Renal dysfunction among HIV-infected patients starting antiretroviral therapy

Renal outcomes in adults with HBV, HIV and HBV/HIV coinfection after 3 years of antiviral therapy in urban Tanzania

BACKGROUND

An enhanced understanding of renal outcomes in persons with chronic HBV, HIV, and HBV/HIV coinfection is needed to mitigate chronic kidney disease in regions where HBV and HIV are endemic.

OBJECTIVES

To investigate changes in estimated glomerular filtration rate (eGFR) in adults with HBV, HIV or HBV/HIV enrolled in a 3 year prospective cohort study of liver outcomes in Dar es Salaam, Tanzania and initiated on antiviral therapy.

METHODS

We compared eGFR between and within groups over time using mixed-effects models.

RESULTS

Four hundred and ninety-nine participants were included in the analysis (HBV: 164; HIV: 271; HBV/HIV: 64). Mean baseline eGFRs were 106.88, 106.03 and 107.18 mL/min/1.73 m2, respectively. From baseline to Year 3, mean eGFR declined by 4.3 mL/min/1.73 m2 (95% CI -9.3 to 0.7) and 3.7 (-7.8 to 0.5) in participants with HBV and HIV, respectively, and increased by 5.1 (-4.7 to 14.9) in those with HBV/HIV. In multivariable models, participants with HBV had lower eGFRs compared with those with HIV or HBV/HIV and, after adjusting for HBV DNA level and hepatitis B e antigen (HBeAg) status, significantly lower eGFRs than those with HBV/HIV at all follow-up visits.

CONCLUSIONS

In this Tanzanian cohort, coinfection with HBV/HIV did not appear to exacerbate renal dysfunction compared with those with either infection alone. Although overall changes in eGFR were small, persons with HBV experienced lower eGFRs throughout follow-up despite their younger age and similar baseline values. Longer-term studies are needed to evaluate continuing changes in eGFR and contributions from infection duration and other comorbidities.

HIV and hypertension epidemiology

PURPOSE OF REVIEW

The aim of this study was to provide an overview of the burden, pathogenesis, and recent recommendations for treating hypertension among people living with HIV (PLWH). This review is relevant because of the increase in the prevalence of HIV as a chronic disease and the intersection of the increasing prevalence of hypertension.

RECENT FINDINGS

The contribution of HIV to the pathogenesis of hypertension is complex and still incompletely understood. Evidence suggests that chronic inflammation from HIV, antiretroviral treatment (ART), and comorbidities such as renal disease and insulin resistance contribute to developing hypertension in PLWH. Treatment is not distinct from guidelines for HIV-noninfected people. Nonpharmacological guidelines such as decreasing blood pressure by promoting a healthy lifestyle emphasizing exercise, weight loss, and smoking cessation are still recommended in the literature. The pharmacological management of hypertension in PLWH is similar, but special attention must be given to specific drugs with potential interaction with ART regimens. Further research is needed to investigate the pathways and effects of hypertension on HIV.

SUMMARY

There are different pathways to the pathogenesis of hypertension in PLWH. Clinicians should take it into consideration to provide more precise management of hypertension in PLWH. Further research into the subject is still required.

Proximal tubular renal dysfunction among HIV infected patients on Tenofovir versus Tenofovir sparing regimen in western Kenya

INTRODUCTION

Tenofovir Disoproxil Fumarate (TDF) is the most widely used Anti-Retroviral Therapy (ART) drug due to its potency, safety profile and World Health Organization (WHO) recommendation. TDF causes proximal tubular renal dysfunction (PTRD) leading to Fanconi syndrome, acute kidney injury and chronic kidney disease. Modest rates (2-4%) of TDF related toxicity based on estimated Glomerular Filtration Rate (GFR) have been described, while TDF-induced PTRD has been reported to be 22%. TDF toxicity is more likely among African patients, it is reversible and TDF may be renal dosed in patients with dysfunction. The objective of this study was to assess proximal tubular renal dysfunction, global renal function, and their determinants among patients on TDF versus TDF-sparing regimen.

METHODS

This was a cross-sectional study among people living with HIV/AIDS (PLWHA) attending the Academic Model Providing Access to Healthcare (AMPATH) program. The primary outcome of interest in this study was PTRD while the secondary outcome of interest was estimated GFR. PTRD was defined as any two of beta-2 microglobulin in urine, metabolic acidosis, normoglycemic glucosuria and fractional excretion of phosphate. Student's t-test, chi-square and their non-parametric equivalents were used to test for statistical significance. Univariate and multivariate logistic regression analysis was carried out.

RESULTS

A total of 516 participants were included in the final analysis, 261 on TDF while 255 were on TDF-sparing regimens. The mean (SD) age of all participants was 41.5 (12.6) years with majority being female (60.3%). The proportion of PTRD was 10.0% versus 3.1% in the TDF compared to TDF-sparing group (P<0.001). Mean estimated GFR was 112.8 (21.5) vs 109.7 (21.9) ml/min/1.73mm3 (P = 0.20) for the TDF compared to TDF-sparing group. TDF users were more likely to have PTRD compared to non-TDF users, adjusted Odds Ratio (AOR) 3.0, 95% CI 1.12 to 7.75.

CONCLUSION

There was significant PTRD in the TDF compared to TDF-sparing group without significant difference in estimated GFR. The clinical significance of these findings may not be clear in the short term.

Duration of Tenofovir Use and Diabetes Mellitus Predict Microalbuminuria among Well-controlled Human Immunodeficiency Virus-infected Patients Attending a Tertiary Clinic in Gaborone, Botswana

The study aimed to determine the prevalence and associated factors of microalbuminuria among patients infected with human immunodeficiency virus (HIV). A cross-sectional study was conducted at the Infectious Disease Control Center of Princess Marina Hospital, a Tertiary Clinic in Gaborone, Botswana. The risk factors of microalbuminuria were determined by comparing the sociodemographic and clinical characteristics of patients with the presence of microalbuminuria or normoalbuminuria. In total, 297 randomly selected HIV-infected patients were included in the analysis. The mean age of the study participants was 48.6 years, with the majority of patients (60.9%) being females. The study participants were largely well-controlled both immunologically and virologically, with 283/297 (95.3%) and 280/297 (94.3%), having CD4 counts of more than 200 cells/mm3 and undetected viral load (<400 copies/mL), respectively. The prevalence of microalbuminuria was found to be 46.5%. Microalbuminuria was associated with the duration of exposure to a regimen containing tenofovir [P <0.001, odds ratio = 1.137, 95% confidence interval (CI) = 1.073-1.205] and a history of diabetes mellitus (P = 0.044, odds ratio = 9.260, 95% CI = 1.058-81.06). Sociodemographic characteristics and other clinical factors were not associated with microalbuminuria. There is a need to carry out prospective studies among HIV- infected patients with microalbuminuria to determine the short- and long-term cardiovascular morbidity and mortality outcomes.

Determinants and Incidence of Chronic Kidney Disease with Tenofovir-Based Antiretroviral Therapy Regimens: A Cohort Study in HIV-Infected Adults in South China

Background:

The data of the impact of tenofovir (TDF) on kidney damage in Chinese HIV-1 infected patients are limited.

Objective:

To evaluate the incidence and risk factors of stage 3 chronic kidney disease (CKD) and rapid kidney function decline (RKFD) among Chinese HIV-1 infected patients starting with a TDF-based regimen.

Method:

We enrolled in 797 TDF-initiated HIV-1-infected patients in a Chinese cohort. Kidney dysfunctions were defined as stage 3 CKD (eGFR < 60 mL/min/1.73 m2 during follow-up) and RKFD (eGFR decline > 10 mL/min/1.73 m2/year). A linear mixed-effects model was used to quantify the average eGFR change per 48 weeks. A generalized estimating equation regression analysis was conducted to determine the risk factors associated with renal dysfunction. The method of multiple imputation was used to reduce the bias caused by missing data.

Results:

In this retrospective study, 14 (2%) patients experienced stage 3 CKD, and 272 (34%) individuals experienced RKFD during a median of 26 (IQR, 4-78; maximum 325) weeks follow-up period. The mean loss in eGFR per 48 weeks increased consistently over time, from -2.59 mL/min/1.73 m2 before 48 weeks to -17.61 mL/min/1.73 m2 after 288 weeks. For every 10 mL/min/1.73 m2 increase of eGFR, the risk of RKFD increased by 29% (95%CI: 18%, 40%). Each 10 years older and every 10 mL/min/1.73 m2 higher in baseline eGFR, the risk of stage 3 CKD increased to 1.56 (95% CI: 1.00, 2.43) and decreased by 65% (95% CI: 48%, 76%), respectively. Anemia and higher viral load were significantly associated with RKFD. The results were robust across a range of multiple imputation analyses.

Conclusions:

TDF-associated CKD is rare in HIV-1 infected Chinese adults. Longer TDF-exposed patients are more likely to have renal dysfunction, especially those with older age, anemia, lower baseline eGFR, and higher viral load.

Interaction of sex and HIV infection on renal impairment: baseline evidence from the CHART cohort

OBJECTIVE

Females are more vulnerable to renal impairment (RI) in people living with HIV (PLWH), but few studies have examined sex disparity in the association of HIV serostatus with RI.

METHODS

In total, 2,101 PLWH on antiretroviral treatment (ART) and 4,202 HIV-negative people were selected and frequency matched in 1:2 ratio by sex and age categories. RI was defined as estimated glomerular filtration rate (eGFR) <90 mL/min/1.73 m². The interaction effect of sex with HIV serostatus and correlates of RI were assessed by logistic regression models.

