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Nkoy AB, Ekulu PM, Labarque V, Van den Heuvel LP, Levtchenko EN. HIV-associated nephropathy in children: challenges in a resource-limited setting. Pediatr Nephrol 2023; 38:2509-2521. [PMID: 36472655 DOI: 10.1007/s00467-022-05819-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 12/12/2022]
Abstract
HIV infection remains one of the leading causes of morbidity and mortality worldwide, especially in children living in resource-limited settings. Although the World Health Organization (WHO) recently recommended antiretroviral therapy (ART) initiation upon diagnosis regardless of the number of CD4, ART access remains limited, especially in children living in sub-Saharan Africa (SSA). HIV-infected children who do not receive appropriate ART are at increased risk of developing HIV-associated nephropathy (HIVAN). Although due to genetic susceptibility, SSA is recognized to be the epicenter of HIVAN, limited information is available regarding the burden of HIVAN in children living in Africa. The present review discusses the information available to date on the prevalence, pathogenesis, risk factors, diagnosis, and management of HIVAN in children, focusing on related challenges in a resource-limited setting.
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Affiliation(s)
- Agathe B Nkoy
- Division of Nephrology, Department of Pediatrics, University Hospital of Kinshasa, University of Kinshasa, Kinshasa, Democratic Republic of Congo
- Laboratory of Pediatric Nephrology, Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Pépé M Ekulu
- Division of Nephrology, Department of Pediatrics, University Hospital of Kinshasa, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Veerle Labarque
- Department of Pediatric Hematology, University Hospital Leuven, Leuven, Belgium
- Center of Molecular and Vascular Biology, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Lambertus P Van den Heuvel
- Laboratory of Pediatric Nephrology, Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Pediatric Nephrology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Elena N Levtchenko
- Laboratory of Pediatric Nephrology, Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium.
- Department of Pediatric Nephrology, University Hospital Leuven, Leuven, Belgium.
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2
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Isac R, Costa R, Frandes M, Lazureanu VE, Stroescu RF, Steflea RM, Bagiu IC, Horhat FG, Chicin GN, Roberta AC, Cornelia PA, Doros G, Gafencu M. Renal Impairment Impact and Survival Analysis in a Romanian Cohort of HIV-1(F1)-Infected Children and Adolescents. Life (Basel) 2023; 13:life13040888. [PMID: 37109416 PMCID: PMC10143557 DOI: 10.3390/life13040888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/20/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Human immunodeficiency virus (HIV) is a lentivirus that is transmissible through blood and other body fluids. During the late 1980s and early 1990s, an estimated 10,000 Romanian children were infected with HIV-1 subtype F nosocomially through contaminated needles and untested blood transfusions. Romania was a special case in the global acquired immunodeficiency syndrome (AIDS) pandemic, displaying the largest population of HIV-infected children by parental transmission between 1987–1990. In total, 205 HIV-infected patients from the western part of Romania were analyzed in this retrospective study. Over 70% of them had experienced horizontal transmission from an unknown source, while vertical transmission was identified in only five cases. Most patients had a moderate to severe clinical manifestation of HIV infection, 77.56% had undergone antiretroviral (ARV) treatment, most of them (71.21%) had experienced no adverse reactions and many of those with HIV (90.73%) had an undetectable viral load. Renal impairment was detected in one third of patients (34.63%). Patients born before 1990, male patients, patients diagnosed with HIV before the age of 10, and those undernourished or with renal impairment had a shorter average survival time than the group born after 1990, female patients, patients receiving ARV treatment, patients with a normal body mass index (BMI) and those without renal impairment. Periodical monitoring of the estimated glomerular filtration rate (eGFR) level, as well as the detection of protein excretion, should be taken into consideration worldwide when monitoring HIV-positive patients; this in order to detect even asymptomatic chronic kidney disease (CKD), and to manage these patients and prolong their lives.
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Innocenti S, Bernardi S, Prévot M, Saldmann A, Tusseau M, Belot A, Duong Van Huyen JP, Boyer O. Diagnostic dilemma in a 3-year-old girl with acute nephritic syndrome and hematologic abnormalities: Answers. Pediatr Nephrol 2022:10.1007/s00467-022-05752-6. [PMID: 36251071 DOI: 10.1007/s00467-022-05752-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Samantha Innocenti
- Néphrologie Pédiatrique, Centre de Référence MARHEA, Hôpital Necker-Enfants Malades, APHP, Institut Imagine, Inserm U1163, Université Paris Cité, Paris, France.
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy.
| | - Silvia Bernardi
- Néphrologie Pédiatrique, Centre de Référence MARHEA, Hôpital Necker-Enfants Malades, APHP, Institut Imagine, Inserm U1163, Université Paris Cité, Paris, France
- School of Nephrology, Università Degli Studi Di Milano, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Maud Prévot
- Néphrologie Pédiatrique, Centre de Référence MARHEA, Hôpital Necker-Enfants Malades, APHP, Institut Imagine, Inserm U1163, Université Paris Cité, Paris, France
| | - Antonin Saldmann
- Immunology Department, Hopital Européen Georges Pompidou, APHP, Cité University, Paris, Paris, France
| | - Maud Tusseau
- Centre International de Recherche en Infectiologie, UMR5308, Univ Lyon Université Claude Bernard Centre National de La Recherche Scientifique ENS de Lyon, Lyon 1, U1111, InsermLyon, France
| | - Alexandre Belot
- Pediatric Nephrology, Dermatology Department, Hôpital Femme Mère Enfant, CRMR RAISE, Hospices Civils de Lyon, Rheumatology Bron, France
- The International Center of Research in Infectiology, UMR 5308, Lyon University CNRSENS, UCBL, INSERM U1111, Lyon, France
| | - Jean-Paul Duong Van Huyen
- Department of Pathology, Necker-Enfants Malades Hospital, APHP, Cité University, Paris, Paris, France
| | - Olivia Boyer
- Néphrologie Pédiatrique, Centre de Référence MARHEA, Hôpital Necker-Enfants Malades, APHP, Institut Imagine, Inserm U1163, Université Paris Cité, Paris, France
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Yusuf H, Agwu A. Adolescents and young adults with early acquired HIV infection in the united states: unique challenges in treatment and secondary prevention. Expert Rev Anti Infect Ther 2021; 19:457-471. [PMID: 32990092 PMCID: PMC8084860 DOI: 10.1080/14787210.2021.1829473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Worldwide, children who acquired human immunodeficiency virus (HIV) at an early age, either perinatally or through blood transfusion, are reaching adolescence and adulthood due to successful antiretroviral treatment (ART). While many are thriving, a significant proportion face unprecedented multilevel challenges that can affect their long-term outcomes. Specifically, longstanding and poorly controlled HIV resulting from inadequate early regimens and nonadherence, along with the toxicities of some ART agents, can predispose them to sequelae including HIV-associated complications and other comorbidities. AREAS COVERED This paper reviews and summarizes the unique issues facing adolescents and young adults with early acquired HIV (AYA-EAHIV), including ART challenges, emerging comorbidities, and complications, including mental health comorbidities, secondary prevention, and transition from pediatric/adolescent to adult care. EXPERT OPINION AYA-EAHIV are a special population that have lived their entire lives with the physical and psychological toll of HIV mandating targeted and purposeful approaches to optimize their management and outcomes. Multifaceted inclusive and context-specific approaches focusing on heightened research, risk reduction interventions, and 'outside the box' thinking will be required to optimize treatment and reduce morbidity and mortality.
