1
|
Cervantes CE, Atta MG. Updates on HIV and Kidney Disease. Curr HIV/AIDS Rep 2023; 20:100-110. [PMID: 36695948 DOI: 10.1007/s11904-023-00645-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW With the advent of antiretroviral therapy, HIV infection has become a chronic disease in developed countries. RECENT FINDINGS Non-HIV-driven risk factors for kidney disease, such as APOL1 risk variants and other genetic and environmental factors, have been discovered and are better described. Consequently, the field of HIV-associated kidney disease has evolved with greater attention given to traditional risk factors of CKD and antiretroviral treatment's nephrotoxicity. In this review, we explore risk factors of HIV-associated kidney disease, diagnostic tools, kidney pathology in HIV-positive individuals, and antiretroviral therapy-associated nephrotoxicity.
Collapse
Affiliation(s)
- C Elena Cervantes
- Department of Medicine, Division of Nephrology, Johns Hopkins University, 1830 E. Monument Street, Suite 416, Baltimore, MD, 21218, USA
| | - Mohamed G Atta
- Department of Medicine, Division of Nephrology, Johns Hopkins University, 1830 E. Monument Street, Suite 416, Baltimore, MD, 21218, USA.
| |
Collapse
|
2
|
Palsson R, Short SAP, Kibbelaar ZA, Amodu A, Stillman IE, Rennke HG, McMahon GM, Waikar SS. Bleeding Complications After Percutaneous Native Kidney Biopsy: Results From the Boston Kidney Biopsy Cohort. Kidney Int Rep 2020; 5:511-518. [PMID: 32274455 PMCID: PMC7136322 DOI: 10.1016/j.ekir.2020.01.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/18/2020] [Accepted: 01/20/2020] [Indexed: 02/07/2023] Open
Abstract
Background The major risk of kidney biopsy is severe bleeding. Numerous risk factors for bleeding after biopsy have been reported, but findings have been inconsistent. Methods We retrospectively reviewed medical records of adult patients enrolled in a native kidney biopsy cohort study to identify major bleeding events (red blood cell [RBC] transfusions, invasive procedures, kidney loss, or death). We used logistic and linear regression models to identify characteristics associated with postbiopsy RBC transfusions and decline in hemoglobin within a week after the procedure. Results Major bleeding events occurred in 28 of 644 (4.3%) patients (28 required an RBC transfusion, 4 underwent angiographic intervention, and 1 had open surgery to control bleeding). No patient lost a kidney or died because of the biopsy. Postbiopsy RBC transfusion risk was driven by the baseline hemoglobin level (odds ratio [OR] 13.6; 95% confidence interval [CI] 5.4–34.1 for hemoglobin <10 vs. ≥10 g/dl). After adjusting for hemoglobin, no other patient characteristics were independently associated with RBC transfusions. Female sex (β = 0.18; 95% CI: 0.04–0.32), estimated glomerular filtration rate (eGFR) <30 ml/min per 1.73 m2 (β = 0.32; 95% CI: 0.14–0.49), and baseline hemoglobin (β = 0.09; 95% CI: 0.05–0.13, per g/dl increase) were independently associated with a larger drop in hemoglobin. Histopathologic lesions were not independently associated with major bleeding after biopsy. Conclusion Biopsies were generally well tolerated. Baseline hemoglobin was the dominant risk factor for RBC transfusions, but female sex and eGFR <30 ml/min per 1.73 m2 were also associated with a larger decline in hemoglobin after the procedure.
Collapse
Affiliation(s)
- Ragnar Palsson
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Division of Nephrology, National University Hospital of Iceland, Reykjavik, Iceland
| | - Samuel A P Short
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Zoe A Kibbelaar
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Renal Section, Boston University Medical Center, Boston, Massachusetts, USA
| | - Afolarin Amodu
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Renal Section, Boston University Medical Center, Boston, Massachusetts, USA
| | - Isaac E Stillman
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Helmut G Rennke
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gearoid M McMahon
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sushrut S Waikar
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Renal Section, Boston University Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Bakdash K, Schramm KM, Annam A, Brown M, Kondo K, Lindquist JD. Complications of Percutaneous Renal Biopsy. Semin Intervent Radiol 2019; 36:97-103. [PMID: 31123379 DOI: 10.1055/s-0039-1688422] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Percutaneous renal biopsy is widely used for diagnosis, prognosis, and management of nephropathies. Complications may arise after renal biopsy, most commonly in the form of bleeding. Efforts should be taken to optimize modifiable risk factors such as hypertension, thrombocytopenia, and coagulopathy prior to the procedure. Unmodifiable risk factors such as poor renal function, gender, and underlying histologic diagnosis may be used to identify high-risk patients. Delayed presentation of bleeding complications is common, and close clinical follow-up is crucial.