RESULTS

In total, 78.2% of participants were males with median age 43.7 (IQR: 32.5-54.4) years. The prevalence of RI was comparable for PLWH and HIV-negative people overall (30.4% vs 30.1%) but significantly higher for HIV-positive females (37.1%) than HIV-negative females (30.1%). Multiple logistic regression identified an interaction between sex and HIV serostatus on RI (adjusted odds ratio [aOR] of the interaction term: 1.66, 95% CI: 1.23-2.26). HIV infection was significantly associated with RI in females (aOR: 1.55, 95% CI: 1.17-2.06) but not in males. Central obesity and nadir CD4 count were significantly associated with RI in HIV-infected females but not in HIV-infected males.

CONCLUSIONS

Sex seems to modify the association between HIV infection and RI, suggesting a sex-specific mechanistic pathogenesis of RI in PLWH, which warrants further investigation and intervention.

Evaluation of kidney function among people living with HIV initiating antiretroviral therapy in Zambia

As the response to the HIV epidemic in sub-Saharan Africa continues to mature, a growing number of people living with HIV (PLHIV) are aging and risk for non-communicable diseases increases. Routine laboratory tests of serum creatinine have been conducted to assess HIV treatment (ART) suitability. Here we utilize those measures to assess kidney function impairment among those initiating ART. Identification of non-communicable disease (NCD) risks among those in HIV care creates opportunity to improve public health through care referral and/or NCD/HIV care integration. We estimated glomerular filtration rates (eGFR) using routinely collected serum creatinine measures among a cohort of PLHIV with an HIV care visit at one of 113 Centre for Infectious Disease Research Zambia (CIDRZ) supported sites between January 1, 2011 and December 31, 2017, across seven of the ten provinces in Zambia. We used mixed-effect Poisson regression to assess predictors of eGFR <60ml/min/1.73m2 allowing random effects at the individual and facility level. Additionally, we assessed agreement between four eGFR formulae with unadjusted CKD-EPI as a standard using Scott/Fleiss method across five categories of kidney function. A total of 72,933 observations among 68,534 individuals met the inclusion criteria for analysis. Of the 68,534, the majority were female 41,042 (59.8%), the median age was 34 (interquartile range [IQR]: 28-40), and median CD4 cell count was 292 (IQR: 162-435). The proportion of individuals with an eGFR <60ml/min/1.73m2 was 6.9% (95% CI: 6.7-7.1%) according to the unadjusted CKD-EPI equation. There was variation in agreement across eGFR formulas considered compared to unadjusted CKD-EPI (χ2 p-value <0.001). Estimated GFR less than 60ml/min/1.73m2, per the unadjusted CKD-EPI equation, was significantly associated with age, sex, body mass index, and blood pressure. Using routine serum creatinine measures, we identified a significant proportion of individuals with eGFR indicating moderate or great kidney function impairment among PLHIV initiating ART in Zambia. It is possible that differentiated service delivery models could be developed to address this subset of those in HIV care with increased risk of chronic kidney disease.

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.

Renal function in a cohort of HIV-infected patients initiating antiretroviral therapy in an outpatient setting in Ethiopia

Aim

To evaluate the prevalence and associated factors of abnormal renal function among Ethiopian HIV-infected patients at baseline prior to initiation of antiretroviral therapy (ART) and during follow-up.

Methods

We conducted a retrospective observational cohort study of HIV infected patients who initiated ART at the outpatient ART clinic of Mehal Meda Hospital of North Shewa, Ethiopia from January 2012 to August 2018. Demographic and clinical data were abstracted from the medical records of patients. Renal function was assessed by estimated glomerular filtration rate (eGFR) calculated using the Modification of Diet in Renal Disease (MDRD) equation. Univariate and multivariate analysis were conducted to determine the factors associated with abnormal renal function at baseline and during follow-up.

Results

Among 353 patients, 70 (19.8%) had baseline eGFR <60 ml/min/1.73m² and 102 (28.9%) had eGFR = 60–89.9 ml/min/1.73m². Factors associated with baseline renal impairment (eGFR <60 ml/min/1.73m²) included female sex (AOR = 3.52, CI 1.75–7.09), CD4 count < 200 cells/mm³ (AOR = 2.75, CI 1.40–5.42), BMI < 25 Kg/m² (AOR = 3.04, CI 1.15–8.92), low hemoglobin (AOR = 2.19, CI 1.16–4.09) and high total cholesterol (AOR = 3.15, CI 1.68–5.92). After a median of 3.0 years of ART, the mean eGFR declined from 112.9 ± 81.2 ml/min/1.73m² at baseline to 93.9 ± 60.6 ml/min/1.73m² (P < 0.001). The prevalence of renal impairment increased from 19.8% at baseline to 22.1% during follow-up. Of 181 patients with baseline normal renal function, 49.7% experienced some degree of renal impairment. Older age (AOR = 3.85, 95% CI 2.03–7.31), female sex (AOR = 4.18, 95% CI 2.08–8.40), low baseline CD4 (AOR = 2.41, 95% CI 1.24–4.69), low current CD4 count (AOR = 2.32, 95% CI 1.15–4.68), high BMI (AOR = 2.91, 95% CI 1.49–5.71), and low hemoglobin (AOR = 3.38, 95% CI 2.00–7.46) were the factors associated with renal impairment during follow-up.

Conclusion

Impaired renal function was common in HIV-infected patients initiating ART in an outpatient setting in Ethiopia, and there appears to be a high prevalence of renal impairment after a median ART follow-up of 3 years. There is a need for assessment of renal function at baseline before ART initiation and regular monitoring of renal function for patients with HIV during follow-up.

Renal Dysfunction among HIV-Infected Patients on Antiretroviral Therapy in Dar es Salaam, Tanzania: A Cross-Sectional Study

Background

HIV-associated renal dysfunction is common among infected patients; the growing burden of this condition may be partly accounted for by improved survival attributed to sustained viral suppression with antiretroviral therapies (ART). Some ART regimens are nephrotoxic and may potentially contribute to renal dysfunction observed in these patients. This study aimed at investigating the prevalence of renal dysfunction among people living with HIV (PLHIV) on ART attending the care and treatment clinic (CTC).

Methods

A cross-sectional study was conducted between June and October 2019 among adults living with HIV on ART for 6 months or more attending CTC at Muhimbili National Hospital in Dar es Salaam, Tanzania. A total of 287 participants were screened for proteinuria and microalbuminuria using the Cybow 300 urine analyzer. Serum creatinine was tested for all participants, and it was used to estimate glomerular filtration rate (eGFR) using the CKD-EPI formula.

Results

Out of 287 participants (72.1% female, mean age ± SD: 46.7 ± 10.6 years), about one-third (32.8%) had eGFR less than 90 ml/min, whereas 7% had eGFR less than 60 ml/min. Microalbuminuria and proteinuria were detected in 38.6% and 25.1% of participants, respectively. In the multivariate analysis, predictive determinants for renal dysfunction were higher viral loads (OR 2.5 (1.1–5.8), p=0.031), diabetes mellitus (OR 5.5 (1.6–18.6), p=0.006), and age above 60 years (OR 2.8 (1.0–7.3), p=0.041); however, this was not the case for serum CD4 counts (OR 1.25 (0.7–2.3), p=0.46).

Conclusion

High prevalence of renal dysfunction among PLHIV on ART was noted in this study. Viral loads above 1000 cp/ml and diabetes mellitus were noted to be associated with increased risk for renal dysfunction.

Prevalence of tubulopathy and association with renal function loss in HIV-infected patients

BACKGROUND

The incidence of chronic kidney disease (CKD) is 10 times higher in human immunodeficiency virus (HIV)-infected patients than in the general population. We explored the prevalence and determinants of proximal tubular dysfunction (PTD) in HIV-infected individuals, and assessed the impact of the tubulopathy on the estimated glomerular filtration rate (eGFR) outcome.

METHODS

A cohort study was performed on 694 outpatients followed in a French centre to analyse the prevalence of PTD, the diagnosis performance of screening tools and the associated factors. eGFR was prospectively evaluated to analyse the predictive value of the tubulopathy on eGFR decrease.

RESULTS

At inclusion, 14% of the patients presented with PTD and 5% with CKD. No individual tubular marker, including non-glomerular proteinuria, glycosuria dipstick or hypophosphataemia, registered sufficient performance to identify PTD. We found a significant interaction between tenofovir disoproxil fumarate exposure and ethnicity (P = 0.03) for tubulopathy risk. Tenofovir disoproxil fumarate exposure was associated with PTD in non-Africans [adjusted odds ratio (aOR) = 4.71, P < 10-3], but not in patients of sub-Saharan African origin (aOR = 1.17, P = 0.73). Among the 601 patients followed during a median of 4.3 years, 13% experienced an accelerated eGFR decline. Unlike microalbuminuria and glomerular proteinuria, tubulopathy was not associated with accelerated eGFR decline.

CONCLUSION

PTD is not rare in HIV-infected individuals but is less frequent in sub-Saharan African patients and is associated with tenofovir disoproxil fumarate exposure only in non-Africans. Its diagnosis requires multiple biochemical testing and it is not associated with an accelerated eGFR decline.

Prevalence of microalbuminuria and associated factors among HIV - infected ART naïve patients at Mulago hospital: a cross-sectional study in Uganda

Background

HIV infection affects multiple organs and the kidney is a common target making renal disease, one of the recognized complications. Microalbuminuria represents an early, important marker of kidney damage in several populations including HIV-infected antiretroviral therapy (ART) naïve patients. Early detection of microalbuminuria is critical to slowing down progression to chronic kidney disease (CKD) in HIV-infected patients, however, the burden of microalbuminuria in HIV-infected antiretroviral therapy (ART) naïve patients in Uganda is unclear.

Methods

A cross-sectional study was conducted in the Mulago Immune suppression syndrome (ISS) clinic among adult HIV − infected ART naïve outpatients. Data on patient demographics, medical history was collected. Physical examination was performed to assess body mass index (BMI) and hypertension. A single spot morning urine sample from each participant was analysed for microalbuminuria using spectrophotometry and colorimetry. Microalbuminuria was defined by a urine albumin creatinine ratio (UACR) 30-299 mg/g and macroalbuminuria by a UACR > 300 mg/g. To assess the factors associated with microalbuminuria, chi-square, Fisher’s exact test, quantile regression and logistic regression were used.