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Affiliation(s)
- Hasiya Yusuf
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Allison Agwu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Drak D, Dahwa R, Reakes E, Heron JE, Shamu T, Chimbetete C, Gracey DM. Baseline renal function predicts mortality in adolescents commenced on HIV antiretroviral therapy. AIDS 2021; 35:843-845. [PMID: 33724258 DOI: 10.1097/qad.0000000000002809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Douglas Drak
- Central Clinical School, University of Sydney, Camperdown
- Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, Australia
| | - Rumbi Dahwa
- Department of Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Edward Reakes
- Renal Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Jack E Heron
- Renal Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Tinei Shamu
- Newlands Clinic, Newlands, Harare, Zimbabwe
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | | | - David M Gracey
- Central Clinical School, University of Sydney, Camperdown
- Renal Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Tariq A, Kim H, Abbas H, Lucas GM, Atta MG. Pharmacotherapeutic options for kidney disease in HIV positive patients. Expert Opin Pharmacother 2020; 22:69-82. [PMID: 32955946 DOI: 10.1080/14656566.2020.1817383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Since the developmentof combined antiretroviral therapy (cART), HIV-associated mortality and the incidence of HIV-associated end-stage kidney disease (ESKD) has decreased. However, in the United States, an increase in non-HIV-associated kidney diseases within the HIV-positive population is expected. AREAS COVERED In this review, the authors highlight the risk factors for kidney disease within an HIV-positive population and provide the current recommendations for risk stratification and for the monitoring of its progression to chronic kidney disease (CKD), as well as, treatment. The article is based on literature searches using PubMed, Medline and SCOPUS. EXPERT OPINION The authors recommend clinicians (1) be aware of early cART initiation to prevent and treat HIV-associated kidney diseases, (2) be aware of cART side effects and discriminate those that may become more nephrotoxic than others and require dose-adjustment in the setting of eGFR ≤ 30ml/min/1.73m2, (3) follow KDIGO guidelines regarding screening and monitoring for CKD with a multidisciplinary team of health professionals, (4) manage other co-infections and comorbidities, (5) consider changing cART if drug induced toxicity is established with apparent eGFR decline of ≥ 10ml/min/1.73m2 or rising creatinine (≥0.5mg/dl) during drug-drug interactions, and (6) strongly consider kidney transplant in appropriately selected individuals with end stage kidney failure.
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Affiliation(s)
- Anam Tariq
- Division of Nephrology, Johns Hopkins University , Baltimore, MD, US
| | - Hannah Kim
- Division of Pediatric Nephrology, Johns Hopkins University , Baltimore, MD, US
| | - Hashim Abbas
- Division of Nephrology, Johns Hopkins University , Baltimore, MD, US
| | - Gregory M Lucas
- Division of Infectious Disease, Johns Hopkins University , Baltimore, MD, US
| | - Mohamed G Atta
- Division of Nephrology, Johns Hopkins University , Baltimore, MD, US
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Aliyannissa A, Kuswiyanto RB, Setiabudi D, Nataprawira HM, Alam A, Sekarwana N. Correlation between CD4 count and glomerular filtration rate or urine protein:creatinine ratio in human immunodeficiency virus-infected children. Kidney Res Clin Pract 2020; 39:40-46. [PMID: 32146732 PMCID: PMC7105624 DOI: 10.23876/j.krcp.19.093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/29/2020] [Accepted: 02/04/2020] [Indexed: 01/23/2023] Open
Abstract
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.
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Affiliation(s)
- Almira Aliyannissa
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Rahmat Budi Kuswiyanto
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Djatnika Setiabudi
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Heda Melinda Nataprawira
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Anggraini Alam
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Nanan Sekarwana
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
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Parigi S, Licari A, Marseglia GL, Galli L, Chiappini E. What the paediatrician needs to know about HIV-1 infection. Pediatr Allergy Immunol 2020; 31 Suppl 24:28-31. [PMID: 32017207 DOI: 10.1111/pai.13155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/10/2019] [Indexed: 12/26/2022]
Abstract
Nowadays, it is spreading the false perception that pediatric HIV infection has been almost completely disappeared in Italy, as well as in other Western countries, and it does not deserve the attention of the primary care pediatrician anymore. Hereby, we report the important role still played by the primary care pediatrician in management and prevention of pediatric HIV infection in Western countries.
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Affiliation(s)
- Sara Parigi
- Infectious Disease Unit, Department of Science Health, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Amelia Licari
- Pediatri Clinic, Fondazione IRCCS, Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Gian Luigi Marseglia
- Pediatri Clinic, Fondazione IRCCS, Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Luisa Galli
- Infectious Disease Unit, Department of Science Health, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Elena Chiappini
- Infectious Disease Unit, Department of Science Health, Meyer Children's Hospital, University of Florence, Florence, Italy
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9
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Chiappini E, Bianconi M, Dalzini A, Petrara MR, Galli L, Giaquinto C, De Rossi A. Accelerated aging in perinatally HIV-infected children: clinical manifestations and pathogenetic mechanisms. Aging (Albany NY) 2019; 10:3610-3625. [PMID: 30418933 PMCID: PMC6286860 DOI: 10.18632/aging.101622] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/27/2018] [Indexed: 12/12/2022]
Abstract
Background: Premature aging and related diseases have been documented in HIV-infected adults. Data are now emerging also regarding accelerated aging process in HIV-infected children. Methods: A narrative review was performed searching studies on PubMed published in English language in 2004-2017, using appropriate key words, including “aging”, “children”, “HIV”, “AIDS”, “immunosenescence”, “pathogenesis”, “clinical conditions”. Results: Premature immunosenescence phenotype of B and T cells in HIV-infected children is mediated through immune system activation and chronic inflammation. Ongoing inflammation processes have been documented by increased levels of pathogen-associated molecular patterns (PAMPS), increased mitochondrial damage, higher levels of pro-inflammatory cytokines, and a positive correlation between sCD14 levels and percentages of activated CD8+ cells. Other reported features of premature aging include cellular replicative senescence, linked to an accelerated telomeres shortening. Finally, acceleration of age-associated methylation pattern and other epigenetic modifications have been described in HIV-infected children. All these features may favor the clinical manifestations related to premature aging. Lipid and bone metabolism, cancers, cardiovascular, renal, and neurological systems should be carefully monitored, particularly in children with detectable viremia and/or with CD4/CD8 ratio inversion. Conclusion: Aging processes in children with HIV infection impact their quality and length of life. Further studies regarding the mechanisms involved in premature aging are needed to search for potential targets of treatment.