Collapse
Affiliation(s)
- Kenaz Bakdash
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Center, Aurora, Colorado
| | - Kristofer M Schramm
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Center, Aurora, Colorado
| | - Aparna Annam
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Center, Aurora, Colorado
| | - Matthew Brown
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Center, Aurora, Colorado
| | - Kimi Kondo
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Center, Aurora, Colorado
| | - Jonathan D Lindquist
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Center, Aurora, Colorado
| |
Collapse
|
4
|
Mejía-Vilet JM, Márquez-Martínez MA, Cordova-Sanchez BM, Ibargüengoitia MC, Correa-Rotter R, Morales-Buenrostro LE. Simple risk score for prediction of haemorrhagic complications after a percutaneous renal biopsy. Nephrology (Carlton) 2018; 23:523-529. [PMID: 28419667 DOI: 10.1111/nep.13055] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/02/2017] [Accepted: 04/09/2017] [Indexed: 01/26/2023]
Abstract
AIM To derive a simple risk score to predict the individual risk of major complications for patients undergoing a percutaneous renal biopsy procedure of native kidneys. METHODS The risk score was derived from a cohort of 1205 adult patients subjected to percutaneous renal biopsy and assigned to training and validation datasets. Factors associated with major complications were derived from univariate analysis and then modelled by stepwise multivariate logistic regression. Based on the odds ratio, independent predictors were assigned a weighted integer. The risk score is calculated from the sum of the integers. RESULTS The overall incidence of major complications was 3.2%. Independent factors associated with MC were lower pre-biopsy haemoglobin, lower platelets, higher blood urea nitrogen, documented chronic kidney disease features in pre-biopsy ultrasound (US) and the presence of haematoma in the post-biopsy US. A score for pre-biopsy evaluation included the first four predictors and stratified patients in three categories with increasing risk at higher scores (low-risk 0.1%, moderate-risk 3.0% and high-risk 26.1%). The score demonstrated good discriminative power (AUC = 0.872). The addition of post-biopsy US findings increased the discriminative power (AUC = 0.938). A higher post-biopsy risk score was also associated with a higher incidence of MC (low-risk 0.2%, moderate-risk 2.7%, high-risk 16.9%). CONCLUSION The risk of major complications after a percutaneous renal biopsy can be assessed by a simple risk score calculated from readily available information.
Collapse
Affiliation(s)
- Juan M Mejía-Vilet
- Department of Nephrology and Mineral Metabolism, National Sciences and Nutrition Institute Salvador Zubiran, México
| | - Manuel A Márquez-Martínez
- Department of Nephrology and Mineral Metabolism, National Sciences and Nutrition Institute Salvador Zubiran, México
| | - Bertha M Cordova-Sanchez
- Department of Nephrology and Mineral Metabolism, National Sciences and Nutrition Institute Salvador Zubiran, México
| | - Mónica Chapa Ibargüengoitia
- Department of Radiology and Image "Dr. Adan Pitol Croda", National Sciences and Nutrition Institute Salvador Zubiran, México
| | - Ricardo Correa-Rotter
- Department of Nephrology and Mineral Metabolism, National Sciences and Nutrition Institute Salvador Zubiran, México
| | - Luis E Morales-Buenrostro
- Department of Nephrology and Mineral Metabolism, National Sciences and Nutrition Institute Salvador Zubiran, México
| |
Collapse
|
5
|
Bleeding complications post ultrasound guided renal biopsy - A single centre experience from Pakistan. Ann Med Surg (Lond) 2017; 21:85-88. [PMID: 28794871 PMCID: PMC5536385 DOI: 10.1016/j.amsu.2017.06.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/20/2017] [Accepted: 06/20/2017] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Renal biopsy is the diagnostic modality of choice for the diagnosis of renal parenchymal diseases. The advent of improved imaging techniques and biopsy needles over the years has increased the safety of the procedure and the ability to obtain adequate renal tissue for diagnosis. However, there is paucity of data in this regard from Pakistan. This study shall help in establishing the local perspective of the frequency of bleeding complications in percutaneous ultrasound guided renal biopsy. MATERIALS AND METHODS This is a prospective case series of hospitalized patients from January till December 2015 at Nephrology Department, Aga Khan University Hospital, Karachi, Pakistan. After enrolment, each participant was followed for 24 h after renal biopsy. RESULTS A total of 220 patients were included. Mean age was 41.65 ± 8.627 years, 82 (37.2%) were male and 138 (62.8%) were female. Pre and post biopsy haemoglobin, pre and post biopsy haematocrit were 10.92 ± 1.25 and 10.60 ± 1.22, and 30.82 ± 4.73 and 30.49 ± 4.68 respectively. Out of 220 patients, 16 (7.27%) developed major complications and 26 (11.8%) developed minor complications in 24 h after renal biopsy. CONCLUSIONS Percutaneous kidney biopsy is a relatively safe procedure. Complication rates following the procedure are minimal. It is important that all nephrology programs train the trainees in performing biopsies, so that there is a wider clinical use of this important investigation even in underprivileged & developing countries.