Results

A total of 185 adult participants were consecutively enrolled with median age and CD4+ counts of 33(IQR = 28–40) years and 428 (IQR = 145–689) cells/μL respectively. The prevalence of microalbuminuria was 18.9% (95% CI, 14–25%). None of the participants had macroalbuminuria. CD4+ count <350cells/μL was associated with increased risk of microalbuminuria (OR: 0.27, 95% CI: 0.12–0.59), P value = 0.001). Diabetes mellitus, hypertension, smoking, alcohol intake were not found to be significantly associated with microalbuminuria.

Conclusion

Microalbuminuria was highly prevalent in adult HIV − infected ART naive patients especially those with low CD4+ count. There is need to study the effect of ART on microalbuminuria in adult HIV − infected patients.

Tenofovir disoproxil fumarate associated nephrotoxicity: a retrospective cohort study at two referral hospitals in Namibia

INTRODUCTION

The incidence and risk factors of tenofovir disoproxil fumarate (TDF)-related renal impairment (RI) in Namibia are unknown where TDF-containing ART regimens are used as the first line for HIV.

METHODOLOGY

A retrospective cohort study among HIV-infected patients at two intermediate hospitals. A decline in estimated glomerular filtration rate (eGFR) was significant if it was ≥25% and included a change to a lower eGFR stage. New-onset RI was defined as an eGFR <50 mL/min/1.73m² .

RESULTS

10 387 patients were included: 11.4% (n = 1182) experienced the decline in eGFR. Of these, 0.6% (n = 62) migrated to eGFR stages IV and V. The incidence was 4.5 (95% CI: 4.3-4.8) per 100 patient years. RI developed in 400 patients for an incidence rate of 2.4 (95% CI: 2.2-2.6) cases per 100 patient years. Risk factors with effect sizes >2.0, for decline-in-eGFR were baseline eGFR >60 (aHR = 15.6); hyperfiltration (aHR = 5.0); and pregnancy (aHR = 2.4); while for RI, they were hyperfiltration (aHR = 4.1) and pregnancy (aHR = 29).

CONCLUSION

The incidence of decline-in-eGFR was higher than in other sub-SSA countries, but not RI. A high baseline eGFR had the greatest risk for the decline, and hyperfiltration for the RI.

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.

Prevalence of non-communicable diseases among individuals with HIV infection by antiretroviral therapy status in Dar es Salaam, Tanzania

Background

Long-term antiretroviral therapy has modified the clinical course of HIV infection to a chronic condition associated with increased risk of developing non-communicable diseases (NCDs). Information is scant, from sub-Saharan Africa, on the prevalence of NCDs and associated factors among individuals on ART.

Methodology

We consecutively enrolled individuals with HIV infection who were ART naïve and those on ART for ≥5 years (LTART) attending health facilities in Dar es Salaam. Participant's blood pressure, anthropometric measurements, and fasting blood glucose were recorded. Participants with impaired fasting blood glucose underwent an oral glucose tolerance test. A venous blood sample was sent to the lab for biochemical tests. Chi-square test was used to compare proportions, Poisson regression with robust standard errors was used to determine associations between variables.

Results

Overall, 612 individuals with HIV infection were enrolled, half of whom were ART naïve. Females comprised 71.9% and 68.0% of participants in the LTART and ART naïve study arms, respectively, p = 0.290. The mean age (±SD) was 44.9 ± 12.7 years and 37.5 ± 11.8 years among LTART and ART naïve participants, respectively, p<0.001. Hypertension was documented in 25.2% in those on LTART compared to 6.9% among ART naïve subjects, p<0.001. Impaired glucose tolerance was found in 22.9% and 4.6% among LTART compared to ART naïve subjects, p<0.001. Diabetes mellitus was detected in 17.0% of those on LTART compared to 3.9% ART naïve participants, p<0.001. Hypercholesterolemia was found in 30.4% of individuals on LTART compared to 16.7% of ART naïve subjects, p<0.001, and hypertriglyceridemia was found in 16.0% of participants on LTART compared to 9.5% of ART naïve, p = 0.015. LTART use, age ≥40 years, history of smoking, and body mass index were independently associated with NCDs.

Conclusion

Hypertension, impaired glucose tolerance, diabetes mellitus, hypercholesterolemia, and hypertriglyceridemia were associated with long-term use of antiretroviral drugs.

Proximal renal tubular function in HIV-infected children on tenofovir disoproxil fumarate for treatment of HIV infection at two tertiary hospitals in Harare, Zimbabwe

BACKGROUND

Renal abnormalities in HIV infected children may be due to the HIV infection or treatment among other factors. Tenofovir disoproxil fumarate (TDF) is associated with proximal renal tubular dysfunction, proteinuria and decrease in glomerular function. Studies in developed countries have shown variable prevalence of proximal renal tubular dysfunction in children on TDF. There are no known studies in developing countries, including Zimbabwe, documenting the proximal tubular function in HIV infected children on TDF. The aim of this study was to assess renal and proximal renal tubular function in HIV infected children receiving TDF and determine factors associated with proximal tubular dysfunction.

METHODS

A descriptive cross-sectional study was conducted in HIV infected patients below 18 years of age attending outpatient clinics at two tertiary hospitals in Harare, who received a TDF-containing antiretroviral regimen for at least six months. Dipstick protein and glucose, serum and urine phosphate and creatinine levels were measured. Fractional excretion of phosphate was calculated. Estimated glomerular filtration rate (eGFR) was calculated using the Schwartz formula. Tubular dysfunction was defined by at least two of the following characteristics: normoglycaemic glycosuria, hypophosphatemia and fractional excretion of phosphate > 18%.

FINDINGS

One hundred and ninety-eight children below 18 years of age were recruited over a period of six months. The prevalence of tubular dysfunction was 0.5%. Normoglycaemic glycosuria occurred in 1 (0.5%), fractional excretion of phosphate >18% in 4 (2%), and hypophosphatemia in 22 [11.1%] patients. Severe stunting was associated with increased risk of hypophosphatemia (OR 9.31 CI (1.18, 80.68) p = 0.03). Reduction in estimated glomerular filtration rate (eGFR) < 90ml/min/1.73m2 and proteinuria was evident in 35.9% and 32.8% of children, respectively. Concurrent TDF and HIV-1 protease inhibitor-based regimen was the only independent factor associated with reduction in GFR (OR 4.43 CI (1.32; 4.89) p = 0.016).

CONCLUSION

Tubular dysfunction was uncommon in Zimbabwean children on a TDF-based ART regimen. Hypophosphatemia, proteinuria and reduction in eGFR were common. Reassessing renal function using more sensitive biomarkers is needed to examine the long-term tolerance of TDF.

A 10-year follow-up study of demographic and cardiometabolic factors in HIV-infected South Africans

OBJECTIVES

Understanding of the interplay between human immunodeficiency virus (HIV) and cardiovascular disease, especially in Africa, is limited to evidence from longitudinal studies. Therefore the demographic profile and cardiometabolic, renal and liver function of an HIV-infected South African population were profiled from 2005 to 2015.

METHODS

The study included 117 HIV-infected and 131 uninfected controls that were examined at baseline, five and 10 years.

RESULTS

Mortality rate declined from 24% (2005-2010) to 0% (2010-2015) after the introduction of ART. Longitudinal increases in C-reactive protein (p = 0.002), alanine transaminase (p = 0.006) and gamma-glutamyl transferase (p = 0.046) levels and estimated glomerular filtration rate (p < 0.001) were seen only in the HIV-infected group. This group also showed increased high-density lipoprotein cholesterol (HDL-C) (p < 0.001) and total cholesterol (p < 0.001) levels and decreased triglyceride:HDL-C (p = 0.011) levels. Low-density lipoprotein cholesterol decreased in both groups (p < 0.001).

CONCLUSIONS

Despite trajectories of deranged lipid and inflammatory profiles, the cardiometabolic disease risk seems stable in HIV-infected South Africans. Inflammation and renal and liver function warrant regular monitoring.

Developing nephrology services in low income countries: a case of Tanzania

BACKGROUND

The burden of kidney diseases is reported to be higher in lower- and middle-income countries as compared to developed countries, and countries in sub-Saharan Africa are reported to be most affected. Health systems in most sub-Sahara African countries have limited capacity in the form of trained and skilled health care providers, diagnostic support, equipment and policies to provide nephrology services. Several initiatives have been implemented to support establishment of these services.

METHODS

This is a situation analysis to examine the nephrology services in Tanzania. It was conducted by interviewing key personnel in institutions providing nephrology services aiming at describing available services and international collaborators supporting nephrology services.

RESULTS

Tanzania is a low-income country in Sub-Saharan Africa with a population of more than 55 million that has seen remarkable improvement in the provision of nephrology services and these include increase in the number of nephrologists to 14 in 2018 from one in 2006, increase in number of dialysis units from one unit (0.03 unit per million) before 2007 to 28 units (0.5 units per million) in 2018 and improved diagnostic services with introduction of nephropathology services. Government of Tanzania has been providing kidney transplantation services by funding referral of donor and recipients abroad and has now introduced local transplantation services in two hospitals. There have been strong international collaborators who have supported nephrology services and establishment of nephrology training in Tanzania.

CONCLUSION

Tanzania has seen remarkable achievement in provision of nephrology services and provides an interesting model to be used in supporting nephrology services in low income countries.

The baseline glomerular filtration rate, predictive of six-year survival in sub-Saharan African patients on antiretroviral therapy for HIV: Cohort study

BACKGROUND

Recently, serious morbidity events associated with initial glomerular filtration rate (GFR) have been described during HIV infection, but this is insufficiently investigated in sub-Saharan Africa very affected by HIV.