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Affiliation(s)
- Elena Chiappini
- Infectious Disease Unit, Meyer Children's Hospital, Department of Science Health, University of Florence, Florence, Italy
| | - Martina Bianconi
- Infectious Disease Unit, Meyer Children's Hospital, Department of Science Health, University of Florence, Florence, Italy
| | - Annalisa Dalzini
- Section of Oncology and Immunology, Department of Surgery, Oncology and Gastroenterology, Unit of viral Oncology and AIDS Reference Center, University of Padova, Padova, Italy
| | - Maria Raffaella Petrara
- Section of Oncology and Immunology, Department of Surgery, Oncology and Gastroenterology, Unit of viral Oncology and AIDS Reference Center, University of Padova, Padova, Italy
| | - Luisa Galli
- Infectious Disease Unit, Meyer Children's Hospital, Department of Science Health, University of Florence, Florence, Italy
| | - Carlo Giaquinto
- Department of Mother and Child Health, University of Padova, Padova, Italy
| | - Anita De Rossi
- Section of Oncology and Immunology, Department of Surgery, Oncology and Gastroenterology, Unit of viral Oncology and AIDS Reference Center, University of Padova, Padova, Italy.,Istituto Oncologico Veneto IOV-IRCCS, Padova, Italy
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10
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Menon S, Munshi R. Blood-borne viral infections in pediatric hemodialysis. Pediatr Nephrol 2019; 34:1019-1031. [PMID: 30032326 DOI: 10.1007/s00467-018-4019-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/21/2018] [Accepted: 07/02/2018] [Indexed: 01/15/2023]
Abstract
Hemodialysis patients are at increased risk for development of blood-borne viral infections. Human immunodeficiency virus (HIV), a once fatal infection, has become treatable, but continues to be associated with increased mortality. Hepatitis B and C viral infections can lead to acute and chronic hepatitis, cirrhosis, or hepatocellular carcinoma. Young children and immunocompromised patients are more likely to develop chronic disease leading to increased morbidity and mortality, as compared to the healthy population. The hemodialysis population is at increased risk of blood-borne viral infections as compared to the general population due to multiple factors. Here we review risk factors of blood-borne viral infections, strategies for prevention, and approach to therapy in the pediatric hemodialysis population.
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Affiliation(s)
- Shina Menon
- Division of Nephrology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Raj Munshi
- Division of Nephrology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA.
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Abstract
: The World Health Organization estimates that over four million children have been infected with HIV, most via perinatal transmission. The availability of safe and effective antiretroviral therapy (ART) has radically reduced mortality in this population and most that have access to ART are now thriving. However, long-term effects of HIV infection and its therapy have significant impact on aging adolescents and young adults with perinatal HIV infection. Many of the complications of long-term HIV infection seen in adults are also present, although the main impact of long-standing HIV infection and its treatment in children has been on growth and development, including neurodevelopment. A better understanding of the complexities of growing up with perinatal HIV will help prepare low and middle-income countries of the world where ART is now available to successfully manage their aging up populations of adolescents and young adults with perinatal HIV infection.
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Tadesse BT, Foster BA, Kabeta A, Ayalew F, H/Meskel G, Jerene D, Makonnen E, Aklillu E. Hepatic and renal toxicity and associated factors among HIV-infected children on antiretroviral therapy: a prospective cohort study. HIV Med 2018; 20:147-156. [PMID: 30474906 DOI: 10.1111/hiv.12693] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of the study was to investigate the prevalence of renal function and liver enzyme abnormalities among HIV-infected children, changes in prevalence with time on combination antiretroviral therapy (cART), and the factors associated with these abnormalities. METHODS A prospective cohort study was conducted among HIV-infected children < 18 years old (n = 705) who were on first-line cART. Liver enzymes, renal function, haematology, immunology and virological response were assessed at enrolment and followed bi-annually for 18 months. Liver fibrosis and cirrhosis were assessed using noninvasive markers including the aspartate aminotransferase (AST) to platelet ratio index (APRI) and fibrosis score (FIB-4). RESULTS The median age was 12 [interquartile range (IQR) 8-14] years; 53.3% of patients were male. At enrolment, the median cART duration was 3.3 (IQR 1.1-6.1) years; 177 (25.1%) and 83 (11.8%) patients had elevated AST and alanine aminotransferase (ALT), respectively. A tenth of the children had an APRI score > 0.5, suggesting liver fibrosis. Being on a zidovudine (ZDV)- or nevirapine (NVP)-based regimen and having a viral load > 1000 HIV-1 RNA copies/mL were significantly associated with elevated ALT. Twenty-four (3.4%) and 84 (12.1%) patients had elevated creatinine and blood urea nitrogen (BUN), respectively. As cART duration increased by 6 months, median BUN increased by 1.6 [95% confidence interval (CI) 0.4-2.7] mg/dL (P = 0.01); the glomerular filtration rate (GFR) decreased by 35.6 (95% CI 17.7-53.4) mL/min/1.73 m2 (P < 0.0001); and AST and ALT decreased by 1.4 (95% CI 0.4-2.5) IU/L (P = 0.01) and 1.4 (95% CI 0.2-2.6) IU/L (P = 0.01), respectively. CONCLUSIONS A high prevalence of liver enzyme and renal function abnormalities was observed at enrolment. Decreasing liver enzyme levels during follow-up are possibly reassuring, while the progressive reduction in GFR and the increase in BUN are worrisome and require further study.
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Affiliation(s)
- B T Tadesse
- Department of Pediatrics, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia.,Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - B A Foster
- Departments of Dermatology and Pediatrics, Oregon Health Sciences University, Portland, OR, USA
| | - A Kabeta
- School of Nursing, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - F Ayalew
- School of Laboratory Medicine, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - G H/Meskel
- School of Laboratory Medicine, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - D Jerene
- Management Sciences for Health, Addis Ababa, Ethiopia
| | - E Makonnen
- CDT Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - E Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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13
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Innes S, Patel K. Noncommunicable diseases in adolescents with perinatally acquired HIV-1 infection in high-income and low-income settings. Curr Opin HIV AIDS 2018; 13:187-195. [PMID: 29432231 PMCID: PMC5934760 DOI: 10.1097/coh.0000000000000458] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Perinatally HIV-infected adolescents may be at increased risk of noninfectious comorbidities later in life. This review summarizes recent advances in the understanding of noncommunicable diseases (NCD) among HIV-infected adolescents in high-income and lower middle-income countries, and identifies key questions that remain unanswered. We review atherosclerotic vascular disease (AVD), chronic bone disease (CBD), chronic kidney disease (CKD), and chronic lung disease (CLD). RECENT FINDINGS Persistent immune activation and inflammation underlie the pathogenesis of AVD, highlighting the importance of treatment adherence and maintenance of viral suppression, and the need to evaluate interventions to decrease risk. Tenofovir disoproxil fumarate (TDF) and trials of vitamin D supplementation have been the focus of recent studies of CBD with limited studies to date evaluating tenofovir alafenamide as an alternative to TDF for decreasing risk for bone and renal adverse effects among HIV-infected adolescents. Recent studies of CKD have focused primarily on estimating prevalence in different settings whereas studies of CLD are limited. SUMMARY As perinatally HIV-infected children age into adolescence and adulthood with effective long-term ART, it is necessary to continue to evaluate their risks for noninfectious comorbidities and complications, understand mechanisms underlying their risks, and identify and evaluate interventions specifically in this population.
