the understanding of HIV infection and regarding the treatments available. As a result, the disease, which before was associated with high morbidity and mortality, is now seen as a chronic disease that can be controlled, regarding both transmission and symptoms. However, even when the virus replication is well controlled, the infected patient remains at high risk of developing renal involvement, either by acute kidney injury not associated with HIV, nephrotoxicity due to antiretroviral drugs, chronic diseases associated with increased survival, or glomerular disease associated to HIV. This review will cover the main aspects of kidney failure associated with HIV.
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Affiliation(s)
- Érica Lofrano Reghine
- Departamento de Medicina (Nefrologia) da Universidade Federal de São Paulo, São Paulo, SP, Brasil
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109
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Camargo JF, Pallikkuth S, Moroz I, Natori Y, Alcaide ML, Rodriguez A, Guerra G, Burke GW, Pahwa S. Pretransplant Levels of C-Reactive Protein, Soluble TNF Receptor-1, and CD38+HLADR+ CD8 T Cells Predict Risk of Allograft Rejection in HIV+ Kidney Transplant Recipients. Kidney Int Rep 2019; 4:1705-1716. [PMID: 31844807 PMCID: PMC6895601 DOI: 10.1016/j.ekir.2019.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/12/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION HIV-positive (HIV+) kidney transplant recipients exhibit a 2- to 3-fold increased risk of allograft rejection. Dysregulated immune activation in HIV infection persists despite successful antiretroviral therapy and is associated with non-AIDS morbidity, including renal disease. We hypothesized that the pathological levels of inflammation and immune activation associated with chronic HIV infection could have clinical utility in the prediction of rejection in HIV+ kidney recipients. METHODS Prospective cohort study of 22 HIV-negative (HIV-; donor) to HIV+ (recipient) kidney transplant recipients who underwent biomarker assessment pretransplant and were subsequently followed for development of acute rejection. Plasma levels of markers of inflammation (soluble tumor necrosis factor receptor 1 [sTNF-R1] and C-reactive protein [CRP]) and microbial translocation (soluble CD14 and lipopolysaccharide) were measured by enzyme-linked immunosorbent assay or chromogenic endpoint assay. Levels of activated (CD38+HLADR+) CD4+ and CD8+ T cells, and T regulatory cells (CD4+CD25highFoxP3+) were measured by flow cytometry. RESULTS Among the biomarkers evaluated, only the pretransplant levels of sTNF-R1, CRP, and frequencies of CD38+HLADR+ CD8 T cells, were found to be at significantly higher levels among patients who experienced biopsy-proven acute rejection. Confirming our hypothesis, patients with high pretransplant levels of sTNF-R1 or activated CD8+ T cells had a significantly increased 200-day cumulative incidence of biopsy-proven acute rejection (0 vs. 38% for both; P = 0.01). Similarly, pretransplant CRP levels higher than 5 μg/ml were associated with increased risk of acute rejection within the first 6 months post-transplant (0 vs. 43%; P = 0.01). CONCLUSION Biomarker-based identification of HIV+ recipients at increased risk for rejection might facilitate individualized induction immunosuppression regimens in this vulnerable patient population.
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Affiliation(s)
- Jose F. Camargo
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Suresh Pallikkuth
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ilona Moroz
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Yoichiro Natori
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Maria L. Alcaide
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Allan Rodriguez
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | | | - Savita Pahwa
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, Florida, USA
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Hamzah L, Williams D, Bailey AC, Jones R, Ibrahim F, Musso CG, Burling K, Barbini B, Campbell L, Post FA. Early safety of tenofovir alafenamide in patients with a history of tubulopathy on tenofovir disoproxil fumarate: a randomized controlled clinical trial. HIV Med 2019; 21:198-203. [PMID: 31679186 DOI: 10.1111/hiv.12819] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVES The aim of the study was to assess the effect of tenofovir alafenamide (TAF) on kidney and bone biomarkers in patients who developed proximal renal tubulopathy (PRT) while receiving tenofovir disoproxil fumarate (TDF). METHODS Individuals with a history of TDF-associated PRT and currently suppressed HIV infection on a tenofovir-sparing regimen were randomized 1:1 to continue current antiretroviral therapy or initiate emtricitabine (F)/TAF with discontinuation of nucleoside reverse transcriptase inhibitors (NRTIs) as appropriate. Renal and bone biomarkers were analysed at baseline, week 4 and week 12. The primary outcome was the mean difference between study arms in urine retinol-binding protein:creatinine ratio (RBPCR) change from baseline to week 12. Data were analysed using linear regression, with robust standard errors (primary outcome), and repeated measures mixed effects models (secondary outcomes). The trial was registered under European Union Drug Regulating Authorities Clinical Trials Database 2016-003345-29. RESULTS We randomized 31 individuals [mean age 52.4 (standard deviation 0.3) years; 97% male; 90% white); all completed the study. At 12 weeks, there was no difference in change in RBPCR (β 19.6; 95% confidence interval -35.3, 74.5; P = 0.47), and no difference in change in estimated glomerular filtration rate (eGFR) (based on creatinine or cystatin C), albuminuria, proteinuria, renal phosphate or urea handling, (fasting) urine osmolality, parathyroid hormone and bone turnover markers in the control versus the F/TAF exposed groups. No cases of PRT were observed. CONCLUSIONS In people with a history of proximal renal tubulopathy while on TDF, 12-week exposure to TAF did not adversely affect renal tubular function. These data support continued evaluation of the long-term safety of TAF in this group of patients.