OBJECTIVE

To assess the impact of baseline GFR prevailing during the first semester of the HIV infection management on six-year survival in peoples taking antiretroviral therapy.

PATIENTS AND METHODS

Closed retrospective cohort study. The death was the expected outcome, the baseline GFR (mL/min/1.73m²) in the first semester of the follow-up was the main exposure. Kaplan-Meier method, Cox regression were used for analysis.

RESULTS

According to baseline GFR: <60, 60-89 and≥90, the six-year survival was 81.6%; 95.8% and 96.4% (P=0.067 Breslow). Adjusted hazard ratio for baseline GFR<60 and 60-89 (vs. ≥90) were respectively 5.4 (95%CI: 1.4-19.9; P=0.012) and 1.2 (95%CI: 0.3-4.0; P=0.754). The etiological fraction of deaths attributable to baseline GFR: GFR<60: 81% (95%CI: 0.31-0.95), GFR=60-89: 18.0% (95%CI: -0.7-0.8). Prognostic concordance index=0.84 (95%CI: 0.59-0.95) for GFR<60 and 0.55 (95%CI: 0.27-0.81) for GFR 60-89.

DISCUSSION

The etiological fraction of death and prognostic concordance index associated to baseline GFR level increase significantly with decline of baseline GFR.

CONCLUSION

Baseline GFR seems to predict the six-year survival in African sub-Saharan patients treated for HIV.

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

INTRODUCTION

The widespread use of antiretroviral therapies (ART) has increased life expectancy in HIV patients, predisposing them to chronic non-communicable diseases including Chronic Kidney Disease (CKD). We performed a systematic review and meta-analysis (PROSPERO registration number CRD42016036246) to determine the global and regional prevalence of CKD in HIV patients.

METHODS

We searched PubMed, Web of Science, EBSCO and AJOL for articles published between January 1982 and May 2016. CKD was defined as estimated glomerular filtration rate (eGFR) <60ml/min using the MDRD, Cockcroft-Gault or CKD-EPI equations. Random effects model was used to combine prevalence estimates from across studies after variance stabilization via Freeman-Tukey transformation.

RESULT

Sixty-one eligible articles (n = 209,078 HIV patients) in 60 countries were selected. The overall CKD prevalence was 6.4% (95%CI 5.2-7.7%) with MDRD, 4.8% (95%CI 2.9-7.1%) with CKD-EPI and 12.3% (95%CI 8.4-16.7%) with Cockcroft-Gault; p = 0.003 for difference across estimators. Sub-group analysis identified differences in prevalence by WHO region with Africa having the highest MDRD-based prevalence at 7.9% (95%CI 5.2-11.1%). Within Africa, the pooled MDRD-based prevalence was highest in West Africa [14.6% (95%CI 9.9-20.0%)] and lowest in Southern Africa (3.2%, 95%CI 3.0-3.4%). The heterogeneity observed could be explained by WHO region, comorbid hypertension and diabetes mellitus, but not by gender, hepatitis B or C coinfection, CD4 count or antiretroviral status.

CONCLUSION

CKD is common in HIV-infected people, particularly in Africa. HIV treatment programs need to intensify screening for CKD with added need to introduce global guidelines for CKD identification and treatment in HIV positive patients.

Prevalence and Evolution of Renal Impairment in People Living With HIV in Rural Tanzania

Background

We assessed the prevalence, incidence, and predictors of renal impairment among people living with HIV (PLWHIV) in rural Tanzania.

Methods

In a cohort of PLWHIV aged ≥15 years enrolled from January 2013 to June 2016, we assessed the association between renal impairment (estimated glomerural filtration rate < 90 mL/min/1.73 m²) at enrollment and during follow-up with demographic and clinical characteristcis using logistic regression and Cox proportional hazards models.

Results

Of 1093 PLWHIV, 172 (15.7%) had renal impairment at enrollment. Of 921 patients with normal renal function at baseline, 117 (12.7%) developed renal impairment during a median follow-up (interquartile range) of 6.2 (0.4–14.7) months. The incidence of renal impairment was 110 cases per 1000 person-years (95% confidence interval [CI], 92–132). At enrollment, logistic regression identified older age (adjusted odds ratio [aOR], 1.79; 95% CI, 1.52–2.11), hypertension (aOR, 1.84; 95% CI, 1.08–3.15), CD4 count <200 cells/mm³ (aOR, 1.80; 95% CI, 1.23–2.65), and World Health Organization (WHO) stage III/IV (aOR, 3.00; 95% CI, 1.96–4.58) as risk factors for renal impairment. Cox regression model confirmed older age (adjusted hazard ratio [aHR], 1.85; 95% CI, 1.56–2.20) and CD4 count <200 cells/mm³ (aHR, 2.05; 95% CI, 1.36–3.09) to be associated with the development of renal impairment.

Conclusions

Our study found a low prevalence of renal impairment among PLWHIV despite high usage of tenofovir and its association with age, hypertension, low CD4 count, and advanced WHO stage. These important and reassuring safety data stress the significance of noncommunicable disease surveillance in aging HIV populations in sub-Saharan Africa.

Prevalence and burden of chronic kidney disease among the general population and high-risk groups in Africa: a systematic review

OBJECTIVES

While increasing attention is paid to the rising prevalence of chronic diseases in Africa, there is little focus on chronic kidney disease (CKD). This systematic review assesses CKD burden among the general population and high-risk groups on the entire African continent.

DESIGN, SETTING AND PARTICIPANTS

We searched Medline and PubMed databases for articles published between 1 January 1995 and 7 April 2017 by sensitive search strategies focusing on CKD surveys at the community level and high-risk groups. In total, 7918 references were evaluated, of which 7766 articles were excluded because they did not meet the inclusion criteria. Thus, 152 studies were included in the final analysis.

OUTCOME MEASUREMENT

The prevalence of CKD in each study group was expressed as a range and pooled prevalence rate of CKD was calculated as a point estimate and 95% CI. No meta-analysis was done. Data were presented for different populations.

RESULTS

In the community-level studies, based on available medium-quality and high-quality studies, the prevalence of CKD ranged from 2% to 41% (pooled prevalence: 10.1%; 95% CI 9.8% to 10.5%). The prevalence of CKD in the high-risk groups ranged from 1% to 46% (pooled prevalence: 5.6%; 95% CI 5.4% to 5.8%) in patients with HIV (based on available medium-quality and high-quality studies), 11%-90% (pooled prevalence: 24.7%; 95% CI 23.6% to 25.7%) in patients with diabetes (based on all available studies which are of low quality except four of medium quality) and 13%-51% (pooled prevalence: 34.5%; 95 % CI 34.04% to 36%) in patients with hypertension (based on all available studies which are of low quality except two of medium quality).

CONCLUSION

In Africa, CKD is a public health problem, mainly attributed to high-risk conditions as hypertension and diabetes. The poor data quality restricts the validity of the findings and draws the attention to the importance of designing future robust studies.

Effect of Tenofovor Diproxil Fumarate on Renal Function and Urinalysis Abnormalities in HIV-Infected Cameroonian Adults

In Sub-Saharan Africa, the prevalence of HIV-associated kidney diseases is as high as 53.3%. Combined antiretroviral treatment (cART), especially tenofovir disoproxil fumarate (TDF), is known to be nephrotoxic. We undertook this cross-sectional study conducted in 2015 at the Regional Hospital Limbe in the Southwest Region of Cameroon to determine the prevalence of renal dysfunction and its correlates among treatment-experienced HIV-infected patients on TDF and treatment-naïve patients. In April 2016, a follow-up was performed on those who had been treatment-naïve and were started on cART after enrolment in the study. We compared 119 patients on TDF-containing regimens with 47 treatment-naïve patients. Proteinuria was significantly more prevalent, and creatinine was significantly higher among treatment-naïve patients than among those on treatment (52.2% versus 26.1%; P = 0.003 and P = 0.009, respectively). The proportion of patients with an estimated glomerular filtration rate (eGFR) < 60 mL/minute was significantly higher among treatment-naïve patients than among those on TDF treatment (40.4% versus 24.4%; P = 0.041). Treatment-naïve patients displayed an improvement in creatinine levels and eGFR after 6 months of treatment. To the best of our knowledge, this is the first study to investigate the impact of TDF on renal parameters in Cameroon. TDF appears to be safe and does not appear to be a significant cause of renal impairment. However, renal parameters should be monitored regularly, as recommended by the guidelines.

Renal manifestations of HIV during the antiretroviral era in South Africa: a systematic scoping review

BACKGROUND

It is estimated that 650,000 patients may develop human immunodeficiency virus (HIV)-related renal disease in South Africa. South Africa has recently adopted WHO policy, stipulating that all HIV-infected patients have access to antiretroviral treatment (ART) irrespective of CD4 cell count.

METHODS

We searched Google Scholar, PubMed, Medline, Cochrane Library, Worldcat.org and EBSCO host databases from July 2015 to December 2015. Eligibility criteria included articles pertaining to renal manifestations of HIV in South Africa from 2004 to 2015 in adult patients (≥ 18 years). We independently reviewed the articles for quality. Thematic content analysis was performed to identify patterns of renal manifestations from the included studies. The risk of bias (e.g. internal validity) in the included studies was evaluated using the mixed methods appraisal tool.

RESULTS

Eleven out 21 studies were eligible for data extraction. The prevalence of urine abnormalities on urine dipsticks was high but had poor sensitivity and specificity for detecting renal impairment. Normal renal function occurred in 28.4 to 79% of patients, mild renal impairment occurred in 19 to 57.1% and moderate renal impairment in 2 to 14.4%. Severe renal impairment occurred in 1.3% of patients. Both the Cockcroft-Gault equation (after correcting for bias) and the 4-variable Modification of Diet in Renal Disease equation (without the ethnicity factor for African Americans) have been validated for the estimation of glomerular filtration rate (eGFR) in Black South Africans. HIV-associated nephropathy was the most prevalent histology seen (57.2%). Older age, a lower CD4 count, a low haemoglobin and a detectable viral load were associated with renal impairment. Renal function improved in the first year of commencing ART as evidenced by the regression of proteinuria and the increase in eGFR.