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Affiliation(s)
- Steve Innes
- Family Infectious Diseases Clinical Research Unit (FAMCRU), Stellenbosch University, and Department of Paediatrics and Child Health, Tygerberg Children’s Hospital, Cape Town, South Africa
| | - Kunjal Patel
- Department of Epidemiology, Harvard T.H. Chan School of Public Health and Center for Biostatistics in AIDS Research (CBAR), Boston, MA, USA
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14
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Unsal AB, Mattingly AS, Jones SE, Purdy JB, Reynolds JC, Kopp JB, Hazra R, Hadigan CM. Effect of Antiretroviral Therapy on Bone and Renal Health in Young Adults Infected With HIV in Early Life. J Clin Endocrinol Metab 2017; 102:2896-2904. [PMID: 28531309 PMCID: PMC5546869 DOI: 10.1210/jc.2017-00197] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 05/17/2017] [Indexed: 01/01/2023]
Abstract
Context HIV antiretroviral (ARV) therapy is associated with renal and bone toxicity, but little is known about the potential cumulative effects in adults exposed to ARVs from birth. Objective To prospectively evaluate renal and bone health in young adults with lifelong HIV and extensive ARV exposure. Design Cross-sectional comparison of bone mineral density (BMD) by dual-energy X-ray absorptiometry, bone turnover, and renal function in young adults infected with HIV in early life (n = 65) to matched healthy controls (n = 23) and longitudinal evaluation (mean follow-up = 4.4 years) within a subset of the HIV cohort (n = 33). Setting Government outpatient research clinic. Results Albumin/creatinine ratio, protein/creatinine ratio, anion gap, N-terminal telopeptides, and osteocalcin were significantly increased in persons with HIV compared with controls, whereas whole-body BMD and BMD z scores were lower. Within the HIV group, duration of tenofovir disoproxil fumarate (TDF) correlated with higher anion gap but did not correlate with bone parameters. Longer duration of didanosine and stavudine use correlated with lower BMD and BMD z scores. Longitudinal analyses revealed that BMD and bone metabolism significantly improved over time. No subject had an estimated glomerular filtration rate (eGFR) <60, but decline in eGFR correlated with increasing years of TDF exposure. Conclusions Subclinical markers of renal dysfunction were increased in HIV-infected young adults and associated with TDF exposure, whereas lower bone density was associated with didanosine and stavudine exposure. The tendency for improvement in markers of bone health over time and the availability of less toxic ARV alternatives may herald improvements in renal and bone health for perinatally infected patients in adulthood.
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Affiliation(s)
- Aylin B. Unsal
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Disease, Bethesda, Maryland 20892
| | - Aviva S. Mattingly
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Disease, Bethesda, Maryland 20892
| | - Sara E. Jones
- Clinical Research Directorate/Clinical Monitoring Research Program, Leidos Biomedical Research, Inc., NCI Campus at Frederick, Frederick, Maryland 21701
| | - Julia B. Purdy
- Critical Care Medicine Department, Clinical Center, Bethesda, Maryland 20892
| | - James C. Reynolds
- Radiology and Imaging Sciences, Nuclear Medicine Division, National Institutes of Health (NIH) Clinical Center, Bethesda, Maryland 20892
| | - Jeffrey B. Kopp
- Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland 20892
| | - Rohan Hazra
- Maternal and Pediatric Infectious Disease, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, Maryland 20892
| | - Colleen M. Hadigan
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Disease, Bethesda, Maryland 20892
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15
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Gupta G, Hemal A, Saha A, Kapoor K, Goyal P, Upadhyay AD. Proteinuria in HIV-infected Indian children. Trop Doct 2016; 47:230-233. [PMID: 27655943 DOI: 10.1177/0049475516668963] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chronic kidney disease (CKD) is a major cause of morbidity and mortality among individuals with HIV infection. Screening for proteinuria in HIV-infected children will help in early detection and treatment, and thus prevention and progression to CKD to end-stage kidney disease (ESRD). We screened 139 HIV-infected children aged 18 months to 18 years for proteinuria by urinary dipstick and confirmed by spot urine protein-to-creatinine ratio. If proteinuria was absent by the above methods, patients were screened for microalbuminuria by urinary albumin to creatinine ratio. We found proteinuria in 11.5% and microalbuminuria in 10.6% of our study population. The prevalence of proteinuria was higher in the advanced stages; 8.05% in stage 1, 12.12% in stage 2 and 26.32% in stages 3 + 4.
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Affiliation(s)
- Gopila Gupta
- 1 Postgraduate Student, Department of Paediatrics, Postgraduate Institute of Medical Education & Research and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Alok Hemal
- 2 Professor of Paediatrics, Department of Paediatrics, Postgraduate Institute of Medical Education & Research and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Abhijeet Saha
- 2 Professor of Paediatrics, Department of Paediatrics, Postgraduate Institute of Medical Education & Research and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Kanika Kapoor
- 3 Senior Resident, Department of Paediatrics, Postgraduate Institute of Medical Education & Research and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Parul Goyal
- 4 Associate Professor of Biochemistry, Department of Biochemistry, Postgraduate Institute of Medical Education & Research and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Ashish Datt Upadhyay
- 5 Statistican, Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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16
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Dettmar AK, Oh J. Infection-Related Focal Segmental Glomerulosclerosis in Children. BIOMED RESEARCH INTERNATIONAL 2016; 2016:7351964. [PMID: 27294131 PMCID: PMC4886048 DOI: 10.1155/2016/7351964] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 04/07/2016] [Accepted: 04/21/2016] [Indexed: 01/16/2023]
Abstract
Focal segmental glomerulosclerosis (FSGS) is the most common cause of steroid resistant nephrotic syndrome in children. It describes a unique histological picture of glomerular damage resulting from several causes. In the majority of patients the causing agent is still unknown, but in some cases viral association is evident. In adults, the most established FSGS causing virus is the human immune-deficiency virus, which is related to a collapsing variant of FSGS. Nevertheless, other viruses are also suspected for causing a collapsing or noncollapsing variant, for example, hepatitis B virus, parvovirus B19, and Cytomegalovirus. Although the systemic infection mechanism is different for these viruses, there are similarities in the pathomechanism for the induction of FSGS. As the podocyte is the key structure in the pathogenesis of FSGS, a direct infection of these cells or immediate damage through the virus or viral components has to be considered. Although viral infections are a very rare cause for FSGS in children, the treating pediatric nephrologist has to be aware of a possible underlying infection, as this has a relevant impact on therapy and prognosis.