Collapse
|
6
|
Xu DM, Chen M, Zhou FD, Zhao MH. Risk Factors for Severe Bleeding Complications in Percutaneous Renal Biopsy. Am J Med Sci 2017; 353:230-235. [DOI: 10.1016/j.amjms.2016.12.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/25/2016] [Accepted: 12/29/2016] [Indexed: 01/19/2023]
|
7
|
Prasad N, Kumar S, Manjunath R, Bhadauria D, Kaul A, Sharma RK, Gupta A, Lal H, Jain M, Agrawal V. Real-time ultrasound-guided percutaneous renal biopsy with needle guide by nephrologists decreases post-biopsy complications. Clin Kidney J 2015; 8:151-6. [PMID: 25815170 PMCID: PMC4370312 DOI: 10.1093/ckj/sfv012] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/03/2015] [Indexed: 01/12/2023] Open
Abstract
Background Percutaneous renal biopsy (PRB) can result in serious complications. The study is aimed to compare the biopsy yield and complications rate of the real-time ultrasonagram (USG)-guided PRB and needle tracking with and without needle guide in two different study periods. Methods We compared the yield and complications of 2138 kidney biopsies performed in two different periods, 1510 biopsies during the first period from April 2004–December 2010 and 628 biopsies during second period from January 2011–March 2013. All biopsies in both periods were performed by nephrologists. Radiologists provided the real-time image without needle guide during the first period while nephrologists performed both imaging and biopsy with needle guide during the second period. Results Of all the 2138 patients, 226 (10.5%) patients developed 118 minor and 108 major complications. Only 13 (2.1%) major complications occurred in the second period and 95 (6.7%) in the first period (P < 0.001). The relative risk of developing a major complication without guide was 3.04 times greater than that of the biopsies performed with use of the guide. The mean number of glomeruli per biopsy obtained during the second period (17.98 ± 6.75) was significantly greater than that of the first period (14.14 ± 6.01) (P = 0.004). The number of passes to acquire adequate tissue (P = 0.001) and percentage of cortex on biopsy (P = 0.001) were also significantly better in the second period. The optimal observation period post biopsy is 24 h. Conclusions Real-time USG imaging supported by needle guide device is associated with better biopsy yield and fewer complications.
Collapse
Affiliation(s)
- Narayan Prasad
- Department of Nephrology and Renal Transplantation , Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
| | - Shashi Kumar
- Department of Nephrology and Renal Transplantation , Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
| | - Revanasiddappa Manjunath
- Department of Nephrology and Renal Transplantation , Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
| | - Dharmendra Bhadauria
- Department of Nephrology and Renal Transplantation , Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
| | - Anupama Kaul
- Department of Nephrology and Renal Transplantation , Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
| | - Raj K Sharma
- Department of Nephrology and Renal Transplantation , Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
| | - Amit Gupta
- Department of Nephrology and Renal Transplantation , Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
| | - Hira Lal
- Department of Radiology , Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
| | - Manoj Jain
- Department of Pathology , Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
| | - Vinita Agrawal
- Department of Pathology , Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
| |
Collapse
|
8
|
Risk of Bleeding after Native Renal Biopsy as a Function of Preprocedural Systolic and Diastolic Blood Pressure. J Vasc Interv Radiol 2015; 26:206-12. [DOI: 10.1016/j.jvir.2014.10.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 08/06/2014] [Accepted: 10/22/2014] [Indexed: 01/26/2023] Open
|
9
|
Lucas GM, Ross MJ, Stock PG, Shlipak MG, Wyatt CM, Gupta SK, Atta MG, Wools-Kaloustian KK, Pham PA, Bruggeman LA, Lennox JL, Ray PE, Kalayjian RC. Clinical practice guideline for the management of chronic kidney disease in patients infected with HIV: 2014 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:e96-138. [PMID: 25234519 PMCID: PMC4271038 DOI: 10.1093/cid/ciu617] [Citation(s) in RCA: 205] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 07/25/2014] [Indexed: 12/15/2022] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Paul A. Pham
- Johns HopkinsSchool of Medicine, Baltimore, Maryland
| | - Leslie A. Bruggeman
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | | | | | - Robert C. Kalayjian
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
10
|
Abstract
Renal disease accounts for significant morbidity and mortality in patients with HIV-1 infection. HIV-associated nephropathy (HIVAN) is an important cause of end stage renal disease in this population. Although multiple genetic, clinical, and laboratory characteristics such as Apolipoproetin-1 genetic polymorphism, high viral load, low CD-4 count, nephrotic range proteinuria, and increased renal echogenicity on ultrasound are predictive of HIVAN, kidney biopsy remains the gold standard to make the definitive diagnosis. Current treatment options for HIVAN include initiation of combined active antiretroviral therapy, blockade of the renin-angiotensin system, and steroids. In patients with progression of HIVAN, renal transplant should be pursued as long as their systemic HIV infection is controlled.