CONCLUSION

The findings of the review have implications to the recently adopted 'test and treat' approach to HIV prevention and management.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016039270.

Risk factors for impaired fasting glucose or diabetes among HIV infected patients on ART in the Copperbelt Province of Zambia

BACKGROUND

Africa has a high prevalence of both Human Immunodeficiency Virus and Non Communicable Diseases (NCDs) but in Zambia there are few data on co-morbid NCDs like Diabetes Mellitus (DM) among HIV-infected individuals. We aimed to identify risk factors for impaired fasting glucose or diabetes among HIV-infected Zambians on long-term Combined Antiretroviral Treatment (cART).

METHODS

This was a cross sectional study of adult HIV patients in five health facilities of Copperbelt Province in Zambia. HIV/AIDS patients aged 18 years and above, enrolled in care at those health facilities and had been on cART for more than 2 years were included. All patients known to have Diabetes mellitus were excluded from the study. Participants underwent assessment of random blood sugar levels at enrolment and returned the following morning for fasting glucose measured by glucometers. The primary outcome was proportion with impaired fasting glucose or DM. Multivariable logistic regression was used to examine if demographics, time on ART, type of ART regimen, body mass index and baseline CD4 count were predictors of impaired fasting glucose.

RESULTS

Overall (n = 270) there were 186 females (69%) and 84 males (31%). The prevalence of impaired fasting blood sugar or diabetes after 8 h of fasting was 15% (95%CI: 11.1, 20.0). Ten percent (26/270) had impaired fasting glucose and 5 % (14/270) had diabetes. Impaired fasting glucose was higher in males than females [AOR = 3.26, (95% CI: 1.15-9.25; p-value = 0.03)]; as well as among patients on second line treatment than those on first line [AOR = 3.87 (95% CI 1.16-12.9); p-value = 0.03]. In contrast those with less likelihood of impaired fasting glucose included patients with a normal BMI (18.5-24.9) than overweight or obese patients [AOR = 0.09 (95% CI 0.03-0.31; p-value < 0.001)]; and participants who had less than 4 diabetes symptoms than those with more than 4 diabetes symptoms [AOR = 0.04 (95% CI 0.02-0.12); p-value < 0.001].

CONCLUSION

We have found high levels of impaired fasting glucose or diabetes among ART patients compared to what is reported in the general population suggesting missed care and support opportunities associated with metabolic imbalance management. There is thus a need to re-package HIV programming to include integration of diabetes screening as part of the overall care and support strategy.

Is laboratory screening prior to antiretroviral treatment useful in Johannesburg, South Africa? Baseline findings of a clinical trial

BACKGROUND

Screening for renal, hepatic and haematological disorders complicates the initiation of current first-line antiretroviral therapy (ART). Each additional test done adds substantial costs, both through direct laboratory expenses, but also by increasing the burden on health workers and patients. Evaluating the prevalence of clinically relevant abnormalities in different population groups could guide decisions about what tests to recommend in national guidelines, or in local adaptations of these.

METHODS

As part of enrolment procedures in a clinical trial, 771 HIV-positive adults, predominantly from inner-city primary health care clinics, underwent laboratory screening prior to ART. Participants had to be eligible for ART, based on the then CD4 eligibility threshold of 350 cells/μL, antiretroviral naïve and have no symptoms of peripheral neuropathy.

RESULTS

Participants were mostly female (57%) and a mean 34 years old. Creatinine clearance rates were almost all above 50 mL/min (99%), although 5% had microalbuminuria. Hepatitis B antigenaemia was common (8% of participants), of whom 40% had a raised AST/ALT, though only 2 had transaminase levels above 200 IU/L. Only 2% of participants had severe anaemia (haemoglobin <8 g/dl) and 1% neutropaenia (neutrophils <0.75 × 10^9/L). Costs per case detected of hepatitis B infection was USD135, but more than USD800 for a raised creatinine.

CONCLUSIONS

Hepatitis B continues to be a common co-infection in HIV-infected adults, and adds complexity to management of ART switches involving tenofovir. Routine renal and haematological screening prior to ART detected few abnormalities. The use of these screening tests should be assessed among patients with higher CD4 counts, who may even have fewer abnormalities. Formal evaluation of cost-effectiveness of laboratory screening prior to ART is warranted.

Determinants of uncontrolled hypertension among clients on anti-retroviral therapy in Kadoma City, Zimbabwe, 2016

Background

Clients on anti-retroviral therapy (ART) are living longer and have risk of hypertension. Side effects of medicines and aging increase this risk. Hypertension prevalence among clients on ART in Kadoma City was estimated to be 30% in 2015. Of these, 61% had uncontrolled hypertension. This was high compared to 46% of hypertensives in the general population who had uncontrolled hypertension. We determined factors associated with uncontrolled hypertension among clients on ART.

Methods

A 1.1 unmatched case control study was conducted. Interviews, anthropometric measurements and record reviews were to collect data on demography and medical history. Epi Info 7 was used for univariate, bivariate analysis and logistic regression.

Results

One hundred and fifty-two cases and 152 controls were recruited into the study. Adding salt to dishes regularly aOR = 5.69 (3.19–10.16), body mass index (BMI) above 25 kg/m² aOR = 2.81 (1.60–4.91) and history of elevated blood pressure in previous year aOR = 2.34 (1.33–4.13) were independent risk factors. Independent protective factors were duration more than 2 years since HIV diagnosis aOR = 0.58 (0.35–0.95), duration less than 5 years since hypertension diagnosis aOR = 0.50 (0.30–0.83) and walking or cycling as a means of transport aOR = 0.27 (0.16–0.48).

Conclusion

Adding salt to dishes regularly, BMI above 25 kg/m², history of elevated blood pressure in the previous year, duration more than 2 years since HIV diagnosis, duration less than 5 years since hypertension diagnosis and walking or cycling as a means of transport were independently associated with uncontrolled hypertension. Health education on lifestyle changes like walking and cycling as transport and dietary modification such as salt intake reduction were recommended.

Renal Function Impairment and Associated Factors among HAART Naïve and Experienced Adult HIV Positive Individuals in Southwest Ethiopia: A Comparative Cross Sectional Study

BACKGROUND

Human immunodeficiency virus (HIV) infection and its treatment cause renal diseases. Renal disease is associated with an increasing cause of morbidity and mortality in HIV positive individuals than in the general population. It has been also associated with adverse outcomes, such as complications of decreased renal functions and progression to renal failure.

OBJECTIVE

To determine the prevalence and factors associated with renal function impairment among highly active antiretroviral therapy (HAART) naive and HAART experienced adult HIV positive individuals.

METHODS

A facility based comparative cross-sectional study was conducted in Jimma University Specialized Hospital (JUSH) from June to September 2014. HIV positive individuals who visited JUSH during the study period were included in the study. Sociodemographic and clinical data were collected using a structured questionnaire. Blood specimen was analyzed for renal function tests. Descriptive statistics, Mann-Whitney U test and logistic regression analysis were done using SPSS version 16 software.

RESULTS

A total of 446 HIV positive individuals, 223 HAART naïve and 223 HAART experienced, were recruited. The overall prevalence of renal function impairment was 18.2% [95%CI: 14.6-21.7]. The prevalence of renal impairment in HAART naive and HAART experienced persons was 28.7% [95%CI: 23.1-34.4] and 7.6% [95%CI: 4.6-11.6], respectively. Age ≥ 50 years (AOR = 3.6; 95% CI 1.4, 9.6), advanced WHO stage (AOR = 2.3; 95% CI 1.1, 4.7), and CD4 count <200 (AOR = 6.9; 95% CI 3.3, 14.2) were independent risk factors among HAART naive participants. Female gender (AOR = 6.6; 95 CI % 1.2, 34), age ≥ 50 years (AOR = 12.1; 95% CI 1.7, 84) and CD4 count <200 (AOR = 17; 95% CI 5.2, 58) were independent risk factors among HAART experienced participants.

CONCLUSION

The prevalence of renal function impairment was higher among HAART naïve than HAART experienced HIV positive individuals. Renal function impairment was associated with disease advancement and old age.

Prevalence of chronic kidney disease in diabetic adult out-patients in Tanzania

Despite the increasing number of patients with Diabetes Mellitus in sub-Saharan Africa, the magnitude of chronic kidney disease among diabetics has not been well established. A study done by Janmohamed et al. found chronic kidney disease in 83.7 % of diabetics which is relatively higher than the prevalence reported elsewhere. However this study was conducted in schistosoma endemic area along the shores of Lake Victoria. Schistosomiasis has been reported to cause a range of renal diseases. Interpretation of these findings should therefore take into account the possibility of schistosomiasis as a possible confounder.

Incidence of stage 3 chronic kidney disease and progression on tenofovir-based regimens

OBJECTIVE

To describe the incidence of rapid kidney function decline (RKFD), and stage 3 chronic kidney disease (CKD) in HIV-1-infected adults initiated on tenofovir-containing antiretroviral therapy.

METHODS

A retrospective cohort study at the infectious diseases clinic of Tygerberg Academic Hospital in Cape Town, South Africa. Patients with more than 3 ml/min per year decline in estimated glomerular filtration were classified as having RKFD, and stage 3 CKD was defined as a value less than 60 ml/min per 1.73 m. We used logistic and Cox proportional hazards regression models to determine factors associated with RKFD and stage 3 CKD.