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Affiliation(s)
- Anne Katrin Dettmar
- Department of Pediatric Nephrology, University Children's Medical Clinic, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Jun Oh
- Department of Pediatric Nephrology, University Children's Medical Clinic, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
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17
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Leão FVF, de Menezes Succi RC, Machado DM, Gouvêa ADFTB, do Carmo FB, Beltrão SV, de Paula Cançado MA, de Abreu Carvalhaes JT. Renal abnormalities in a cohort of HIV-infected children and adolescents. Pediatr Nephrol 2016; 31:773-8. [PMID: 26637410 DOI: 10.1007/s00467-015-3260-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 10/20/2015] [Accepted: 10/26/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study aimed to identify the prevalence of renal abnormalities and the evolution of glomerular filtration rate (GFR) among human immunodeficiency virus (HIV)- infected children and adolescents followed up in an infectious disease outpatient pediatric clinic. METHODS We performed a cohort study of 115 children and adolescents. Outcomes of two evaluations for urinalysis, microalbuminuria/urinary creatinine ratio, urinary retinol-binding protein (uRBP) concentration, and estimated GFR (eGFR) were obtained for each patient, with an average interval of 6 months between evaluations. These changes were correlated with gender, age, race, body mass index (BMI), height-for-age (H/A) percentile, clinical and immunological classification of HIV infection, use of antiretroviral therapy (ART), HIV viral load (VL), and CD4+ T-lymphocyte count. RESULTS Mean patient age at the time of inclusion in the study was 12.6 ± 3.2 years; 50.4 % were male, 81.7 % had acquired immune defeciency syndrome (AIDS), 80.9 % had CD4+ < 500 cells/mm(3), and 87.8 % were on ART. Urinary changes included hematuria (11.3 %), proteinuria (7 %), and microalbuminuria (11.6 %); uRBP was present in 3.8 %; and mean eGFR was 163 ± 32 ml/min/1.73 m(2). CONCLUSIONS The subclinical renal abnormalities found in this study may indicate early manifestations of a broad spectrum of renal dysfunction associated with HIV and involves the decision to initiate or modify ART.
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Affiliation(s)
- Flávia Vanesca Felix Leão
- Pediatric Nephrology Division, Escola Paulista de Medicina-Universidade Federal de SãoPaulo, Rua Borges Lagoa, 442 Vl. Clementino, São Paulo, SP, CEP: 04038-030, Brazil
| | - Regina Célia de Menezes Succi
- Pediatric Infectious Disease Division, Escola Paulista de Medicina-Universidade Federal de SãoPaulo, São Paulo, Brazil.
| | - Daisy Maria Machado
- Pediatric Infectious Disease Division, Escola Paulista de Medicina-Universidade Federal de SãoPaulo, São Paulo, Brazil
| | | | - Fabiana Bononi do Carmo
- Pediatric Infectious Disease Division, Escola Paulista de Medicina-Universidade Federal de SãoPaulo, São Paulo, Brazil
| | - Suenia Vasconcelos Beltrão
- Pediatric Infectious Disease Division, Escola Paulista de Medicina-Universidade Federal de SãoPaulo, São Paulo, Brazil
| | - Maria Aparecida de Paula Cançado
- Pediatric Nephrology Division, Escola Paulista de Medicina-Universidade Federal de SãoPaulo, Rua Borges Lagoa, 442 Vl. Clementino, São Paulo, SP, CEP: 04038-030, Brazil
| | - João Tomas de Abreu Carvalhaes
- Pediatric Nephrology Division, Escola Paulista de Medicina-Universidade Federal de SãoPaulo, Rua Borges Lagoa, 442 Vl. Clementino, São Paulo, SP, CEP: 04038-030, Brazil
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18
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Wang JJ, Mao JH. The etiology of congenital nephrotic syndrome: current status and challenges. World J Pediatr 2016; 12:149-58. [PMID: 26961288 DOI: 10.1007/s12519-016-0009-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 05/11/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND Congenital nephrotic syndrome (CNS), defined as heavy proteinuria, hypoalbuminemia, hyperlipidemia and edema presenting in the first 0-3 months of life, may be caused by congenital syphilis, toxoplasmosis, or congenital viral infections (such as cytomegalovirus). However, the majority of CNS cases are caused by monogenic defects of structural proteins that form the glomerular filtration barrier in the kidneys. Since 1998, an increasing number of genetic defects have been identified for their involvements in the pathogenesis of CNS, including NPHS1, NPHS2, WT1, PLCE1, and LAMB2. DATA SOURCES We searched databases such as PubMed, Elsevier and Wanfang with the following key words: congenital nephrotic syndrome, proteinuria, infants, neonate, congenital infection, mechanism and treatment; and we selected those publications written in English that we judged to be relevant to the topic of this review. RESULTS Based on the data present in the literature, we reviewed the following topics: 1) Infection associated CNS including congenital syphilis, congenital toxoplasmosis, and congenital cytomegalovirus infection; 2) genetic CNS including mutation of NPHS1 (Nephrin), NPHS2 (Podocin), WT1, LAMB2 (Laminin-β2), PLCE1 (NPHS3); 3) Other forms of CNS including maternal systemic lupus erythematosus, mercury poisoning, renal vein thrombosis, neonatal alloimmunization against neutral endopeptidase. CONCLUSION At present, the main challenge in CNS is to identify the cause of disease for individual patients. To make a definitive diagnosis, with the exclusion of infection-related CNS and maternal-associated disorders, pathology, family history, inheritance mode, and other accompanying congenital malformations are sometimes, but not always, useful indicators for diagnosing genetic CNS. Next-generation sequencing would be a more effective method for diagnosing genetic CNS in some patients, however, there are still some challenges with next-generation sequencing that need to be resolved in the future.
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Affiliation(s)
- Jing-Jing Wang
- Department of Nephrology, Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jian-Hua Mao
- Department of Nephrology, Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China. .,Department of Nephrology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China.
