Proteinuria is common among HIV patients: what are we missing?

Aging with HIV in Latin America and the Caribbean: a Systematic Review

PURPOSE OF REVIEW

With the establishment of antiretroviral treatment (ART) programs in low- and middle-income countries, people with HIV (PWH) in Latin America and the Caribbean (LAC) are living longer, subsequently developing chronic non-communicable diseases (NCDs). Few studies focus on the impact of aging among older LAC PWH. This systematic review aims to fill this information gap and understand the burden of aging with HIV in LAC. We identified peer-reviewed literature published in English, Spanish, or Portuguese from several databases to assess currently available evidence on the burden of aging with HIV in LAC and selected six common NCDs found in older PWH (cardiovascular disease [CVD], bone and musculoskeletal [MSK] disorders, cancer, renal disease, neurocognitive impairment [NCI], and depression).

RECENT FINDINGS

Of the 5942 publications reviewed, only 53 articles were found with populations 40 years and older or age-related findings (27 CVD, 13 NCI or depression, 6 MSK disorders, 4 renal disease, 3 cancer). Most (79%) publications were from Brazil with few longitudinal studies on aging with HIV. Prevalence of illnesses such as CVD, NCI, depression, or osteoporosis varied widely depending on the screening instrument utilized and geographic population surveyed. Age was a significant predictor of comorbidity in nearly all studies. Our results demonstrate the need for longitudinal studies and validated screening instruments appropriate for use among PWH in LAC. Understanding the mechanisms behind aging in HIV and the roles of sociocultural factors and genetic diversity specific to LAC is needed to appropriately manage chronic comorbidities as PWH age.

Correlation between CD4 count and glomerular filtration rate or urine protein:creatinine ratio in human immunodeficiency virus-infected children

Background

Studies on kidney complications in human immunodeficiency virus (HIV)-infected children are lacking. CD4 T lymphocytes are an important immune functions regulator and used as a basis for initiating antiretroviral therapy (ART) and monitoring disease progression. This study aims to determine the correlation between CD4 and estimated glomerular filtration rate (eGFR) or urine protein:creatinine ratio (uPCR) as markers of kidney complications.

Methods

This cross sectional study was conducted on HIV-infected children aged 5 to 18 years who visited the Teratai HIV Clinic at Hasan Sadikin Hospital for monthly monitoring in June 2019. CD4 count, eGFR based on the Schwartz formula, and uPCR were obtained. Correlation analysis was performed with the Pearson test.

Results

Subjects were 42 HIV-infected children, consisting of 23 males (54.8%) and 19 females (45.2%). Most children (65.0%) were in an advanced clinical stage and had been diagnosed with HIV for an average of 8 ± 3 years. All subjects had received ART, and six received tenofovir. Compliance to medications were good, and most subjects (79.0%) had normal nutritional status and CD4 count. All subjects had eGFR > 90 mL/min/1.73 m², of which 21 (50.0%) were above normal value. Proteinuria was found in 12 patients (28.6%), and it was not significantly associated with clinical stages of HIV infection. CD4 count was correlated positively with eGFR (r = 0.473, P = 0.001) and negatively with uPCR (r = -0.284, P = 0.034).

Conclusion

The degree of immunodeficiency appears to correlate with severity of renal injury. Screening at diagnosis and periodic monitoring of kidney functions are crucial in all childhood HIV patients.

HIV Prevalence and Morbidity in Older Inpatients in a High HIV Prevalence Setting

Understanding of the burden of HIV infection and comorbid conditions in older adults is limited, especially in low- and middle-income countries. Antiretroviral therapy (ART) has increased longevity of HIV-positive individuals, making age-related comorbidities more likely. This study aimed to compare the demographic and disease profiles, including chronic comorbid conditions of inpatients, at least 50 years of age, by HIV status, admitted to a regional hospital in South Africa. Adults, 50 years of age and older, admitted to internal medicine wards from November 2015 to February 2016 were approached to participate. Sociodemographic data, laboratory results, anthropometric data, discharge diagnoses, and HIV status were collected and compared by HIV serostatus. Overall, 151 participants were enrolled. Their median age was 61 years (IQR: 56-68 years); 89 (58.9%) were women. Overall, 47 (31.1%) were HIV positive, of whom 10 (6.6%) were first diagnosed during the admission. HIV-positive inpatients were younger than HIV-negative patients. The leading discharge diagnoses of all participants were acute gastroenteritis (11.5%) and community-acquired pneumonia (11.5%). Hypertension and type 2 diabetes mellitus (T2DM) were the leading comorbidities in both HIV-negative and HIV-positive participants. Prevalence of hypertension was 75.0% in seronegative, 59.5% in those with a prior diagnosis of HIV, and 40.0% in newly diagnosed; similarly, prevalence of T2DM was 22.1% in HIV-negative and 24.3% in known HIV-positive participants. Similar proportions died during admission; 11.3% of HIV-negative and 12.7% of HIV-positive admitted inpatients died. Almost one third of patients admitted were HIV positive. In HIV-positive older admitted to hospital, the leading cause for hospitalization was coinfections. In the ART era, irrespective of HIV status, older patients have similar age-related chronic illnesses and similar mortality rates, despite younger age at admission.