RESULTS

Of 650 patients, 361 (55%) experienced RKFD and 15 (2%) developed stage 3 CKD during a median interquartile range follow-up time of 54 (46.6-98) weeks. For every 10-year increase in age and 10 ml/min lower baseline estimated glomerular filtration, the odds of RKFD increased by 70% [adjusted odds ratio = 1.70, 95% confidence interval (CI) 1.36-2.13] and 57% (adjusted odds ratio = 1.57, 95% CI 1.38-1.80), respectively. Each 10-year older age was associated with a 1.90-fold increased risk of developing stage 3 CKD (adjusted hazard ratio = 1.90, 95% CI: 1.10-3.29). Women had about four-fold greater risk of stage 3 CKD compared with men (adjusted hazard ratio = 3.96, 95% CI: 1.06-14.74).

CONCLUSION

About half of our study population developed RKFD but only 2% progressed to stage 3 CKD. Approaches that provide balanced allocation of limited resources toward screening and monitoring for kidney dysfunction and HIV disease management are critically needed in this setting.

Tenofovir is associated with increased tubular proteinuria and asymptomatic renal tubular dysfunction in Ghana

BACKGROUND

HIV infection is associated with increased risk of renal dysfunction, including tubular dysfunction (TD) related to antiretroviral therapy (ART). Tenofovir disoproxil fumarate (TDF) is becoming available for ART in sub-Saharan Africa, although data on its long-term safety there is limited. We aimed to study the prevalence of HIV-associated renal dysfunction in Ghana and explore associations between proteinuria or TD and potential risk factors, including TDF use.

METHODS

A single-centre cross-sectional observational study of patients taking ART was undertaken. Creatinine clearance (CrCl) was calculated and proteinuria detected with dipsticks. Spot urinary albumin and protein:creatinine ratios (uACR/uPCR) were measured and further evidence of TD (defined as having two or more characteristic features) sought. Logistic regression analysis identified factors associated with proteinuria or TD.

RESULTS

In 330 patients, of whom 101 were taking TDF (median 20 months), the prevalence of CrCl < 60 ml/min/1.73 m(2), dipstick proteinuria and TD was 7 %, 37 % and 15 %. Factors associated with proteinuria were baseline CD4-count [aOR 0.86/100 cell increment (95 % CI, 0.74-0.99)] and TDF use [aOR 2.74 (95 % CI, 1.38-5.43)]. The only factor associated with TD was TDF use [aOR 3.43 (95 % CI, 1.10-10.69)]. In a subset with uPCR measurements, uPCRs were significantly higher in patients taking TDF than those on other drugs (10.8 vs. 5.7 mg/mmol, p < 0.001), and urinary albuin:protein ratios significantly lower (0.24 vs. 0.58, p < 0.001).

CONCLUSIONS

Both proteinuria and TD are common and associated with TDF use in Ghana. Further longitudinal studies to determine whether proteinuria, TD or TDF use are linked to progressive decline in renal function or other adverse outcomes are needed in Africa.

HAART, DOTS and renal disease of patients co-infected with HIV/AIDS and TB in the South West Region of Cameroon

Background

Tuberculosis is the commonest infection among HIV/AIDS patients. This co-infection constitutes a major death threat in the world. There is paucity of data about renal disease amongst patients on HAART and DOTS therapy in Cameroon.

Methods

This was a hospital-based cross-sectional study in the Buea, Limbe and Kumba government Hospitals. Spectrophotometric method was used for the quantitative determination of serum creatinine, urea, albumin and total protein levels. Glomerular filtration rate was estimated using the MDRD method. The student’s t test, ANOVA and logistic regression were used to analyse the data.

Results

Out of 200 participants, 101 (50.5 %) were males. The ages ranged from 21 to 65 years with a mean age of 38.04 ± 10.52 years. Compared to adults on DOTS alone, adults on HAART alone had a significantly higher prevalence of eGFR <60 ml/min/1.73 m² (10/70 (14.3 %) vs. 1/70 (1.4 %), OR = 11.5 [1.4–92.5], p = 0.02) while more participants on HAART/DOTS had significantly higher serum creatinine (18/60 (30 %) vs 10/70 (14.3) OR = 2.57 [1.08–6.12], p = 0.033). Though participants on HAART/DOTS combined therapy had low eGFR, the association was not statistically significant (OR = 6.27, 95 % CI;0.71–55.27, p = 0.098). Participants on the Zidovudine, Lamivudine, Nevirapine regimen showed a statistically significant difference in the mean serum creatinine and albumin levels between the HAART/DOTS combined therapy and HAART group (p = 0.0219 and 0.0001 respectively).

Conclusion

Compared to adults on DOTS, adults on HAART were more likely to have renal dysfunction (eGFR <60 ml/min per 1.73 m²). Adult on a combination of HAART and DOTS had a similar prevalence of renal dysfunction as those on HAART alone. This study showed that the use of the HAART regimen (Tenofovir, Lamivudine and Efavirenz combination) among the HAART treated adults was nephrotoxic. However, other combined HAART and DOTS regimens had no nephrotoxic effect. Abnormal kidney function can be associated with HAART use.

Prevalence of persistent microalbuminuria and associated factors among HIV infected children attending a Tertiary Hospital in Northern Tanzania: a cross sectional, analytical study

INTRODUCTION

Human Immunodeficiency Virus (HIV) infection is a significant cause of paediatric morbidity and mortality especially in Sub-Saharan Africa. It affects the kidney by injuring the glomerular and tubular epithelial cells causing leakage of albumin in urine. Microalbuminuria is known to be an early indicator of kidney injury including HIVAN. The purpose of this study was to identify the prevalence and factors associated with microalbuminuria among HIV infected children receiving care and treatment at Kilimanjaro Christian Medical Centre (KCMC).

METHODS

We conducted a cross sectional hospital based analytical study at KCMC from December 2012 to April 2013. It involved children who are HIV infected attending child centred family care clinics (CCFCC). Patients' demographic and clinical characteristics were extracted from the file; physical examination performed. Urine samples were analysed for by HemoCue Albumin 201 system analyzer. Statistical package for social sciences (SPSS) version 16.0 was be used to process and analyze the data.

RESULTS

Three hundred thirty HIV-infected children under 18 years were recruited during the study period. Mean age was 119.4 (5-218) months. Prevalence of microalbuminuria by using HemoCue Albumin 201 analyzer was 28.8% (n = 95). Presence of microalbuminuria was significantly associated with severity of HIV disease progression according to WHO disease stage (p = 0.0015) and CD4 count less than 350 cells/µL (p = 0.044).

CONCLUSION

The study has shown that microalbuminuria is common in HIV infected children. Early screening and treatment of microalbuminuria is important to minimize the risk of developing end stage kidney disease. Children with advanced HIV disease and those with CD4 count less than 350 cells/µL should be given priority for urinary albumin screening in a setting without routine screening for microalbuminuria.

The influence of HIV and schistosomiasis on renal function: a cross-sectional study among children at a hospital in Tanzania

Background

Schistosomiasis and HIV are both associated with kidney disease. Prevalence and factors associated with abnormal renal function among HIV-infected children in Africa compared to uninfected controls have not been well described in a schistosomiasis endemic area.

Methodology/Principal Findings

This cross-sectional study was conducted at the Sekou Toure Regional Hospital HIV clinic in Mwanza, Tanzania. A total of 122 HIV-infected children and 122 HIV-uninfected siblings were consecutively enrolled. Fresh urine was obtained for measurement of albuminuria and Schistosoma circulating cathodic antigen. Blood was collected for measurement of serum creatinine. Estimated glomerular filtration rate (eGFR) was calculated using the modified Schwartz equation. Renal dysfunction was defined operationally as eGFR<60mL/min/1.73m2 and/or albuminuria>20mg/L in a single sample. Among 122 HIV-infected children, 61/122 (50.0%) met our criteria for renal dysfunction: 54/122 (44.3%) had albuminuria>20mg/L and 9/122 (7.4%) had eGFR<60. Among 122 HIV-uninfected children, 51/122 (41.8%) met our criteria for renal dysfunction: 48/122 (39.3%) had albuminuria>20mg/L and 6/122 (4.9%) had eGFR<60. Schistosomiasis was the only factor significantly associated with renal dysfunction by multivariable logistic regression (OR = 2.51, 95% CI 1.46–4.31, p = 0.001).

Conclusions/Significance

A high prevalence of renal dysfunction exists among both HIV-infected Tanzanian children and their HIV-uninfected siblings. Schistosomiasis was strongly associated with renal dysfunction.

Ninety percent of schistosomiasis occurs in sub-Saharan Africa, where 91% of HIV-infected children reside. Both schistosomiasis and HIV affect the kidney, but their respective effects on kidney disease in children are not well described. Our prior work in HIV-infected adults demonstrated a high prevalence of kidney disease, possibly worsened by schistosomiasis, but adults are less commonly and less heavily infected with schistosomiasis than children. Therefore, we sought to describe the prevalence and factors associated with renal dysfunction (defined operationally as eGFR <60mL/min/1.73m² and/or albuminuria >20mg/L in a single urine test) among HIV-infected children and their uninfected siblings living in a schistosomiasis endemic area. We found that half of HIV-infected children and more than one third of HIV-uninfected children had renal dysfunction. Schistosomiasis was the only factor significantly associated with renal dysfunction, increasing odds of renal dysfunction by 2.5-fold. Nearly 50% of the renal dysfunction we observed in both groups could be explained by schistosomiasis. The strong association between schistosomiasis and renal dysfunction among both HIV-infected and uninfected children should remind clinicians to screen for schistosomiasis. It also ought to spur further prospective research to assess for causality and outcomes in the relationship between S. mansoni and kidney disease in children.