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19
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Fredrick F, Francis JM, Ruggajo PJ, Maro EE. Renal abnormalities among HIV infected children at Muhimbili National Hospital (MNH)-Dar es Salaam, Tanzania. BMC Nephrol 2016; 17:30. [PMID: 27000018 PMCID: PMC4800772 DOI: 10.1186/s12882-016-0242-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/16/2016] [Indexed: 02/06/2023] Open
Abstract
Background Human Immunodeficiency Virus infection is a multisystem disease that contributes to significant morbidity. Renal involvement is reported to be common among patients with HIV. This study was carried out to determine renal involvement using simple bedside tests combined with ultrasonography examination. Methods We recruited 240 children from the HIV clinic at Muhimbili National Hospital. Data were collected using structured questionnaires and included demographic, clinical information, radiological tests; renal ultrasound and laboratory tests; serum creatinine, white blood cells, CD4+ counts and percent, urine for microalbuminuria and proteinuria. Results Microalbuminuria and proteinuria were present in 20.4 % and 7.1 % respectively. Significantly higher prevalence of microalbuminuria (p < 0.01) and proteinuria p < 0.01) were noted with low CD4 percent (<25 %). Lower mean CD4+ count were noted among children with microalbuminuria [937.4 ± 595.3 cells/μL vs 1164.7 ± 664.3 cell/μL, (p < 0.05)] and proteinuria [675.5 ± 352.3 cells/μL vs 1152 ± 662 cells/μL (p < 0.001)]. Fourteen (5.8 %) HIV infected children had estimated glomerular filtration rate (eGFR of 30–59) consistent with severe renal impairment. Increased cortical echogenicity was noted in 69/153 (39.2 %) of participants who had ultrasound examination. Conclusion Microalbuminuria, proteinuria and renal dysfunction were noted to be prevalent among HIV infected children indicating the need to consider routine screening of renal complications in these children.
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Affiliation(s)
- Francis Fredrick
- Department of Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), P. O. Box 65001, Dar es Salaam, Tanzania. .,Renal Unit, Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania.
| | - Joel M Francis
- National Institute of Medical Research (NIMR), Mwanza-Centre, Mwanza, Tanzania
| | - Paschal J Ruggajo
- Renal Unit, Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania.,Department of Internal Medicine, School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Eden E Maro
- Department of Internal Medicine, School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
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20
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Abstract
The kidney is involved in a wide range of bacterial, viral, fungal, and parasitic diseases. In most systemic infections, renal involvement is a minor component of the illness, but in some, renal failure may be the presenting feature and the major problem in management. Although individual infectious processes may have a predilection to involve the renal vasculature, glomeruli, interstitium, or collecting systems, a purely anatomic approach to the classification of infectious diseases affecting the kidney is rarely helpful because most infections may involve several different aspects of renal function. In this chapter, a microbiological classification of the organisms affecting the kidney is adopted. Although they are important causes of renal dysfunction in infectious diseases, urinary tract infections and hemolytic uremic syndrome (HUS) are not discussed in detail because they are considered separately in chapters XX and XX, respectively.
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Affiliation(s)
- Ellis D. Avner
- Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Hospital, Health System of Wisconsin, Milwaukee, Wisconsin USA
| | - William E. Harmon
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts USA
| | - Patrick Niaudet
- Service de Néphrologie Pédiatrique, Hôpital Necker-Enfants Malades, Université Paris-Descartes, Paris, France
| | | | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children’s Hospital – IRCCS, Rome, Italy
| | - Stuart L. Goldstein
- Division of Nephrology and Hypertension, The Heart Institute, Cincinnati Children’s Hospital Medical Center, College of Medicine, Cincinnati, Ohio USA
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21
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22
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Vreeman RC, Scanlon ML, McHenry MS, Nyandiko WM. The physical and psychological effects of HIV infection and its treatment on perinatally HIV-infected children. J Int AIDS Soc 2015; 18:20258. [PMID: 26639114 PMCID: PMC4670835 DOI: 10.7448/ias.18.7.20258] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/25/2015] [Accepted: 09/02/2015] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION As highly active antiretroviral therapy (HAART) transforms human immunodeficiency virus (HIV) into a manageable chronic disease, new challenges are emerging in treating children born with HIV, including a number of risks to their physical and psychological health due to HIV infection and its lifelong treatment. METHODS We conducted a literature review to evaluate the evidence on the physical and psychological effects of perinatal HIV (PHIV+) infection and its treatment in the era of HAART, including major chronic comorbidities. RESULTS AND DISCUSSION Perinatally infected children face concerning levels of treatment failure and drug resistance, which may hamper their long-term treatment and result in more significant comorbidities. Physical complications from PHIV+ infection and treatment potentially affect all major organ systems. Although treatment with antiretroviral (ARV) therapy has reduced incidence of severe neurocognitive diseases like HIV encephalopathy, perinatally infected children may experience less severe neurocognitive complications related to HIV disease and ARV neurotoxicity. Major metabolic complications include dyslipidaemia and insulin resistance, complications that are associated with both HIV infection and several ARV agents and may significantly affect cardiovascular disease risk with age. Bone abnormalities, particularly amongst children treated with tenofovir, are a concern for perinatally infected children who may be at higher risk for bone fractures and osteoporosis. In many studies, rates of anaemia are significantly higher for HIV-infected children. Renal failure is a significant complication and cause of death amongst perinatally infected children, while new data on sexual and reproductive health suggest that sexually transmitted infections and birth complications may be additional concerns for perinatally infected children in adolescence. Finally, perinatally infected children may face psychological challenges, including higher rates of mental health and behavioural disorders. Existing studies have significant methodological limitations, including small sample sizes, inappropriate control groups and heterogeneous definitions, to name a few. CONCLUSIONS Success in treating perinatally HIV-infected children and better understanding of the physical and psychological implications of lifelong HIV infection require that we address a new set of challenges for children. A better understanding of these challenges will guide care providers, researchers and policymakers towards more effective HIV care management for perinatally infected children and their transition to adulthood.
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Affiliation(s)
- Rachel C Vreeman
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Child Health and Paediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya;
| | - Michael L Scanlon
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Megan S McHenry
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Winstone M Nyandiko
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Child Health and Paediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
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23
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Rodieux F, Wilbaux M, van den Anker JN, Pfister M. Effect of Kidney Function on Drug Kinetics and Dosing in Neonates, Infants, and Children. Clin Pharmacokinet 2015; 54:1183-204. [PMID: 26138291 PMCID: PMC4661214 DOI: 10.1007/s40262-015-0298-7] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neonates, infants, and children differ from adults in many aspects, not just in age, weight, and body composition. Growth, maturation and environmental factors affect drug kinetics, response and dosing in pediatric patients. Almost 80% of drugs have not been studied in children, and dosing of these drugs is derived from adult doses by adjusting for body weight/size. As developmental and maturational changes are complex processes, such simplified methods may result in subtherapeutic effects or adverse events. Kidney function is impaired during the first 2 years of life as a result of normal growth and development. Reduced kidney function during childhood has an impact not only on renal clearance but also on absorption, distribution, metabolism and nonrenal clearance of drugs. 'Omics'-based technologies, such as proteomics and metabolomics, can be leveraged to uncover novel markers for kidney function during normal development, acute kidney injury, and chronic diseases. Pharmacometric modeling and simulation can be applied to simplify the design of pediatric investigations, characterize the effects of kidney function on drug exposure and response, and fine-tune dosing in pediatric patients, especially in those with impaired kidney function. One case study of amikacin dosing in neonates with reduced kidney function is presented. Collaborative efforts between clinicians and scientists in academia, industry, and regulatory agencies are required to evaluate new renal biomarkers, collect and share prospective pharmacokinetic, genetic and clinical data, build integrated pharmacometric models for key drugs, optimize and standardize dosing strategies, develop bedside decision tools, and enhance labels of drugs utilized in neonates, infants, and children.