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Affiliation(s)
- L Hamzah
- St George's Healthcare NHS Trust, London, UK
| | - D Williams
- Brighton and Sussex University Hospitals, Brighton, UK
| | - A C Bailey
- Imperial College Healthcare NHS Trust, London, UK
| | - R Jones
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - C G Musso
- Italian Hospital, Buenos Aires, Argentina
| | - K Burling
- Core Biochemical Assay Laboratory, NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - B Barbini
- King's College Hospital NHS Foundation Trust, London, UK
| | - L Campbell
- King's College Hospital NHS Foundation Trust, London, UK
| | - F A Post
- King's College London, London, UK.,King's College Hospital NHS Foundation Trust, London, UK
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111
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Gao X, Rosales A, Karttunen H, Bommana GM, Tandoh B, Yi Z, Habib Z, D'Agati V, Zhang W, Ross MJ. The HIV protease inhibitor darunavir prevents kidney injury via HIV-independent mechanisms. Sci Rep 2019; 9:15857. [PMID: 31676833 PMCID: PMC6825220 DOI: 10.1038/s41598-019-52278-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 10/10/2019] [Indexed: 12/13/2022] Open
Abstract
HIV-associated nephropathy (HIVAN) is a rapidly progressive kidney disease that is caused by HIV infection of renal epithelial cells with subsequent expression of viral genes, including vpr. Antiretroviral therapy ameliorates HIVAN without eradicating HIV from the kidneys and the mechanism by which it protects kidneys is poorly understood. Since HIV protease inhibitors have "off target" cellular effects, we studied whether darunavir, the most commonly prescribed protease inhibitor, protects kidneys from HIV-induced injury via mechanisms independent of HIV protease and viral replication. Renal epithelial cells were transduced with lentiviruses encoding HIV (lacking protease and reverse transcriptase), Vpr, or vector control. Darunavir attenuated HIV and Vpr-induced activation of Stat3, Src, Erk, and cytokines, which are critical for HIVAN pathogenesis. We then studied HIV-transgenic mice, which develop HIVAN in the absence of HIV protease or reverse transcriptase. Mice were treated with darunavir, zidovudine, darunavir + zidovudine, or control. Darunavir and darunavir + zidovudine reduced albuminuria and histologic kidney injury and normalized expression of dysregulated proteins. RNA-seq analyses demonstrated that darunavir suppressed HIV-induced upregulation of immune response genes in human kidney cells. These data demonstrate that darunavir protects against HIV-induced renal injury via mechanisms that are independent of inhibition of HIV protease.
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Affiliation(s)
- Xiaobo Gao
- Division of Nephrology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Alan Rosales
- Division of Nephrology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Heidi Karttunen
- Division of Nephrology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | | | - Buadi Tandoh
- Division of Nephrology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Zhengzi Yi
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Vivette D'Agati
- Department of Pathology, Columbia University, College of Physicians & Surgeons, New York, NY, USA
| | - Weijia Zhang
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael J Ross
- Division of Nephrology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA.
- Department of Development and Molecular Biology, Albert Einstein College of Medicine, Bronx, NY, USA.
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112
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Jose S, Hamzah L, Jones R, Williams D, Winston A, Burns F, Phillips AN, Sabin CA, Post FA. Chronic Kidney Disease Risk in African and Caribbean Populations With HIV. J Infect Dis 2019; 218:1767-1772. [PMID: 29982487 PMCID: PMC6195659 DOI: 10.1093/infdis/jiy397] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/04/2018] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Sophie Jose
- Institute for Global Health, University College London
| | - Lisa Hamzah
- Department of Sexual Health, King's College Hospital NHS Foundation Trust, London
| | - Rachael Jones
- Department of Sexual Health, Chelsea and Westminster Hospital NHS Foundation Trust, London
| | - Debbie Williams
- Department of Sexual Health, Brighton and Sussex University Hospitals NHS Trust
| | - Alan Winston
- Division of Infectious Diseases, Department of Medicine, Imperial College London, United Kingdom
| | - Fiona Burns
- Institute for Global Health, University College London
| | | | | | - Frank A Post
- Department of Sexual Health, King's College Hospital NHS Foundation Trust, London
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113
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Alfano G, Cappelli G, Fontana F, Di Lullo L, Di Iorio B, Bellasi A, Guaraldi G. Kidney Disease in HIV Infection. J Clin Med 2019; 8:jcm8081254. [PMID: 31430930 PMCID: PMC6722524 DOI: 10.3390/jcm8081254] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Gaetano Alfano
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, 41125 Modena, Italy.