A consensus statement on the renal monitoring of Australian patients receiving tenofovir based antiviral therapy for HIV/HBV infection

A number of antiviral agents used against Human Immunodeficiency Virus (HIV) infection and hepatitis B virus (HBV) mono or co-infection have been associated with real nephrotoxicity (including tenofovir disoproxil fumarate (TDF), atazanavir, indinavir and lopinavir) or apparent changes in renal function (e.g. cobicistat, ritonavir, rilpivirine and dolutegravir). Patients with HIV are at higher risk of acute and chronic renal dysfunction, so baseline assessment and ongoing monitoring of renal function is an important part of routine management of patients with HIV.

Given the paucity of evidence in this area, we sought to establish a consensus view on how routine monitoring could be performed in Australian patients on ART regimens, especially those involving TDF. A group of nephrologists and prescribers (an HIV physician and a hepatologist) were assembled by Gilead to discuss practical and reasonable renal management strategies for patients particularly those on TDF-based combination regimens (in the case of those with HIV-infection) or on TDF-monotherapy (in the case of HBV-mono infection). The group considered which investigations should be performed as part of routine practice, their frequency, and when specialist renal referral is warranted. The algorithm presented suggests testing for serum creatinine along with plasma phosphate and an assessment of urinary protein (rather than albumin) and glucose.

Here we advocate baseline tests of renal function at initiation of therapy. If creatinine excretion inhibitors (e.g. cobicistat or rilpivirine) are used as part of the ART regimen, we suggest creatinine is rechecked at 4 weeks and this value used as the new baseline. Repeat testing is suggested at 3-monthly intervals for a year and then at least yearly thereafter if no abnormalities are detected. In patients with abnormal baseline results, renal function assessment should be performed at least 6 monthly. In HBV mono-infected patients advocate that a similar testing protocol may be logical.

Low-grade proteinuria is highly prevalent in HIV-positive patients on antiretroviral treatment

OBJECTIVES

HIV-positive patients are at an increased risk for chronic kidney disease. However, these data mainly derive from cohorts with a high percentage of African-American patients, representing a specific ethnical risk group for chronic kidney disease. The aim of this study was to estimate the prevalence and risk factors specifically for early signs of kidney dysfunction in a large, predominantly white cohort of HIV patients.

DESIGN

Cross-sectional study.

METHODS

Prevalence of low-grade proteinuria was measured by quantitative analysis of urinary protein-to-creatinine ratio (cutoff >70 mg/g) and further differentiated by assessing α1-microglobulin (tubular proteinuria) and albumin-to-creatinine ratio (glomerular proteinuria) of HIV patients attending the University Hospital in Cologne, Germany. Together with standard and HIV-related laboratory findings and medical history, risk factors for each form of proteinuria were identified using multivariate forward selection.

RESULTS

Of 945 enrolled patients, 55% were identified with low-grade proteinuria, 41% with tubular proteinuria, and 20% with glomerular proteinuria. Older age was a risk factor for all forms of proteinuria in multivariate analysis. Low-grade proteinuria was also associated with concomitant diabetes and exposure to nucleoside reverse transcriptase inhibitor [anytime during HIV infection, not tenofovir (TDF)-specific], whereas tubular proteinuria was linked to current and any exposure to nucleoside reverse transcriptase inhibitor (TDF-specific). Further risk factors for glomerular proteinuria were hypertension and diabetes in this cohort.

CONCLUSION

Low-grade, glomerular and tubular proteinuria are highly prevalent in this large white HIV cohort. Older age represents a nonmodifiable risk factor for all forms of proteinuria. Glomerular proteinuria is associated with modifiable cardiovascular, but not HIV-related risk factors, whereas tubular proteinuria is linked to TDF exposure.

Hypertension, kidney disease, HIV and antiretroviral therapy among Tanzanian adults: a cross-sectional study

BACKGROUND

The epidemics of HIV and hypertension are converging in sub-Saharan Africa. Due to antiretroviral therapy (ART), more HIV-infected adults are living longer and gaining weight, putting them at greater risk for hypertension and kidney disease. The relationship between hypertension, kidney disease and long-term ART among African adults, though, remains poorly defined. Therefore, we determined the prevalences of hypertension and kidney disease in HIV-infected adults (ART-naive and on ART >2 years) compared to HIV-negative adults. We hypothesized that there would be a higher hypertension prevalence among HIV-infected adults on ART, even after adjusting for age and adiposity.

METHODS

In this cross-sectional study conducted between October 2012 and April 2013, consecutive adults (>18 years old) attending an HIV clinic in Tanzania were enrolled in three groups: 1) HIV-negative controls, 2) HIV-infected, ART-naive, and 3) HIV-infected on ART for >2 years. The main study outcomes were hypertension and kidney disease (both defined by international guidelines). We compared hypertension prevalence between each HIV group versus the control group by Fisher's exact test. Logistic regression was used to determine if differences in hypertension prevalence were fully explained by confounding.

RESULTS

Among HIV-negative adults, 25/153 (16.3%) had hypertension (similar to recent community survey data). HIV-infected adults on ART had a higher prevalence of hypertension (43/150 (28.7%), P = 0.01) and a higher odds of hypertension even after adjustment (odds ratio (OR) = 2.19 (1.18 to 4.05), P = 0.01 in the best model). HIV-infected, ART-naive adults had a lower prevalence of hypertension (8/151 (5.3%), P = 0.003) and a lower odds of hypertension after adjustment (OR= 0.35 (0.15 to 0.84), P = 0.02 in the best model). Awareness of hypertension was ≤ 25% among hypertensive adults in all three groups. Kidney disease was common in all three groups (25.6% to 41.3%) and strongly associated with hypertension (P <0.001 for trend); among hypertensive participants, 50/76 (65.8%) had microalbuminuria and 20/76 (26.3%) had an estimated glomerular filtration rate (eGFR) <60 versus 33/184 (17.9%) and 16/184 (8.7%) participants with normal blood pressure.

CONCLUSIONS

HIV-infected adults on ART >2 years had two-fold greater odds of hypertension than HIV-negative controls. HIV-infected adults with hypertension were rarely aware of their diagnosis but often have evidence of kidney disease. Intensive hypertension screening and education are needed in HIV-clinics in sub-Saharan Africa. Further studies should determine if chronic, dysregulated inflammation may accelerate hypertension in this population.

Impact of antiretroviral therapy on renal function among HIV-infected Tanzanian adults: a retrospective cohort study

Background

Data regarding the outcomes of HIV-infected adults with baseline renal dysfunction who start antiretroviral therapy are conflicting.

Methods

We followed up a previously-published cohort of HIV-infected adult outpatients in northwest Tanzania who had high prevalence of renal dysfunction at the time of starting antiretroviral therapy (between November 2009 and February 2010). Patients had serum creatinine, proteinuria, microalbuminuria, and CD4⁺ T-cell count measured at the time of antiretroviral therapy initiation and at follow-up. We used the adjusted Cockroft-Gault equation to calculate estimated glomerular filtration rates (eGFRs).

Results

In this cohort of 171 adults who had taken antiretroviral therapy for a median of two years, the prevalence of renal dysfunction (eGFR <90 mL/min/1.73 m²) decreased from 131/171 (76.6%) at the time of ART initiation to 50/171 (29.2%) at the time of follow-up (p<0.001). Moderate dysfunction (eGFR<60 mL/min/1.73 m²) decreased from 21.1% at antiretroviral therapy initiation to 1.1% at follow-up (p<0.001), as did the prevalence of microalbuminuria (72% to 44%, p<0.001). Use of tenofovir was not associated with renal dysfunction at follow-up.

Conclusion

Mild and moderate renal dysfunction were common in this cohort of HIV-infected adults initiating antiretroviral therapy, and both significantly improved after a median follow-up time of 2 years. Our work supports the renal safety of antiretroviral therapy in African adults with mild-moderate renal dysfunction, suggesting that these regimens do not lead to renal damage in the majority of patients and that they may even improve renal function in patients with mild to moderate renal dysfunction.

Low body weight in females is a risk factor for increased tenofovir exposure and drug-related adverse events

Treatment with tenofovir sometimes leads to non-reversible kidney and/or bone diseases. Factors associated with these drug-related adverse events are poorly characterized. Our objective was to investigate such factors in patients treated long term with daily tenofovir. One-hundred Caucasian HIV-positive patients with basal creatinine clearance >80 mL/min treated with tenofovir for at least 6 months and with at least one assessment of tenofovir plasma trough concentrations were considered. Tenofovir-associated adverse events were defined as the appearance of pathological proteinuria, worsening of renal function or bone demineralization. By multivariate regression analysis, we found that serum creatinine (p = 0.003) and body weight (p = 0.002) were the factors independently associated with plasma tenofovir concentrations. In particular, women with body weight<50 kg had significantly higher plasma tenofovir concentrations than those weighting >50 Kg (160±93 vs.71±52 ng/mL, p<0.001). High tenofovir plasma trough concentrations and the age of the patients were independently associated with the development of drug-related kidney and bone toxicity. In this retrospective study we have shown that HIV-infected women with low body weight are at risk to be exposed to high tenofovir plasma trough concentrations, ultimately resulting in a significant hazard to develop long-term tenofovir complications.

Prevalence of chronic kidney disease in diabetic adult out-patients in Tanzania

Background

The number of adults with diabetes mellitus is increasing worldwide, particularly in Asia and Africa. In sub-Saharan Africa, renal complications of diabetes may go unrecognized due to limited diagnostic resources. The prevalence of chronic kidney disease (CKD) among adult diabetics in sub-Saharan Africa has not been well described.

Methods

This study was conducted at the diabetes mellitus clinic of Bugando Medical Centre in Mwanza, Tanzania. A total 369 consecutive adult diabetic patients were enrolled and interviewed. Each patient provided a urine sample for microalbuminuria and proteinuria and a blood sample for serum creatinine level. Estimated glomerular filtration rate (eGFR) was calculated using the Cockroft-Gault equation. CKD was staged according to the Kidney Disease Improving Global Outcomes system.