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Affiliation(s)
- Frederique Rodieux
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland.
| | - Melanie Wilbaux
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland
| | - Johannes N van den Anker
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland.
- Division of Pediatric Clinical Pharmacology, Children's National Health System, Washington, DC, USA.
- Intensive Care, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Marc Pfister
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland
- Quantitative Solutions LP, Menlo Park, CA, USA
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Bamford A, Turkova A, Lyall H, Foster C, Klein N, Bastiaans D, Burger D, Bernadi S, Butler K, Chiappini E, Clayden P, Della Negra M, Giacomet V, Giaquinto C, Gibb D, Galli L, Hainaut M, Koros M, Marques L, Nastouli E, Niehues T, Noguera-Julian A, Rojo P, Rudin C, Scherpbier HJ, Tudor-Williams G, Welch SB. Paediatric European Network for Treatment of AIDS (PENTA) guidelines for treatment of paediatric HIV-1 infection 2015: optimizing health in preparation for adult life. HIV Med 2015; 19:e1-e42. [PMID: 25649230 PMCID: PMC5724658 DOI: 10.1111/hiv.12217] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2014] [Indexed: 02/06/2023]
Abstract
The 2015 Paediatric European Network for Treatment of AIDS (PENTA) guidelines provide practical recommendations on the management of HIV‐1 infection in children in Europe and are an update to those published in 2009. Aims of treatment have progressed significantly over the last decade, moving far beyond limitation of short‐term morbidity and mortality to optimizing health status for adult life and minimizing the impact of chronic HIV infection on immune system development and health in general. Additionally, there is a greater need for increased awareness and minimization of long‐term drug toxicity. The main updates to the previous guidelines include: an increase in the number of indications for antiretroviral therapy (ART) at all ages (higher CD4 thresholds for consideration of ART initiation and additional clinical indications), revised guidance on first‐ and second‐line ART recommendations, including more recently available drug classes, expanded guidance on management of coinfections (including tuberculosis, hepatitis B and hepatitis C) and additional emphasis on the needs of adolescents as they approach transition to adult services. There is a new section on the current ART ‘pipeline’ of drug development, a comprehensive summary table of currently recommended ART with dosing recommendations. Differences between PENTA and current US and World Health Organization guidelines are highlighted and explained.
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Affiliation(s)
- A Bamford
- Department of Paediatric Infectious Diseases and Immunology, Great Ormond Street Hospital NHS Trust, London, UK
| | - A Turkova
- Medical Research Council Clinical Trials Unit, London, UK
| | - H Lyall
- Department of Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK
| | - C Foster
- Department of Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, UK
| | - N Klein
- Institute of Child Health, University College London, London, UK
| | - D Bastiaans
- Radboud University Medical Center, Nijmegan, The Netherlands
| | - D Burger
- Radboud University Medical Center, Nijmegan, The Netherlands
| | - S Bernadi
- University Department of Immunology and Infectious Disease, Bambino Gesù Children's Hospital, Rome, Italy
| | - K Butler
- Our Lady's Children's Hospital Crumlin & University College Dublin, Dublin, Ireland
| | - E Chiappini
- Meyer University Hospital, Florence University, Florence, Italy
| | | | - M Della Negra
- Emilio Ribas Institute of Infectious Diseases, Sao Paulo, Brazil
| | - V Giacomet
- Paediatric Infectious Disease Unit, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - C Giaquinto
- Department of Paediatrics, University of Padua, Padua, Italy
| | - D Gibb
- Medical Research Council Clinical Trials Unit, London, UK
| | - L Galli
- Department of Health Sciences, Pediatric Unit, University of Florence, Florence, Italy
| | - M Hainaut
- Department of Pediatrics, CHU Saint-Pierre, Free University of Brussels, Brussels, Belgium
| | - M Koros
- Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - L Marques
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Pediatric Department, Porto Central Hospital, Porto, Portugal
| | - E Nastouli
- Department of Clinical Microbiology and Virology, University College London Hospitals, London, UK
| | - T Niehues
- Centre for Pediatric and Adolescent Medicine, HELIOS Hospital Krefeld, Krefeld, Germany
| | - A Noguera-Julian
- Infectious Diseases Unit, Pediatrics Department, Sant Joan de Déu Hospital, University of Barcelona, Barcelona, Spain
| | - P Rojo
- 12th of October Hospital, Madrid, Spain
| | - C Rudin
- University Children's Hospital, Basel, Switzerland
| | - H J Scherpbier
- Department of Paediatric Immunology and Infectious Diseases, Emma Children's Hospital Academic Medical Centre, Amsterdam, The Netherlands
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Kayange NM, Smart LR, Downs JA, Maskini M, Fitzgerald DW, Peck RN. The influence of HIV and schistosomiasis on renal function: a cross-sectional study among children at a hospital in Tanzania. PLoS Negl Trop Dis 2015; 9:e0003472. [PMID: 25612312 PMCID: PMC4303314 DOI: 10.1371/journal.pntd.0003472] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 12/12/2014] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Neema M. Kayange
- Department of Pediatrics, Weill Bugando School of Medicine, Catholic University of Health and Allied Sciences, Mwanza, United Republic of Tanzania
- * E-mail:
| | - Luke R. Smart
- Department of Pediatrics, Weill Bugando School of Medicine, Catholic University of Health and Allied Sciences, Mwanza, United Republic of Tanzania
- Center for Global Health, Weill Cornell Medical College, New York, New York, United States of America
| | - Jennifer A. Downs
- Center for Global Health, Weill Cornell Medical College, New York, New York, United States of America
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
| | - Mwanaisha Maskini
- Department of Pediatrics, Weill Bugando School of Medicine, Catholic University of Health and Allied Sciences, Mwanza, United Republic of Tanzania
| | - Daniel W. Fitzgerald
- Center for Global Health, Weill Cornell Medical College, New York, New York, United States of America
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
| | - Robert N. Peck
- Department of Pediatrics, Weill Bugando School of Medicine, Catholic University of Health and Allied Sciences, Mwanza, United Republic of Tanzania
- Center for Global Health, Weill Cornell Medical College, New York, New York, United States of America
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
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Mitchell CD, Chernoff MC, Seage GR, Purswani MU, Spiegel HML, Zilleruelo G, Abitbol C, Heckman B, Ponce CB, Oleske JM. Predictors of resolution and persistence of renal laboratory abnormalities in pediatric HIV infection. Pediatr Nephrol 2015; 30:153-65. [PMID: 25149850 PMCID: PMC4301405 DOI: 10.1007/s00467-014-2909-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/07/2014] [Accepted: 07/09/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Among human immunodeficiency virus (HIV)-infected youth, the role of renal disease (RD) and its management has become increasingly important as these children/adolescents mature into young adults. The identification of predictors of abnormal renal laboratory events (RLE) may be helpful in the management of their HIV infection and its associated renal complications. METHODS Data collected from HIV-infected youth followed for ≥ 48 months were analyzed to identify predictors of resolution versus persistence of RLE and determine the utility of RLE to predict the onset of RD. Analysis included descriptive and inferential methods using a multivariable extended Cox proportional hazards model. RESULTS Of the 1,874 at-risk children enrolled in the study, 428 (23 %) developed RLE, which persisted in 229 of these (54 %). CD4 percentages of <25 % [hazard ratio (HR) 0.63, p < 0.002) and an HIV viral load of >100,000 copies/ml (HR 0.31, p < 0.01) were associated with reduced rates of resolution, while in most cases exposure to highly active antiretroviral therapy (HAART)/nephrotoxic HAART prior to or subsequent to RLE were not. Persistence of RLE was 88 % sensitive for identifying new RD. Negative predictive values for RD were >95 % for both the at-risk cohort and those with RLE. CONCLUSIONS Advanced HIV disease predicted persistence of RLE in HIV-infected youth. Persistent RLE were useful for identifying RD.
