Human immunodeficiency virus (HIV)-associated nephropathy among antiretroviral naïve adults with persistent proteinuria at the Moi teaching and referral hospital (MTRH)

Abstract

BACKGROUND: As the HIV/AIDS pandemic continues to affect millions in sub-Saharan Africa, more will fall victim to its systemic complications. Among African Americans, HIV-associated nephropathy (HIVAN)has been noted to be of particular predilection. Very little is known about this form of kidney disease in sub-Saharan Africa even though potentially life-saving antiretroviral drugs are increasingly available and are useful in the treatment of this serious renal disease. METHODS: We conducted a cross-sectional study and screened HIV-infected non-febrile, non-hypertensive and non-diabetic, antiretroviral naïve adults attending a large HIV care program in Western Kenya for the presence of persistent microalbuminuria/macroalbuminuria (proteinuria). Those with persistent proteinuria, subject to consent, underwent a renal biopsy. Subjects were interviewed, examined and blood taken for laboratory analysis. Data on demographics, clinical presentation, CD4 counts, serum creatinine, urine dipstick protein, urinary albumin to creatinine ratio (UACR) and biopsy diagnosis were collected and analyzed. Proportions and means were calculated and inferential statistics was done using the exact method of chi-squared test. RESULTS: 523 subjects were screened between December 2010 and May 2011. 85/523 (16.3%) had spot proteinuria; 53/85 (62.4%) came back for follow-up, 32/53 (60.4%) had had persistent proteinuria and by imputation 9.8% of all screened had persistent proteinuria. 27 subjects with persistent proteinuria underwent biopsy, 17/27 (63%) were female. The mean age was 36.6 years (range 23-65 years).14/27 (52%) reported being on medications,21/27 (78%) reported no symptoms and 23/27 (85%) had a normal physical exam. 24/26 (92%) had normal renal function.24/26 (92%) had UACR less than 1 g/g, mean UACR was 384.2 mg/g (range 5-1384 mg/g). Mean CD4 count was 340.7 cells/μL, median 369 cells/μL (range 3-1060 cells/ μL). None of them had histologic features consistent with HIVAN. 11/27 (41%) had a primary diagnosis of acute interstitial nephritis (AIN), 9/27 (33%) had non-specific findings, 2/27 (7.4%) arteriosclerosis, while focal segmental sclerosis (FSGS), acute postinfectious glomerulonephritis (APIGN), chronic interstitial nephritis (CIN), pyelitis and papillary sickling were 1/27 (3.7%) each. No association was found between age, sex, tribal lineage, UACR and CD4 with any particular diagnosis. CONCLUSIONS: The prevalence of HIVAN among antiretroviral naïve adults with persistent proteinuria at the Moi Teaching and Referral Hospital (MTRH) is low. AIN is the most common cause of persistent proteinuria in this setting.