Results

A total of 309 (83.7%) study participants had CKD; 295 (80.0%) had significant albuminuria and 91 (24.7%) had eGFR < 60 ml/min. None of these patients were aware of their renal disease, and only 5 (1.3%) had a diagnosis of diabetic nephropathy recorded in their file. Older age was significantly associated with CKD in this population [OR 1.03, p = 0.03, 95%CI (1.00-1.05)].

Conclusions

Chronic kidney disease is highly prevalent among adult diabetic outpatients attending our clinic in Tanzania, but is usually undiagnosed. Nearly ¼ of patients had an eGFR low enough to require dose adjustment of diabetic medications. More diagnostic resources are needed for CKD screening among adults in Tanzania in order to slow progression and prevent complications.

Update on tenofovir toxicity in the kidney

Tenofovir (TFV) is a widely used and effective treatment for HIV infection. Numerous studies have shown that TFV exposure is associated with small but significant declines in estimated glomerular filtration rate (eGFR). However, TFV toxicity is targeted mainly at the proximal tubule (PT), and in severe cases can cause the renal Fanconi syndrome or acute kidney injury. Severe toxicity occurs in a minority of patients, but milder PT dysfunction is more common; the long-term significance of this on kidney and bone health is uncertain. Recent work suggests that changes in eGFR on TFV therapy might be explained by inhibition of PT creatinine secretion rather than actual alterations in glomerular function. Risk factors for nephrotoxicity include pre-existing kidney disease, increased age, and low body mass. Mitochondria in the PT are the targets of TFV toxicity, but the exact mechanisms remain unclear. Substantial improvement of renal function occurs in many patients with TFV toxicity upon stopping therapy, but function does not always return to baseline. In recent years, TFV usage has been extended to new clinical spheres, including pediatrics, resource-poor settings and treatment of hepatitis B infection; theoretical reasons exist as to why some of these patients might be at higher or lower risk of TFV toxicity. Finally, strategies have been proposed to prevent TFV toxicity or enhance recovery.

HIV-associated nephropathy in Saudi Arabia

BACKGROUND AND OBJECTIVES

Human immunodeficiency virus-associated nephropathy (HIVAN) is the most common cause of chronic renal failure in HIV patients with African descent. It usually presents with proteinuria, enlarged kidneys, and rapidly progressive renal failure, often over several weeks to months. We conducted this study to determine the prevalence of HIVAN in our HIV population.

DESIGN AND SETTINGS

Cross-sectional observational study in a referral center covering the period of 1990- 2010.

METHODS

Proteinuria and estimated glomerular filtration rate (e-GFR) were used to identify renal disease and suspicious cases of HIVAN with abnormal proteinuria and e-GFR of < 60 mL/min/1.73 m2.

RESULTS

Of 585 HIV-positive patients, 248 were eligible to inclusion criteria. Most of the patients were male, that is, 165 (67%) were male compared to 83 (33%) female with the mean age 39 years; 240 (96.7%) were on antiretroviral therapy. Thirty (12%) patients had abnormal proteinuria and 218 (88%) had normal urinary protein and e-GFR. No significant differences were observed in demographic data, CD4+ T-lymphocyte count, viral load, creatinine level, and e-GFR among both groups. Significant differences were observed in the prevalence of diabetes mellitus in the abnormal proteinuria group (10 patients [33.3%] compared to 30 patients [13.8%] in the normal group (P=.0139) and the prevalence of hypertension in the abnormal proteinuria group (11 patients [36.7%] compared to 22 patients [10%] in the normal group (P=.002). Sixteen patients (6.6% of the cohort) met the study definition of HIVAN.

CONCLUSION

The prevalence of abnormal proteinuria and HIVAN among HIV-infected patients in Saudi Arabia is higher than that of non-African patients in developed countries.

High prevalence of renal dysfunction and association with risk of death amongst HIV-infected Ghanaians

OBJECTIVES

To determine the prevalence of HIV-associated renal dysfunction (RD), identify risk factors for RD and explore the association between baseline renal function and mortality in an HIV-infected population in Ghana.

METHODS

Creatinine clearance (CrCl) or estimated glomerular filtration rate (eGFR) was calculated in patients attending an HIV clinic between 2004 and 2011 using Cockcroft-Gault, MDRD and CKD-EPI formulae. Logistic regression analysis was used to identify risk factors associated with RD and Kaplan-Meier/Cox proportional regression analyses to explore associations between baseline CrCl/eGFR and subsequent mortality.

RESULTS

In 3137 patients starting antiretroviral therapy (ART) the frequency (95%-CI) of RD, defined by CrCl <60 ml/min/1.73 m(2) using Cockroft-Gault formula was 38.8% (37.1-40.5%). RD prevalence in a sub-population of 238 patients, including proteinuria in the definition, was 15.3% (10.3-22.1%) in ART-treated and 43.6% (34.0-53.7%) in ART-naïve patients. RD at baseline was associated with increasing age, low CD4 counts, advanced WHO stage and female gender. Cox proportional hazard analysis identified an increased hazard of death with decreasing CrCl, HR 1.46 (1.31-1.63) for each tertile lower than CrCl of 90 ml/min/1.73 m(2).

CONCLUSIONS

RD is very common in HIV-infected ART-naïve Ghanaians, and associated with increased risk of mortality. Screening and monitoring of RD is important in this setting, particularly as tenofovir use increases.

Prevalence of proteinuria and elevated serum cystatin C among HIV-Infected Adolescents in the Reaching for Excellence in Adolescent Care and Health (REACH) study

OBJECTIVE

In the United States, kidney dysfunction is prevalent in almost 30% of HIV-infected patients and is an independent predictor of mortality. Proteinuria and elevated serum cystatin C (eCysC) are used as markers of kidney disease in the general population; however, the prevalence of these markers in HIV-infected adolescents is largely unknown.

METHODS

This study includes 304 HIV-infected adolescents from the Reaching for Excellence in Adolescent Care and Health (REACH) cohort, an observational study of adolescents recruited from 13 US cities. Clinical and demographic characteristics of participants were evaluated as correlates of proteinuria, a urine protein to creatinine ratio of ≥200 mg/g. Select univariate predictors were assessed to determine the association with urinary protein excretion and serum cystatin C in multivariable linear regression models and proteinuria and eCysC (eCysC ≥ 75th percentile) in multivariable logistic regression models.

RESULTS

Overall, 19.1% of the participants had proteinuria, whereas 23.7% had an eCysC. Low CD4 T-lymphocyte counts (<200 cells/mm) were significantly associated with a greater urine protein to creatinine ratio in linear models and with proteinuria in logistic regression models. CD4 T-lymphocyte counts <500 cells/mm were significantly associated with a greater serum cystatin C concentration in linear models and with eCysC in logistic regression models.

CONCLUSIONS

Proteinuria among HIV-infected adolescents in the REACH cohort was approximately 2-fold greater than healthy US adolescents. Both proteinuria and eCysC are associated with CD4 T-lymphocyte counts. Further studies investigating early markers of kidney disease and the association with immune status and inflammation in HIV-infected adolescents are needed.

Kidney Disease in HIV-Infected Persons

Kidney disease is more prevalent among persons living with HIV, and may arise from a combination of comorbidities, co-infections, and medication-associated toxicities. Additional effects of HIV-1 viral replication, immunodeficiency and genetic factors also contribute to kidney disease. As is true in the general population, persons of African descent exhibit a disproportionate risk for severe kidney disease. Antiretroviral therapy (ART) modifies the natural history of HIV-associated nephropathy (HIVAN), and renal benefits of ART may not be limited to persons with HIVAN. Robust associations between proteinuria and cardiovascular disease imply that common mechanisms of vascular endothelial dysfunction may contribute to both processes.

Prevalence of low estimated glomerular filtration rate, proteinuria, and associated risk factors among HIV-infected black patients using Cockroft-Gault and modification of diet in renal disease study equations

OBJECTIVE

To evaluate the prevalence of low estimated glomerular filtration rate (eGFR), proteinuria, and associated risk factors among HIV-infected black patients at primary health care.

METHODS

A cross-sectional screening involving consecutive HIV-infected patients 18 years and older was done. Eighty-eight percent of patients were receiving highly active antiretroviral therapy (94% on first-line regimen: zidovudine + lamivudine + nevirapine). Simplified Modification of Diet in Renal Disease Study and Cockroft-Gault (CG) equations were used to estimate glomerular filtration rate and creatinine clearance, respectively. Determinants of dipstick proteinuria and low kidney function (<60 mL·min(-1)·1.73 m(-2)) were assessed using multivariate logistic regression analysis.

RESULTS

Three hundred HIV-infected (231 females) patients were screened. Their mean age, duration of HIV, and CD4(+) count were 43 ± 9 years, 33 ± 27 months, and 397 ± 224 cells per cubic millimeter, respectively. The prevalence of low eGFR according to Modification of Diet in Renal Disease Study and CG equations was 3% and 10%, respectively. Proteinuria was observed in 20.5% of patients. Only CD4(+) cell count ≤200 cells per cubic millimeter emerged as a strong determinant of low CG creatinine clearance [adjusted odds ratio (OR) 3.03; 95% confidence interval (CI): 1.099 to 8.352], whereas age ≥45 years (adjusted OR 3.69; 95% CI: 1.756 to 7.787), familial history of diabetes mellitus (adjusted OR 2.20; 95% CI: 1.067 to 4.543), and hypertension (adjusted OR 3.07; 95% CI: 1.278 to 7.787) were significantly associated with proteinuria.

CONCLUSIONS

Low eGFR and proteinuria are prevalent among these HIV-infected persons. Immunodeficiency emerged as one of the strongest determinants of renal impairment. This finding emphasizes the importance of highly active antiretroviral therapy in tackling the burden of chronic kidney disease in African HIV population.