Collapse
Affiliation(s)
- Sana Waheed
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | |
Collapse
|
11
|
Kidney disease in children and adolescents with perinatal HIV-1 infection. J Int AIDS Soc 2013; 16:18596. [PMID: 23782479 PMCID: PMC3687339 DOI: 10.7448/ias.16.1.18596] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 04/14/2013] [Accepted: 04/16/2013] [Indexed: 12/20/2022] Open
Abstract
Introduction Involvement of the kidney in children and adolescents with perinatal (HIV-1) infection can occur at any stage during the child's life with diverse diagnoses, ranging from acute kidney injury, childhood urinary tract infections (UTIs), electrolyte imbalances and drug-induced nephrotoxicity, to diseases of the glomerulus. The latter include various immune-mediated chronic kidney diseases (CKD) and HIV-associated nephropathy (HIVAN). Discussion The introduction of highly active anti-retroviral therapy (HAART) has dramatically reduced the incidence of HIVAN, once the commonest form of CKD in children of African descent living with HIV, and also altered its prognosis from eventual progression to end-stage kidney disease to one that is compatible with long-term survival. The impact of HAART on the outcome of other forms of kidney diseases seen in this population has not been as impressive. Increasingly important is nephrotoxicity secondary to the prolonged use of anti-retroviral agents, and the occurrence of co-morbid kidney disease unrelated to HIV infection or its treatment. Improved understanding of the molecular pathogenesis and genetics of kidney diseases associated with HIV will result in better screening, prevention and treatment efforts, as HIV specialists and nephrologists coordinate clinical care of these patients. Both haemodialysis (HD) and peritoneal dialysis (PD) are effective as renal replacement therapy in HIV-infected patients with end-stage kidney disease, with PD being preferred in resource-limited settings. Kidney transplantation, once contraindicated in this population, has now become the most effective renal replacement therapy, provided rigorous criteria are met. Given the attendant morbidity and mortality in HIV-infected children and adolescents with kidney disease, routine screening for kidney disease is recommended where resources permit. Conclusions This review focuses on the pathogenesis and genetics, clinical presentation and management of kidney disease in children and adolescents with perinatal HIV-1 infection.
Collapse
|
12
|
Frequency of and risk factors for complications after liver radiofrequency ablation under CT fluoroscopic guidance in 1500 sessions: single-center experience. AJR Am J Roentgenol 2013; 200:658-64. [PMID: 23436859 DOI: 10.2214/ajr.12.8691] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The purpose of this article is to retrospectively evaluate the frequency of and risk factors for complications after liver radiofrequency ablation (RFA). MATERIALS AND METHODS This was a retrospective study of 656 patients (with 1755 liver tumors) who underwent 1500 CT fluoroscopy-guided liver RFA sessions. Of those patients, 501 had primary liver tumor and 155 had liver metastases. Mortality and treatment-related complications were documented. Complications were evaluated according to the Common Terminology Criteria for Adverse Events (version 4.0). Major complications were defined as grade 3 or higher adverse events. Factors affecting frequent complications with a frequency of 1% or more were detected using multivariate analysis. RESULTS Two deaths (0.1% [2/1500]) occurred. One patient died of liver failure subsequent to hemorrhage, and the other died of liver failure. The major complication rate was 2.8% (42/1500). The most frequent major complication was hemorrhage (1.1% [16/1500]). The absence of arterial embolization before RFA (p < 0.01), low hemoglobin level (p < 0.04), and elevated serum creatinine level (p < 0.04) were identified as significant risk factors for major hemorrhage. The minor complication rate was 17.1% (257/1500). Pneumothorax (7.7% [116/1500]) was the most frequent minor complication, followed by hemorrhage (7.0% [105/1500]). A transthoracic approach (p < 0.01) and subphrenic tumor location (p < 0.01) were significant risk factors for pneumothorax, and the use of a cluster needle (p < 0.02) and multiple tumors (p < 0.01) were significant risk factors for minor hemorrhage. CONCLUSION CT fluoroscopy-guided RFA is a safe procedure with an acceptably low rate of major complications for liver tumor treatment. Factors identified in this study will help to stratify high-risk patients.
Collapse
|
13
|
Abstract
At our institution, kidney biopsies are performed by an interventional nephrologist with standardized guidelines using real-time ultrasound. We hypothesized that patient factors could predict post biopsy complications. We did a retrospective review of 100 patients who underwent renal biopsy. Prebiopsy data obtained included demographics, blood pressure, laboratory studies, and kidney size. Biopsy procedure information was also recorded. Complications and post biopsy imaging was noted. A minor complication was defined as one not requiring intervention while a major complication required interventions like readmission or blood transfusion. The average age was 47 years, 41 were men, 51 were black, 30 had diabetes, 42 were obese, and 81 had hypertension. Twenty-six patients had a complication; 14 minor and 12 major including 1 nephrectomy. Factors predictive of a complication were thrombocytopenia (p=0.002) and inpatient status (p=0.04). Drop in hemoglobin at 6 hours was moderately sensitive and specific for a bleeding complication with an ROC of 0.723. Thrombocytopenia and inpatient status are risk factors for complications after renal biopsy. Serum creatinine, obesity, blood pressure, kidney size, needle size, and number of passes were not predictive of a major complication in our study.