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, 41125 Modena, Italy.
| | - Gianni Cappelli
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, 41125 Modena, Italy
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, 41125 Modena, Italy
| | - Francesco Fontana
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, 41125 Modena, Italy
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, "L. Parodi-Delfino" Hospital, 00034 Colleferro, Italy
| | - Biagio Di Iorio
- Department of Medicine, AORN "Antonio Cardarelli", 80131 Naples, Italy
| | - Antonio Bellasi
- Department of Research, Innovation, Brand Reputation, Ospedale di Bergamo, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Giovanni Guaraldi
- Clinic of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico di Modena, 41125 Modena, Italy
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114
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Lavinya AA, Lee CS, Hashim OH, Azwa I, Rajasuriar R, Lim SK, Wong YF. Proteomics analysis of blood plasma in HIV-infected patients with chronic kidney disease. Clin Biochem 2019; 73:90-97. [PMID: 31401122 DOI: 10.1016/j.clinbiochem.2019.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/30/2019] [Accepted: 08/07/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patients treated for human immunodeficiency virus (HIV) infection are prone to developing chronic kidney disease (CKD). Current methods used in assessing kidney function suffer inaccuracy in HIV-infected patients. This study aims to identify biomarkers that could complement existing methods of kidney assessment among HIV-infected subjects. METHODS Plasma protein profiling was performed for HIV patients with CKD presented with negative/trace proteinuria (non-proteinuric) (n = 8) and their matched non-CKD controls, using two-dimensional gel electrophoresis (2DE); selected protein candidates were identified using mass spectrometry. Subsequently, altered plasma abundance of protein candidates were verified using Western blotting in HIV-infected subjects with non-proteinuric CKD (n = 8), proteinuric CKD (n = 5), and their matched non-CKD controls, as well as in HIV-uninfected subjects with impaired kidney function (n = 3) and their matched controls. RESULTS Analysis of 2DE found significantly altered abundance of five protein candidates between HIV-infected patients with non-proteinuric CKD and without CKD: alpha-1-microglobulin (A1M), serum albumin (ALB), zinc-alpha-2-glycoprotein (AZGP1), haptoglobin (HP), and retinol binding protein (RBP4). Western blotting showed an increased abundance of A1M and HP in HIV-infected patients with non-proteinuric CKD compared to their non-CKD controls, whereas A1M, AZGP1, and RBP4 were significantly increased in HIV-infected patients with proteinuric CKD compared to their non-CKD controls. Such pattern was not found in HIV-uninfected subjects with impaired kidney function. CONCLUSION The data suggests four proteins that may be used as biomarkers of CKD in HIV-infected patients. Further validation in a larger cohort of HIV-infected patients is necessary for assessing the clinical use of these proposed biomarkers for CKD.
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Affiliation(s)
- Amanda Anne Lavinya
- Department of Pharmacy, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Cheng Siang Lee
- Centre of Excellence for Research in AIDS, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Onn Haji Hashim
- University of Malaya Centre for Proteomics Research, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia; Department of Molecular Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Iskandar Azwa
- Infectious Diseases Unit, Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Reena Rajasuriar
- Department of Pharmacy, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia; Centre of Excellence for Research in AIDS, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Soo Kun Lim
- Nephrology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Yuen Fei Wong
- Department of Pharmacy, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
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115
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Abstract
OBJECTIVE To describe the spectrum of kidney disease in African patients with HIV and tuberculosis (TB). METHODS We used data from three cohorts: consecutive patients with HIV/TB in South London (UK, 2004-2016; n = 95), consecutive patients with HIV/TB who underwent kidney biopsy in Cape Town (South Africa, 2014-2017; n = 70), and consecutive patients found to have HIV/TB on autopsy in Abidjan (Cote d'Ivoire, 1991; n = 100). Acute kidney injury (AKI) was ascertained using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. In the Cape Town cohort, predictors of recovery of kidney function at 6 months were assessed using Cox regression. RESULTS In the London cohort, the incidence of moderate/severe AKI at 12 months was 15.1 (95% CI 8.6-26.5) per 100 person-years, and the prevalence of chronic and end-stage kidney disease (ESKD) 13.7 and 5.7%, respectively. HIV-associated nephropathy (HIVAN) was diagnosed in 6% of patients in London, and in 6% of autopsy cases in Abidjan. Evidence of renal TB was present in 60% of autopsies in Abidjan and 61% of kidney biopsies in Cape Town. HIVAN and acute tubular necrosis (ATN) were also common biopsy findings in Cape Town. In Cape Town, 40 patients were dialyzed, of whom 28 (70%) were able to successfully discontinue renal replacement therapy. Antiretroviral therapy status, CD4 cell count, estimated glomerular filtration rate (eGFR) at biopsy and renal histology, other than ATN, were not predictive of eGFR recovery. CONCLUSION Kidney disease was common in Africans with HIV/TB. Monitoring of kidney function, and provision of acute dialysis to those with severe kidney failure, is warranted.