Proteinuria Is Associated With Increased Risk of Fragility Fracture in Men With or at Risk of HIV Infection

BACKGROUND

Proteinuria has been associated with bone loss and fractures in general population, but data in HIV-infected population are lacking.

SETTING

Prospective, multicenter cohort study of men with or at risk of HIV infection.

METHODS

Between 2006 and 2015, urine protein measurements and bone fracture histories were ascertained semiannually in 947 HIV-infected (HIV+) and 969 HIV-uninfected (HIV-) men aged 40 years or older. Proteinuria was defined as protein-to-creatinine ratio ≥200 mg/g at ≥2 consecutive visits. Outcome measures (1) all fractures (excluding fractures of skull, face, and digits) and (2) fragility fractures (fractures of vertebral column, femur, wrist, and humerus). Multivariable Cox proportional hazards models assessed the association between proteinuria and fracture after adjusting for additional risk factors.

RESULTS

The overall period prevalence of proteinuria was higher among HIV+ than HIV- (29% vs 6%, P < 0.001). Men with proteinuria had a significantly higher risk of fragility fracture compared with men without proteinuria [adjusted hazard ratio (aHR) = 2.29 (1.12-4.66)] and did not differ by HIV serostatus (p-interaction = 0.83). The risk of all fractures was not statistically different between men with or without proteinuria [aHR = 1.31 (0.84-2.05)]. Among HIV+ men, the association between confirmed proteinuria and fragility fracture was attenuated [aHR = 2.12 (0.95-4.73)] after additional adjustment for CD4 T-cell count/mm, history of AIDS, the presence of detectable plasma HIV-1 RNA, and cumulative exposure to tenofovir disoproxil fumarate.

CONCLUSIONS

Proteinuria was more common in HIV+ than in HIV- men and was a strong independent risk factor for fragility fracture regardless of HIV serostatus. Proteinuria should prompt consideration of a thorough evaluation for bone disease among HIV+ persons.

Prevalence of Nephrotoxicity in HIV Patients Treated with Tenofovir Disoproxil Fumarate: A Single-center Observational Study

Objectives

Tenofovir disoproxil fumarate (TDF) has been reported to cause nephrotoxicity necessitating cessation in some patients. No information is available on the nephrotoxic effect of TDF in Omani or regional patients with HIV infection. We sought to determine the prevalence of the nephrotoxic effects of TDF in our cohort of Omani patients with HIV and investigate the nephrotoxic effects of other cofactors.

Methods

We conducted an observational cohort study on 83 Omani patients currently on TDF-containing antiretroviral therapy. Renal dysfunction was monitored by measuring the serum creatinine estimated glomerular function rate (eGFR), urinary protein creatinine ratio (uPCR), and fractional excretion of phosphate (FEPi). Fisher's exact test was used to determine any additional nephrotoxic effects of cofactors.

Results

The median values for the duration of TDF use, patient age, and body mass index (BMI) at the time of the study were 178 weeks (range = 3-554), 42 years (range = 21-80), and 27 (range = 17.4-42.7), respectively. The median initial CD4 count and viral load were 205 × 10⁶/L (range = 3-1745) and 37 250 copies/mL (range = undetectable-9 523 428), respectively. FEPi was high in two (2.4%) patients, moderate in 26 (31.3%), and low in 55 (66.3%) patients. uPCR was high in 10 (12.0%) patients, moderate in 28 (33.7%), and low in 45 (54.2%) patients. No cofactors added to the nephrotoxicity except hypertension (p = 0.045).

Conclusions

Better definitions for TDF-associated toxicity are needed. uPCR is not a very good indicator of TDF-associated tubular dysfunction. Omani patients with HIV on TDF have a 4% prevalence of renal toxicity, but a study with a larger number of patients is required to explore this observation further. Cofactors like duration of TDF use, age, BMI, gender, diabetes mellitus, and use of protease inhibitors did not have an impact on the severity of FEPi and uPCR.

HIV and renal disease: a contemporary review

The presence of human immunodeficiency virus (HIV)-related kidney disease is an important cause of mortality and morbidity. HIV infection induces renal injury by direct cytotoxicity or immune complex-mediated glomerulonephritis in patients with genetic susceptibility factors. In the last decades, with the development and diffusion of combination antiretroviral therapy, which has prolonged patient survival, there has been a shift in the spectrum of renal diseases in HIV-infected patients, with the decrease of glomerular diseases and increase in the role of nephrotoxicity and co-morbidities. This review provides a contemporary and critical review on the main renal syndromes occurring in HIV-infected patients.