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Affiliation(s)
- Charles D Mitchell
- Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Miami Miller School of Medicine, Room 286, Batchelor Children's Research Institute, 1580 NW 10th Avenue, Miami, 33136, FL, USA,
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Abstract
Viral infections associate temporally with the onset of many glomerular diseases, particularly in children. In other cases of glomerulonephritis, when infection is clinically silent, viral syndromes can still be implicated as a trigger. However, strong evidence for viral causality in most glomerular disease is still lacking. While numerous case reports in children document the occurrence of specific forms of glomerular disease after seroconversion to a wide range of viruses, relatively few reports provide pathologic evidence of viral infection associated with glomerular lesions on kidney biopsy. Strong associations between hepatitis viruses and glomerular injury have been acknowledged in adults, but hepatitis C virus appears not to be an etiology in children. In the context of treating glomerular diseases, when diagnosed, the treatment of hepatitis B virus, cytomegalovirus and human immunodeficiency virus in children with membranoproliferative, membranous and collapsing glomerulopathy plays an important role. Otherwise, there is no evidence suggesting that the identification of a viral infection in a child with glomerulopathy should change the management of the infection or the glomerulonephritis. Therefore, additional research into this topic is very much needed.
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Abstract
Purpose of review Recent WHO guidelines recommend immediate initiation of lifelong antiretroviral therapy (ART) in all children below 5 years, irrespective of immune/clinical status, to improve access to paediatric ART. Interim trial results provide strong evidence for immediate ART during infancy because of high short-term risk of mortality and disease progression, but there is wider debate regarding the potential risks and benefits of immediate ART in asymptomatic children aged above 1 year. Concerns include long-term toxicities and treatment failure, particularly in resource-constrained settings with limited paediatric treatment options. Recent findings Benefits of immediate ART among infants appear to be maintained in the mid-term to long-term, with low risk of treatment failure, and better neurodevelopmental outcomes. In contrast, a trial reported no benefits of immediate versus deferred ART in asymptomatic children aged above 1 year. However, observational studies suggest that ART initiation at older ages and lower CD4 reduces the probability of immune reconstitution, with unclear implications on risk of clinical events or treatment change. A recent trial on treatment interruption following early intensive ART suggest that this may be a safe alternative approach. Summary Although there are clear benefits of immediate ART among infants, there remains conflicting evidence on the benefits for older children.
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Lowenthal ED, Bakeera-Kitaka S, Marukutira T, Chapman J, Goldrath K, Ferrand RA. Perinatally acquired HIV infection in adolescents from sub-Saharan Africa: a review of emerging challenges. THE LANCET. INFECTIOUS DISEASES 2014; 14:627-39. [PMID: 24406145 DOI: 10.1016/s1473-3099(13)70363-3] [Citation(s) in RCA: 305] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Worldwide, more than three million children are infected with HIV, 90% of whom live in sub-Saharan Africa. As the HIV epidemic matures and antiretroviral treatment is scaled up, children with HIV are reaching adolescence in large numbers. The growing population of adolescents with perinatally acquired HIV infection living within this region presents not only unprecedented challenges but also opportunities to learn about the pathogenesis of HIV infection. In this Review, we discuss the changing epidemiology of paediatric HIV and the particular features of HIV infection in adolescents in sub-Saharan Africa. Longstanding HIV infection acquired when the immune system is not developed results in distinctive chronic clinical complications that cause severe morbidity. As well as dealing with chronic illness, HIV-infected adolescents have to confront psychosocial issues, maintain adherence to drugs, and learn to negotiate sexual relationships, while undergoing rapid physical and psychological development. Context-specific strategies for early identification of HIV infection in children and prompt linkage to care need to be developed. Clinical HIV care should integrate age-appropriate sexual and reproductive health and psychological, educational, and social services. Health-care workers will need to be trained to recognise and manage the needs of these young people so that the increasing numbers of children surviving to adolescence can access quality care beyond specialist services at low-level health-care facilities.
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Affiliation(s)
- Elizabeth D Lowenthal
- Departments of Pediatrics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA; Department of Paediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Botswana-UPenn Partnership, Gaborone, Botswana
| | - Sabrina Bakeera-Kitaka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Tafireyi Marukutira
- Botswana-Baylor Children's Clinical Centre of Excellence, Gaborone, Botswana
| | - Jennifer Chapman
- Department of Paediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathryn Goldrath
- Departments of Pediatrics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Rashida A Ferrand
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Biomedical Research and Training Institute, Harare, Zimbabwe.
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Abstract
The great success in the prevention and treatment of pediatric HIV in high resource countries, and now in low resource countries, has changed the face of the HIV epidemic in children from one of near certain mortality to that of a chronic disease. However, these successes pose new challenges as perinatally HIV-infected youth survive into adulthood. Increased survival of HIV-infected children is associated with challenges in maintaining adherence to what is likely life-long therapy, and in selecting successive antiretroviral drug regimens, given the limited availability of pediatric formulations, limitations in pharmacokinetic and safety data of drugs in children, and the development of extensive drug resistance in multi-drug-experienced children. Pediatric HIV care must now focus on morbidity related to long-term HIV infection and its treatment. Survival into adulthood of perinatally HIV-infected youth in high resource countries provides important lessons about how the epidemic will change with increasing access to antiretroviral therapy for children in low resource countries. This series of papers will focus on issues related to management of perinatally infected youth and young adults.
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