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116
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Davidson B, Nel D, Jones ESW, Manning K, Spies R, Bohmer R, Omar A, Ash S, Wearne N. Granulomatous interstitial nephritis on renal biopsy in human immunodeficiency virus positive patients: Prevalence and causes in Cape Town, South Africa. Nephrology (Carlton) 2019; 24:681-688. [PMID: 30663206 DOI: 10.1111/nep.13564] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2019] [Indexed: 12/16/2022]
Abstract
South Africa continues to be burdened by human immunodeficiency virus (HIV) and tuberculosis (TB). In Cape Town, the epidemic of HIV-TB co-infection is as high as 70%. Granulomatous interstitial nephritis (GIN) has increased in frequency on renal biopsy. This study aimed to determine GIN prevalence and causes in HIV-positive patients as well as renal outcomes, patient survival and associated factors. This observational cohort study reviewed HIV-positive renal biopsies for GIN from 2005 to 2012. Causes of GIN (medications, TB, fungal and other), and baseline characteristics were analysed. A comparison of baseline data, renal function and survival was made between GIN and non-GIN cohorts. There were 45/316 biopsies demonstrating GIN. TB was the likely cause of GIN in 27 (60%) and 9 (20%) were due to a drug. Low estimated glomerular filtration rate was a statistically significant factor associated with mortality in both GIN (P = 0.045) and non-GIN cohorts (P < 0.000). In the GIN group, there were 12 (26.7%) deaths. Mortality for all patients was greatest in the first 6 months (P = 0.057). TB co-infection in both cohorts was associated with a higher mortality. The multivariate logistic regression demonstrated that a higher urine protein/creatinine ratio (uPCR) and lower estimated glomerular filtration rate were statistically associated with death. GIN is common in HIV-positive renal biopsies in Cape Town. TB-GIN was the commonest cause and associated with a high early mortality. GIN should be considered in HIV-positive patients with acute kidney injury, its presence conveys a survival benefit. There is a need for improved diagnostic accuracy and treatment strategies of TB-GIN.
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Affiliation(s)
- Bianca Davidson
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Debbie Nel
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Erika S W Jones
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Kathryn Manning
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Ruan Spies
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Raphaela Bohmer
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Aadil Omar
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Samantha Ash
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nicola Wearne
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
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117
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Verma B, Singh A. Clinical spectrum of renal disease in hospitalized HIV/AIDS patients: A teaching hospital experience. J Family Med Prim Care 2019; 8:886-891. [PMID: 31041219 PMCID: PMC6482726 DOI: 10.4103/jfmpc.jfmpc_98_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Bhupendra Verma
- Department of Cardiology, Ujala Hospital, Kashipur, Uttarakhand, India
| | - Amrita Singh
- Department of Nephrology, Ujala Hospital, Kashipur, Uttarakhand, India
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118
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Wearne N, Okpechi IG, Swanepoel CR. Nephrology in South Africa: Not Yet ubuntu. KIDNEY DISEASES 2019; 5:189-196. [PMID: 31259181 DOI: 10.1159/000497324] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 01/27/2019] [Indexed: 12/16/2022]
Abstract
Background South Africa (SA) is an upper middle-income country with a human immunodeficiency virus (HIV) epidemic, an accelerated burden of non-communicable diseases, and a concurrent epidemic of tuberculosis. These con-ditions overwhelm a health system struggling under the pressure of restricted resources, including an insufficient workforce. Private practice has become more involved in the care of patients in the country but serves mainly those who are members of a Medical Aid. These Medical Aids will usually cover up to 100% of the costs for management of chronic kidney disease (CKD). Summary There are currently 2.3 nephrologists per million individuals, which is far lower than the global average and grossly inadequate to meet the nephrology care needs in SA. Covert chronic dialysis rationing has occurred in the public sector since the 1960s. However, the lack of formality triggered the formation of explicit rationing guidelines in one province. These guidelines have been ethically endorsed but not embraced nationally. The demand for hemodialysis (HD) has led some provinces to practicing "PD-First" programs. SA remains one of only 12 countries within Africa that perform renal transplantation, and it is the only country in Africa that relies on deceased donation for the majority of its transplants. The first kidney transplant in SA took place at the University of the Witwatersrand, Johannesburg, in 1966 and the first dialysis was performed by a general practitioner working in a town close to Johannesburg in 1957. The University of Cape Town successfully pioneered the transplantation of kidneys from HIV-positive donors to positive recipients. SA was the second country in the world to form a National Kidney Foundation as well as a renal society. Nephrology training is in place and incorporates master's and PhD programs in nephrology. Despite the numerous challenges, SA nephrologists have been among the leading researchers in nephrology from the African continent.
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Affiliation(s)
- Nicola Wearne
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa.,Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ikechi G Okpechi
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa.,Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Charles R Swanepoel
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa.,Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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119
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Abstract
The success of combination antiretroviral therapy in the treatment of HIV-1-positive individuals has shifted clinical attention toward combination antiretroviral drug regimens that optimize tolerability, long-term safety, and durable efficacy. Wherever patients have access to treatment, morbidity and mortality are increasingly driven by non-HIV-associated comorbidities, which may be observed earlier than in age-matched controls and despite the best available combination antiretroviral therapy. Similarly, HIV-1-positive individuals are now diagnosed and treated earlier with anticipated lifelong therapy. The contribution of specific antiretroviral agents to long-term morbidity and mortality is dependent on the pharmacologic characteristics of these agents, and it is increasingly important in this context.