Collapse
Affiliation(s)
- Imran Sethi
- University of Louisville, Louisville, Kentucky Robley Rex VA Medical Center, Louisville, Kentucky
| | | | | |
Collapse
|
14
|
Ando M, Tsuchiya K, Nitta K. How to manage HIV-infected patients with chronic kidney disease in the HAART era. Clin Exp Nephrol 2012; 16:363-72. [PMID: 22294158 DOI: 10.1007/s10157-012-0585-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 01/03/2012] [Indexed: 12/13/2022]
Abstract
As human immunodeficiency virus (HIV)-infected patients now live longer while receiving highly active antiretroviral therapy (HAART), chronic kidney disease (CKD) has emerged as a significant cause of morbidity and mortality among urban HIV population. Risk factors associated with CKD in such HIV-infected population include aging, hypertension, diabetes mellitus, co-infection with hepatitis C virus, low CD4 cell count, and high HIV viral load. Clinical experience has shown that HIV-infected individuals often have one or more concurrent risk factors for CKD. The cumulative effect of multiple risk factors on the development of CKD should be noted in this population. Glomerular disease directly related to HIV infection, so-called HIV-associated nephropathy, remains an important cause of CKD among limited HIV population of African descent. The impact of exposure to nephrotoxic antiretroviral agents on the development of kidney disease is both an old and a new concern. In particular, the association of tenofovir with kidney disease has been an area of great interest. The findings regarding tenofovir's adverse effect on long-term kidney function vary among studies. Early identification and treatment of kidney disease is imperative for reducing the burden of patients requiring dialysis in HIV-infected populations. Periodic monitoring of urinary albumin excretion, tubular parameters such as low-molecular-weight proteinuria, and the estimated glomerular filtration rate may be useful for early diagnosis of patients at risk for incident CKD. This review focuses on recent developments in epidemiology, risk factors, identification, estimation, and management of CKD in HIV-infected population in the HAART era.
Collapse
Affiliation(s)
- Minoru Ando
- Department of Nephrology, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan.
| | | | | |
Collapse
|
15
|
Wyatt CM. The kidney in HIV infection: beyond HIV-associated nephropathy. TOPICS IN ANTIVIRAL MEDICINE 2012; 20:106-110. [PMID: 22954611 PMCID: PMC6148945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Acute kidney injury (AKI) and chronic kidney disease (CKD) are more common in HIV-infected persons than in the general population. AKI is associated with poor health outcomes, including increased risk of heart failure, cardiovascular events, end-stage renal disease (ESRD), and mortality. The most common causes of AKI in HIV-infected persons are systemic infections and adverse drug effects. The prevalence of CKD is rising in the HIV-infected population and CKD is increasingly likely to be caused by comorbid conditions, such as diabetes and hypertension, that frequently cause CKD in the general population. Guidelines for CKD screening in HIV-infected patients are being revised. It is currently recommended that all patients be screened for creatinine-based estimates of glomerular filtration rate and for urine protein at the time of HIV diagnosis. Annual screening is recommended for high-risk patients. Hemodialysis, peritoneal dialysis, and kidney transplantation are all options for treating ESRD in HIV-infected patients. Hemodialysis and peritoneal dialysis offer similar survival in HIV-infected patients with ESRD. In selected patients with well-controlled HIV infection, kidney transplantation is associated with survival intermediate between that in the overall transplant population and that among transplant recipients older than 65 years. This article summarizes a presentation by Christina M. Wyatt, MD, at the IAS-USA continuing medical education program held in Chicago in May 2012, describing AKI and CKD using case illustrations.
Collapse
|
16
|
Whittier WL. Complications of the percutaneous kidney biopsy. Adv Chronic Kidney Dis 2012; 19:179-87. [PMID: 22578678 DOI: 10.1053/j.ackd.2012.04.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 04/04/2012] [Accepted: 04/06/2012] [Indexed: 12/11/2022]
Abstract
Percutaneous kidney biopsy is an integral part of a nephrologist's practice. It has helped to define nephrology as a subspecialty. When indicated, it is a necessary procedure to help patients, as it allows for diagnostic, prognostic, and therapeutic information. Although very safe, this procedure can give rise to complications, mainly related to bleeding. Since its development in the 1950s, modifications have been made to the approach and the technique, which have improved the diagnostic yield while keeping it a safe procedure. Alterations to the standard approach may be necessary if risk factors for bleeding are present. In addition, obesity, pregnancy, and solitary kidney biopsy are all special circumstances that change the procedure itself or the risk of the procedure. Today, kidney biopsy is a vital procedure for the nephrologist: clinically relevant, safe, and effective.