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Affiliation(s)
- Mohamed G. Atta
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Sophie De Seigneux
- Service and Laboratory of Nephrology, Department of Internal Medicine Specialties and
- Department of Physiology and Metabolism, University Hospital and University of Geneva, Geneva, Switzerland
| | - Gregory M. Lucas
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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120
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Wearne N, Swanepoel CR, Duffield MS, Davidson BJ, Manning K, Tiffin N, Boulle A, Rayner BL, Naidu P, Okpechi IG. The effects of add-on corticosteroids on renal outcomes in patients with biopsy proven HIV associated nephropathy: a single centre study from South Africa. BMC Nephrol 2019; 20:44. [PMID: 30728003 PMCID: PMC6366071 DOI: 10.1186/s12882-019-1208-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 01/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to assess, the efficacy and safety of add-on corticosteroids to antiretroviral therapy [ART] in patients with biopsy proven HIV associated nephropathy. METHODS All included patients had histological evidence of either collapsing or non-collapsing focal segmental glomerulosclerosis (FSGS) or podocyte and/or parietal cell hypertrophy or hyperplasia. All patients had evidence of tubulointerstitial inflammation with microcysts. Patients were randomized to ART with the addition of 1 mg/kg of corticosteroids [ART+C] or remained in the group [ART Alone] and followed for 2 years. A repeat biopsy was performed at 6 months. RESULTS Twenty-one patients were randomized to [ART+C] and 17 to [ART Alone]. The baseline estimated glomerular filtration rate (eGFR) was significantly lower in the [ART+C] vs. [ART Alone] group [35mls/min/1.73m2 vs. 47 mls/min/1.73m2, p = 0.015]. The [ART+C] cohort had a statistically significant improvement in median (eGFR) from baseline to last follow up compared with [ART Alone] i.e. [Δ = 25mls/min (IQR: 15;51) vs 9 mls/min (IQR: 0-24), p = 0.008]. There were no statistically significant differences between the groups when proteinuria and histology were analyzed. There were 8 deaths during the trial period, 7 from [ART+C] (Log rank p = 0.071). CONCLUSIONS In the [ART+C] cohort there was a significant improvement in eGFR over 2-years with increased mortality. Routine corticosteroid use cannot currently be recommended. Further investigation to define which subgroup of this cohort would safely benefit from the positive effects is required. TRIAL REGISTRATION ISRCTN study ID ( 56112439 ] was retrospectively registered on the 5 September 2018.
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Affiliation(s)
- Nicola Wearne
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Charles R. Swanepoel
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Maureen S. Duffield
- Division of Pathology, Department of Clinical Laboratory Services, University of Cape Town, Cape Town, South Africa
| | - Bianca J. Davidson
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Kathryn Manning
- Department of Medicine, Statistical Analyst, University of Cape Town, Cape Town, South Africa
| | - Nicki Tiffin
- CIDER: School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- CIDER: School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Brian L. Rayner
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Priyanka Naidu
- Department of Undergraduate Medicine, University of Cape Town, Cape Town, South Africa
| | - Ikechi G. Okpechi
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
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121
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Matthai SM, Valson AT, Duhli N, Rupali P, Pulimood AB, Varughese S. Fibrillary glomerulonephritis in a human immunodeficiency virus-positive, hepatitis C-negative Indian patient: Expanding the profile of renal involvement in human immunodeficiency virus infection. INDIAN J PATHOL MICR 2019; 61:610-613. [PMID: 30303165 DOI: 10.4103/ijpm.ijpm_52_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Highly active anti retroviral therapy (HAART) has dramatically improved life expectancy of human immunodeficiency virus (HIV) infected patients, converting HIV infection into a chronic illness with associated changes in its attendant renal complications. The past two decades have witnessed a decrease in the prevalence of HIV associated nephropathy (HIVAN), traditionally considered to be the hall mark of renal involvement in HIV infection. Simultaneously a host of other glomerular and tubulo-interstitial diseases have emerged, expanding the spectrum of HIV associated renal diseases, predominant among which is HIV associated immune complex mediated kidney diseases (HIVICK). Of the diverse glomerular diseases constituting HIVICK, fibrillary glomerulonephritis (FGN) remains a rarity, with only two existing reports to date, confined to patients co-infected with Hepatitis C virus (HCV). The pathogenetic role of HIV in these patients remains under a cloud because of previously well established association of HCV infection and FGN. We report a case of FGN in a HIV seropositive, HCV negative Indian patient, highlighting the diagnostic electron microscopy (EM) findings of FGN and strengthening the causal association of HIV with FGN. In view of increasing heterogeneity of renal complications in HIV infection, the diagnostic utility of a comprehensive renal biopsy evaluation inclusive of EM is emphasized for appropriate selection of treatment modalities.
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Affiliation(s)
- Smita Mary Matthai
- Department of Pathology, Central Electron Microscopy Facility, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anna T Valson
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Neelaveni Duhli
- Department of General Pathology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Priscilla Rupali
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anna B Pulimood
- Department of Pathology, Central Electron Microscopy Facility, Christian Medical College, Vellore, Tamil Nadu, India
| | - Santosh Varughese
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
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122
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An P, Kirk GD, Limou S, Binns-Roemer E, Kopp JB, Winkler CA. Impact of APOL1 Genetic Variants on HIV-1 Infection and Disease Progression. Front Immunol 2019; 10:53. [PMID: 30733721 PMCID: PMC6353846 DOI: 10.3389/fimmu.2019.00053] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/09/2019] [Indexed: 01/03/2023] Open
Abstract
Apolipoprotein L1 (APOL1) has broad innate immune functions and has been shown to restrict HIV replication in vitro by multiple mechanisms. Coding variants in APOL1 are strongly associated with HIV-associated nephropathy (HIVAN) in persons with untreated HIV infection; however, the mechanism by which APOL1 variant protein potentiates renal injury in the presence of high viral load is not resolved. Little is known about the association of APOL1 genotypes with HIV viral load, HIV acquisition, or progression to AIDS. We assessed the role of APOL1 coding variants on HIV-1 acquisition using the conditional logistic regression test, on viral load using the t-test or ANOVA, and on progression to AIDS using Cox proportional hazards models among African Americans enrolled in the ALIVE HIV natural history cohort (n = 775). APOL1 variants were not associated with susceptibility to HIV-1 acquisition by comparing genotype frequencies between HIV-1 positive and exposed or at-risk HIV-1 uninfected groups (recessive model, 12.8 vs. 12.5%, respectively; OR 1.02, 95% CI 0.62-1.70). Similar null results were observed for dominant and additive models. APOL1 variants were not associated with HIV-1 viral load or with risk of progression to AIDS [Relative hazards (RH) 1.33, 95% CI 0.30-5.89 and 0.96, 95% CI 0.49-1.88, for recessive and additive models, respectively]. In summary, we found no evidence that APOL1 variants are associated with host susceptibility to HIV-1 acquisition, set-point HIV-1 viral load or time to incident AIDS. These results suggest that APOL1 variants are unlikely to influence HIV infection or progression among individuals of African ancestry.
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Affiliation(s)
- Ping An
- Molecular Genetic Epidemiology Section, Basic Science Program, Basic Research Laboratory, Frederick National Laboratory for Cancer Research, National Cancer Institute, Frederick, MD, United States
| | - Gregory D Kirk
- Departments of Epidemiology and Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Sophie Limou
- Molecular Genetic Epidemiology Section, Basic Science Program, Basic Research Laboratory, Frederick National Laboratory for Cancer Research, National Cancer Institute, Frederick, MD, United States.,CRTI UMR1064, Inserm, Université de Nantes & ITUN, CHU Nantes, Nantes, France.,Ecole Centrale de Nantes, Nantes, France
| | - Elizabeth Binns-Roemer
- Molecular Genetic Epidemiology Section, Basic Science Program, Basic Research Laboratory, Frederick National Laboratory for Cancer Research, National Cancer Institute, Frederick, MD, United States
| | - Jeffrey B Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD, United States
| | - Cheryl A Winkler
- Molecular Genetic Epidemiology Section, Basic Science Program, Basic Research Laboratory, Frederick National Laboratory for Cancer Research, National Cancer Institute, Frederick, MD, United States
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123
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Verma B, Singh A. Histological spectrum of renal disease in HIV/AIDS patients with significant proteinuria: An Indian perspective. J Family Med Prim Care 2019; 8:860-865. [PMID: 31041214 PMCID: PMC6482772 DOI: 10.4103/jfmpc.jfmpc_104_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Chronic kidney disease (CKD) has become epidemic in HIV/AIDS patients across Western and Eastern countries. HIV-associated nephropathy (HIVAN) has been consistently reported in studies from North America, Europe and African countries. However, studies from Asian countries are very sparse and differ strikingly in histological spectrum of renal disease, particularly in presence of HIVAN. Objectives: The study was carried out to in a teaching hospital from India to delineate the histological spectrum of renal disease and detect presence HIVAN in those with significant proteinuria (≥1gm/day). Patients and Methods: Urine analysis was done in 510 consecutive hospitalised HIV/AIDS patients after screening 640 such patients with age >18years. Patients with dipstick proteinuria ≥1+ were subjected to 24-hour urinary protein estimation. Renal biopsy was done in 10 patients with proteinuria ≥1gm/day. Results: Dipstick proteinuria ≥1+ was present in 29% patients. In patients undergoing kidney biopsy, the most frequent glomerular lesion was mesangial proliferative glomerulonephritis (30%) followed by HIVAN (20%). Tubulo-interstitial lesions were seen in 60% of biopsies. Pooled analysis of all the available kidney biopsy series from India revealed prevalence of HIVAN to be 16.5%. Conclusion: Contrary to the popular belief, HIVAN appears to be a common entity in this part of world too. High degree of clinical suspicion is required as diagnosis of HIVAN caries higher morbidity and mortality. Moreover, an early diagnosis and timely management can improve prognosis in such patients.