Collapse
|
17
|
Corapi KM, Chen JLT, Balk EM, Gordon CE. Bleeding complications of native kidney biopsy: a systematic review and meta-analysis. Am J Kidney Dis 2012; 60:62-73. [PMID: 22537423 DOI: 10.1053/j.ajkd.2012.02.330] [Citation(s) in RCA: 247] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 02/22/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Kidney biopsy provides important information for nephrologists, but the risk of complications has not been systematically described. STUDY DESIGN Meta-analysis of randomized controlled trials and prospective or retrospective observational studies. SETTING & POPULATION Adults undergoing native kidney biopsy in an inpatient or outpatient setting. SELECTION CRITERIA FOR STUDIES MEDLINE indexed studies from January 1980 through June 2011; sample size of 50 or more. INTERVENTION Native kidney biopsy with automated biopsy device and real-time ultrasonographic guidance. OUTCOMES Macroscopic hematuria and erythrocyte transfusion rates and factors associated with these outcomes. RESULTS 34 studies of 9,474 biopsies met inclusion criteria. The rate of macroscopic hematuria was 3.5% (95% CI, 2.2%-5.1%), and erythrocyte transfusion was 0.9% (95% CI, 0.4%-1.5%). Significantly higher rates of transfusion were seen with the following: 14-gauge compared with smaller needles (2.1% vs 0.5%; P = 0.009), studies with mean serum creatinine level ≥2.0 mg/dL (2.1% vs 0.4%; P = 0.02), ≥50% women (1.9% vs 0.6%; P = 0.03), and ≥10% of biopsies for acute kidney injury (1.1% vs 0.04%; P < 0.001). Higher transfusion rates also were observed in studies with a mean age of 40 years or older (1.0% vs 0.2%; P = 0.2) and mean systolic blood pressure ≥130 mm Hg (1.4% vs 0.1%; P = 0.09). Similar relationships were noted for the macroscopic hematuria rate with the same predictors, but none was statistically significant. LIMITATIONS Publication bias, few randomized controlled trials, and missing data. CONCLUSIONS Native kidney biopsy using automated biopsy devices and real-time ultrasonography is associated with a relatively small risk of macroscopic hematuria and erythrocyte transfusion requirement. Using smaller gauge needles may lower complication rates. Patient selection may affect outcome because studies with higher serum creatinine levels, more women, and higher rates of acute kidney injury had higher complication rates. Future studies should further evaluate risk factors for complications.
Collapse
Affiliation(s)
- Kristin M Corapi
- Department of Medicine, Boston University Medical Center, MA 02118, USA
| | | | | | | |
Collapse
|
18
|
Chen TK, Estrella MM, Fine DM. Predictors of kidney biopsy complication among patients with systemic lupus erythematosus. Lupus 2012; 21:848-54. [PMID: 22415926 DOI: 10.1177/0961203312439334] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Kidney biopsy is essential for the diagnosis and management of lupus nephritis. The risk of bleeding complication, however, is not defined in the systemic lupus erythematosus population. A retrospective cohort study was conducted to determine predictors of major and minor complications among patients with systemic lupus erythematosus undergoing percutaneous ultrasound-guided kidney biopsy. Major complications included bleeding necessitating intervention, hypotension requiring vasopressors or higher level of care or death. Minor complications included moderate or large (≥ 4 cm in largest diameter) perinephric hematoma, gross hematuria or voiding difficulties. All patients were observed for at least 23 h post-procedure. The overall incidence of bleeding was 10.5% (2.7% major, 7.8% minor). Adjusted logistic regression showed that for every 10,000 cells/mm(3) decrease in platelet count, risk for major and any complication increased by 27% (odds ratio 1.27; 95% confidence intervals 1.06-1.51; p = 0.01) and 8% (odds ratio 1.08; 95% confidence intervals 1.02-1.15; p = 0.01), respectively. Patients with a platelet count <150,000 cells/mm(3) were 30 times more likely to experience a major complication (p = 0.002). Other candidate predictors, including steroid exposure, kidney function, hematocrit and histopathology, were not significant. Kidney biopsies are well tolerated in patients with systemic lupus erythematosus. However, patients with pre-biopsy platelet counts <150,000 cells/mm(3) are at markedly increased risk for a major bleeding complication.
Collapse
Affiliation(s)
- T K Chen
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, USA.