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Affiliation(s)
- Bhupendra Verma
- Department of Cardiology, Ujala Hospital, Kashipur, Uttarakhand, India
| | - Amrita Singh
- Department of Nephrology, Ujala Hospital, Kashipur, Uttarakhand, India
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124
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Tiewsoh K, Kumar Jindal A, Sharma D, Arora S, Minz RW, Agrawal P, Nada R, Suri D. Spectrum of renal disease in HIV-infected children: report of five cases. Paediatr Int Child Health 2018; 38:271-276. [PMID: 29726752 DOI: 10.1080/20469047.2018.1463126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
There is a paucity of literature on renal diseases associated with HIV infection in Asian countries. Renal disease in HIV-infected children can involve the glomerulus, interstitium, tubules or blood vessels of the kidney. In this case series, five HIV-infected children with various forms of renal disease are reported. The renal pathology included HIV-associated nephropathy, collapsing focal segmental glomerulosclerosis without tubular changes, tubule-interstitial nephritis and minimal change disease (MCD). Case five fulfilled the classification criteria for childhood polyarteritis nodosa (PAN). It is important to screen all HIV-infected children for renal disease to enable detection at an early stage.
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Key Words
- ATN, acute tubular necrosis
- Collapsing focal segmental glomerulosclerosis
- EULAR/PRINTO/PRES, European League Against Rheumatism/Paediatric Rheumatology International Trials Organisation/Paediatric Rheumatology European Society
- HIV-associated nephropathy
- HIVAN, HIV-associated nephropathy
- HVICK, HIV immune complex kidney disease
- NACO, National AIDS Control Organization
- NGAL, neutrophil gelatinase associated lipocalin
- NHL, non-Hodgkin lymphoma
- PAH, pulmonary artery hypertension
- PAN, polyarteritis nodosa
- TIN, tubule-interstitial nephritis
- cART, combination anti-retroviral therapy
- eGFR, estimated glomerular filtration rate
- interstitial nephritis
- minimal change disease
- non-Hodgkin lymphoma
- proteinuria
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Affiliation(s)
- Karalanglin Tiewsoh
- a Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre , PGIMER , Chandigarh , India
| | - Ankur Kumar Jindal
- a Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre , PGIMER , Chandigarh , India
| | - Dhrubajyoti Sharma
- a Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre , PGIMER , Chandigarh , India
| | - Sunil Arora
- b Department of Immunopathology , PGIMER , Chandigarh , India
| | - Ranjana W Minz
- b Department of Immunopathology , PGIMER , Chandigarh , India
| | - Parimal Agrawal
- c Department of Histopathology , PGIMER , Chandigarh , India
| | - Ritambhra Nada
- c Department of Histopathology , PGIMER , Chandigarh , India
| | - Deepti Suri
- a Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre , PGIMER , Chandigarh , India
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125
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Mu Y, Kodidela S, Wang Y, Kumar S, Cory TJ. The dawn of precision medicine in HIV: state of the art of pharmacotherapy. Expert Opin Pharmacother 2018; 19:1581-1595. [PMID: 30234392 DOI: 10.1080/14656566.2018.1515916] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Combination antiretroviral therapy (ART) reduces viral load to under the limit of detection, successfully decreasing HIV-related morbidity and mortality. Due to viral mutations, complex drug combinations and different patient response, there is an increasing demand for individualized treatment options for patients. AREAS COVERED This review first summarizes the pharmacokinetic and pharmacodynamic profile of clinical first-line drugs, which serves as guidance for antiretroviral precision medicine. Factors which have influential effects on drug efficacy and thus precision medicine are discussed: patients' pharmacogenetic information, virus mutations, comorbidities, and immune recovery. Furthermore, strategies to improve the application of precision medicine are discussed. EXPERT OPINION Precision medicine for ART requires comprehensive information on the drug, virus, and clinical data from the patients. The clinically available genetic tests are a good starting point. To better apply precision medicine, deeper knowledge of drug concentrations, HIV reservoirs, and efficacy associated genes, such as polymorphisms of drug transporters and metabolizing enzymes, are required. With advanced computer-based prediction systems which integrate more comprehensive information on pharmacokinetics, pharmacodynamics, pharmacogenomics, and the clinically relevant information of the patients, precision medicine will lead to better treatment choices and improved disease outcomes.
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Affiliation(s)
- Ying Mu
- a Department of Clinical Pharmacy and Translational Science , University of Tennessee Health Science Center College of Pharmacy , Memphis , USA
| | - Sunitha Kodidela
- b Department of Pharmaceutical Science , University of Tennessee Health Science Center College of Pharmacy , Memphis , USA
| | - Yujie Wang
- b Department of Pharmaceutical Science , University of Tennessee Health Science Center College of Pharmacy , Memphis , USA
| | - Santosh Kumar
- b Department of Pharmaceutical Science , University of Tennessee Health Science Center College of Pharmacy , Memphis , USA
| | - Theodore J Cory
- a Department of Clinical Pharmacy and Translational Science , University of Tennessee Health Science Center College of Pharmacy , Memphis , USA
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126
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Venter WDF, Fabian J, Feldman C. An overview of tenofovir and renal disease for the HIV-treating clinician. South Afr J HIV Med 2018; 19:817. [PMID: 30167339 PMCID: PMC6111387 DOI: 10.4102/sajhivmed.v19i1.817] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 03/29/2018] [Indexed: 12/12/2022] Open
Abstract
Tenofovir disoproxil fumarate (TDF, commonly termed ‘tenofovir’) is the antiretroviral most commonly implicated in antiretroviral-induced nephrotoxicity. As patients on successful antiretroviral therapy (ART) age, their risk for developing renal disease may increase in part because of ART itself, but more importantly, because of HIV-associated and non-HIV-associated comorbidity. Therefore, clinicians need an approach to managing renal disease in people on TDF. TDF as a cause of acute kidney injury (AKI) or chronic kidney disease (CKD) is uncommon, and clinicians should actively exclude other causes (Box 1). In TDF-associated AKI, TDF should be interrupted in all cases, and replaced, or ART interrupted altogether. Tenofovir disoproxil fumarate toxicity can present as AKI or CKD, and as a full or partial Fanconi’s syndrome. TDF has a small but definite negative impact on kidney function (up to a 10% decrease in glomerular filtration rate [GFR]). This occurs because of altered tubular function in those exposed to TDF for treatment and as pre-exposure prophylaxis. Renal function should be assessed using creatinine-based estimated GFR at the time of initiation of TDF, if ART is changed, at 1–3 months, and then ideally every 6–12 months if stable. Specific tests of tubular function are not routinely recommended; in the case of clinical concern, a spot protein or albumin: creatinine ratio is preferable, but in resource-limited settings, urine dipstick can be used. More frequent monitoring may be required in those with established CKD (estimated glomerular filtration rate [eGFR] < 50 mL/min/1.73 m2) or risk factors for kidney disease. The most common risk factors are comorbid hypertension, diabetes, HIV-associated kidney disease, hepatitis B or C co-infection, and TDF in combination with a ritonavir-boosted protease inhibitor. Management of these comorbid conditions must be prioritised in this group. If baseline screening eGFR is < 50 mL/min/1.73 m2, abacavir (the preferred option), and dose-adjusted TDF (useful if concomitant hepatitis B), zidovudine or stavudine (d4T) remain alternatives to full-dose TDF. If there is a rapid decline in kidney function (eGFR drops by more than 25% and decreases to < 50 mL/min/1.73 m2 from of baseline function), or there is new onset or worsening of proteinuria or albuminuria, clinicians should review ART and other potentially nephrotoxic medications and comorbidity and conduct further testing if indicated. If kidney function does not improve after addressing reversible causes of renal failure, then referral to a nephrologist is appropriate. In the case of severe CKD, timeous referral for planning for renal replacement therapy is recommended. Tenofovir alafenamide, a prodrug of tenofovir, appears to have less renal toxicity and is likely to replace TDF in future.
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Affiliation(s)
- Willem D F Venter
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, South Africa
| | - June Fabian
- Wits Donald Gordon Medical Centre, South Africa.,Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Charles Feldman
- Wits Donald Gordon Medical Centre, South Africa.,Charlotte Maxeke Johannesburg Academic Hospital, South Africa
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Palau L, Menez S, Rodriguez-Sanchez J, Novick T, Delsante M, McMahon BA, Atta MG. HIV-associated nephropathy: links, risks and management. HIV AIDS (Auckl) 2018; 10:73-81. [PMID: 29872351 PMCID: PMC5975615 DOI: 10.2147/hiv.s141978] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Despite the decreased incidence of human immunodeficiency virus (HIV)-associated nephropathy due to the widespread use of combined active antiretroviral therapy, it remains one of the leading causes of end-stage renal disease (ESRD) in HIV-1 seropositive patients. Patients usually present with low CD4 count, high viral load and heavy proteinuria, with the pathologic findings of collapsing focal segmental glomerulosclerosis. Increased susceptibility exists in individuals with African descent, largely due to polymorphism in APOL1 gene. Other clinical risk factors include high viral load and low CD4 count. Advanced kidney disease and nephrotic range proteinuria have been associated with progression to ESRD. Improvement in kidney function has been observed after initiation of combined active antiretroviral therapy. Other treatment options, when clinically indicated, are inhibition of the renin-angiotensin system and corticosteroids. Further routine management approaches for patients with chronic kidney disease should be implemented. In patients with progression to ESRD, kidney transplant should be pursued, provided that viral load control is adequate. Screening for the presence of kidney disease upon detection of HIV-1 seropositivity in high-risk populations is recommended.
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Affiliation(s)
- Laura Palau
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Steven Menez
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Tessa Novick
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Marco Delsante
- Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Blaithin A McMahon
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Mohamed G Atta
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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