| | | | | |
Collapse
|
19
|
Fine DM, Wasser WG, Estrella MM, Atta MG, Kuperman M, Shemer R, Rajasekaran A, Tzur S, Racusen LC, Skorecki K. APOL1 risk variants predict histopathology and progression to ESRD in HIV-related kidney disease. J Am Soc Nephrol 2011; 23:343-50. [PMID: 22135313 DOI: 10.1681/asn.2011060562] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
With earlier institution of antiretroviral therapy, kidney diseases other than HIV-associated nephropathy (HIVAN) predominate in HIV-infected persons. Outcomes for these diseases are typically worse among those infected with HIV, but the reasons for this are not clear. Here, we examined the role of APOL1 risk variants in predicting renal histopathology and progression to ESRD in 98 HIV-infected African Americans with non-HIVAN kidney disease on biopsy. We used survival analysis to determine time to ESRD associated with APOL1 genotype. Among the 29 patients with two APOL1 risk alleles, the majority (76%) had FSGS and 10% had hypertensive nephrosclerosis. In contrast, among the 54 patients with one APOL1 risk allele, 47% had immune-complex GN as the predominant lesion and only 23% had FSGS. Among the 25 patients with no APOL1 risk allele, 40% had immune-complex GN and 12% had FSGS. In 310 person-years of observation, 29 patients progressed to ESRD. In adjusted analyses, individuals with two APOL1 risk alleles had a nearly three-fold higher risk for ESRD compared with those with one or zero risk alleles (P=0.03). In summary, these data demonstrate an association between APOL1 variants and renal outcomes in non-HIVAN kidney disease, suggesting a possible use for APOL1 genotyping to help guide the care of HIV-infected patients.
Collapse
Affiliation(s)
- Derek M Fine
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Abstract
The classic kidney disease of HIV infection, HIV-associated nephropathy (HIVAN), is an aggressive form of collapsing focal segmental glomerulosclerosis with accompanying tubular and interstitial lesions. HIVAN was first described among African-Americans and Haitian immigrants with advanced HIV disease, an early suggestion of a strong genetic association. This genetic susceptibility was recently linked to polymorphisms on chromosome 22 in individuals of African descent. The association with advanced HIV infection and evidence from HIV-transgenic mice suggested the possibility that HIV directly infects the kidney and that specific HIV gene expression induces host cellular pathways that are responsible for HIVAN pathogenesis. Although combination antiretroviral therapy has substantially reduced the impact of HIVAN in the United States, continued growth of the HIV epidemic in susceptible African populations may have important public health implications. This article reviews recent progress in the pathogenesis and treatment of HIVAN and describes the changing epidemiology of HIV-related kidney disease.
Collapse
Affiliation(s)
- Christina M Wyatt
- Department of Medicine, Division of Nephrology, Mount Sinai School Medicine, New York, New York 10029, USA.
| | | | | |
Collapse
|
21
|
George E, Nadkarni GN, Estrella MM, Lucas GM, Sperati CJ, Atta MG, Fine DM. The impact of hepatitis C coinfection on kidney disease related to human immunodeficiency virus (HIV): a biopsy study. Medicine (Baltimore) 2011; 90:289-295. [PMID: 21857365 DOI: 10.1097/md.0b013e31822f5915] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Approximately 1 in 4 individuals infected with the human immunodeficiency virus (HIV) in the United States is coinfected with the hepatitis C virus. Both conditions increase the risk for the development and progression of kidney disease. The effect, however, of coexisting HIV and hepatitis C infection on the spectrum and progression of kidney disease is not well known. To compare the clinical features, histopathologic kidney diagnoses, and proportion of individuals progressing to end-stage kidney disease (ESKD), we reviewed the clinical records of HIV-infected individuals with and without hepatitis C coinfection who underwent ultrasound-guided percutaneous kidney biopsies between February 7, 1995, and March 30, 2009.Of the 249 HIV-infected individuals included in this study, 58% were coinfected with hepatitis C. Coinfected individuals were older (mean age, 46 ± 7 vs. 44 ± 10 yr, respectively; p < 0.01) and more likely to have used illicit drugs (85% vs. 14%, respectively; p < 0.01) compared to HIV-infected individuals without hepatitis C. HIV-associated nephropathy was the most common histopathologic diagnosis in both groups. Immune-complex glomerulonephritides (ICGNs), including lupus-like nephritis, postinfectious glomerulonephritis, membranous glomerulopathy, membranoproliferative glomerulonephritis, IgA nephropathy, and nonspecific ICGNs, occurred more frequently in individuals coinfected with hepatitis C than in those not coinfected (22% vs. 11%, respectively; p = 0.02). Although the proportion of those who died was similar between the 2 groups, hepatitis C coinfection was independently associated with a greater risk of progression to ESKD (hazard ratio, 1.81; 95% confidence interval, 1.09-2.99; p = 0.02).The current study demonstrates that coinfection with hepatitis C in individuals infected with HIV predisposes these individuals to immune-complex glomerulonephritides and is associated with increased risk of ESKD in the biopsied population.
Collapse
Affiliation(s)
- Elizabeth George
- From All India Institute of Medical Sciences (EG), New Delhi, India; Department of Medicine (GNN), St. Luke's-Roosevelt Hospital Center, New York, New York; Division of Nephrology (MME, CJS, MGA, DMF) and Division of Infectious Diseases (GML), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | | |
Collapse
|
22
|
Nephrotoxicity of HAART. AIDS Res Treat 2011; 2011:562790. [PMID: 21860787 PMCID: PMC3157198 DOI: 10.1155/2011/562790] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Revised: 04/10/2011] [Accepted: 06/19/2011] [Indexed: 12/14/2022] Open
Abstract
Highly active antiretroviral therapy (HAART) and other medical therapies for HIV-related infections have been associated with toxicities. Antiretroviral therapy can contribute to renal dysfunction directly by inducing acute tubular necrosis, acute interstitial nephritis, crystal nephropathy, and renal tubular disorders or indirectly via drug interactions. With the increase in HAART use, clinicians must screen patients for the development of kidney disease especially if the regimen employed increases risk of kidney injury. It is also important that patients with chronic kidney disease (CKD) are not denied the best combinations, especially since most drugs can be adjusted based on the estimated GFR. Early detection of risk factors, systematic screening for chronic causes of CKD, and appropriate referrals for kidney disease management should be advocated for improved patient care. The interaction between immunosuppressive therapy and HAART in patients with kidney transplants and the recent endorsement of tenofovir/emtricitabine by the Centers for Disease Control (CDC) for preexposure prophylaxis bring a new dimension for nephrotoxicity vigilance. This paper summarizes the common antiretroviral drugs associated with nephrotoxicity with particular emphasis on tenofovir and protease inhibitors, their risk factors, and management as well as prevention strategies.
Collapse
|
23
|
Bigé N, Lanternier F, Viard JP, Kamgang P, Daugas E, Elie C, Jidar K, Walker-Combrouze F, Peraldi MN, Isnard-Bagnis C, Servais A, Lortholary O, Noël LH, Bollée G. Presentation of HIV-associated nephropathy and outcome in HAART-treated patients. Nephrol Dial Transplant 2011; 27:1114-21. [PMID: 21745806 DOI: 10.1093/ndt/gfr376] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Among the numerous renal diseases observed in human immunodeficiency virus (HIV) patients, HIV-associated nephropathy (HIVAN) is a major cause of end-stage renal disease (ESRD). The purpose of our study was to describe the presentation and outcome of HIVAN in the era of highly active antiretroviral therapy (HAART). METHODS We analysed clinical features and outcome of 57 patients with histologically proven HIVAN diagnosed between 2000 and 2009 in four teaching hospitals in Paris, France. RESULTS This series was characterized by median age of 41 years (18-58), frequent African origin (87%), severe renal dysfunction [estimated glomerular filtration rate (eGFR) 20 mL/min/1.73m(2) (1-68)], high-grade proteinuria [4.1 g/day (0.6-16.8)], high proportion of sclerotic glomeruli [31.5% (0-95)], high HIV load [4.5 log copies/mL (0-6.7)] and low CD4+ count [127/mm(3) (3-713)]. Nevertheless, a non-negligible proportion of patients did not present with these typical features. Follow-up data were available for 51 patients. ESRD occurred in 30 patients (58.8%). Median renal survival was 40 months. Baseline characteristics significantly associated with ESRD were as follows: severity of renal dysfunction, percentage of sclerotic glomeruli, time from HIV infection to HIVAN diagnosis longer than 1 year and prior exposure to antiretroviral drugs. There was an insignificant trend towards better renal outcome being associated with viral suppression during follow-up. Use of renin-angiotensin system (RAS) blockers was associated with higher renal survival (P < 0.05). CONCLUSION Despite HAART, HIVAN led to ESRD in more than half of the cases. Early recognition of the disease is crucial to start HAART and RAS blockers before irreversible renal injury.
Collapse
Affiliation(s)
- Naïke Bigé
- Department of Nephrology, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, Paris, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Estrella MM, Fine DM, Atta MG. Recent developments in HIV-related kidney disease. ACTA ACUST UNITED AC 2010; 4:589-603. [PMID: 21331321 DOI: 10.2217/hiv.10.42] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Although kidney disease has been a recognized complication of HIV infection since the beginning of the HIV epidemic, its epidemiology, underlying causes and treatment have evolved in developed countries where HAART has been widely available. HIV-associated nephropathy and HIV immune complex-mediated kidney disease were the prominent renal diagnoses in the earlier period of the HIV epidemic. While HIV immune complex-mediated kidney disease remains a common finding among HIV-infected individuals with kidney disease, the incidence of HIV-associated nephropathy has been diminishing in developed countries. The role of the metabolic effects of long-term HAART exposure and nephrotoxicity of certain antiretroviral medications on the development and progression of chronic kidney disease is now of increasing concern. The long-term clinical implications of acute kidney injury among HIV-infected persons are increasingly recognized. Kidney disease in HIV-infected persons continues to be a major risk factor for morbidity and mortality in this patient population; therefore, early recognition and treatment of kidney disease are imperative in lessening the impact of kidney disease on the health of HIV-infected individuals. This review focuses on recent developments and ongoing challenges in the understanding, diagnosis and management of HIV-related kidney disease.
Collapse
Affiliation(s)
- Michelle M Estrella
- Johns Hopkins University School of Medicine, Division of Nephrology, 1830 E Monument Street, Suite 416, Baltimore, MD 21205, USA
| | | | | |
Collapse
|
25
|
|