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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA - AFRICA  
Year : 2016  |  Volume : 27  |  Issue : 1  |  Page : 129-134
Prevalence and clinical and laboratory characteristics of kidney disease in anti-retroviral-naive human immunodeficiency virus-infected patients in South-South Nigeria


1 Renal Unit, Department of Medicine, Enugu State University Teaching Hospital, Parklane Enugu, Nigeria
2 Renal Unit, Department of Medicine, University of Benin Teaching Hospital, Benin City, Nigeria
3 Renal Unit, Department of Medicine, Federal Medical Center, Umuahia, Nigeria

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Date of Web Publication15-Jan-2016
 

   Abstract 

Since the emergence of acquired immune deficiency syndrome (AIDS) about three decades ago, several renal disorders have been reported as common complications of human immunodeficiency virus (HIV) infection. These renal disorders result from diverse etiologies. The aim of this cross-sectional study was to determine the prevalence and clinical and laboratory characteristics of anti-retroviral-naοve HIV-infected patients with impaired kidney disorder in South-South Nigeria. This study was conducted on patients presenting at the University of Benin Teaching Hospital, Benin City in South-South Nigeria for six months. The patients' demographic data and clinical, hematological and biochemical parameters were assessed. Their glomerular filtration rate (GFR) was calculated and the protein excretion was assessed from the protein- creatinine ratio. Data were analyzed using statistical software program SPSS version 15.0. Threehundred and eighty-three patients with a mean age of 35.39 ± 8.78 years and a male: female ratio of 1:1 were studied; 53.3% had evidence of kidney disorder. The main clinical features in patients with kidney disorder were evidence of fluid retention, urinary symptoms, pallor and encephalopathy. The mean systolic and diastolic blood pressures were 115.33 ± 17.17 and 72.33 ± 14.31 mm Hg, respectively. The mean estimated GFR was 52.5 mL/min/1.73 m 2 . Patients with kidney disorder had higher proteinuria (P = 0.001), lower mean CD4 cell count and packed cell volume (P = 0.019 and 0.001, respectively). Kidney disorder is a common complication in HIV-infected patients, and they have clinical and laboratory anomalies. Screening of HIV/AIDS patients at the time of diagnosis will facilitate early diagnosis of kidney disorders in them.

How to cite this article:
Okafor U H, Unuigbe E I, Chukwuonye E. Prevalence and clinical and laboratory characteristics of kidney disease in anti-retroviral-naive human immunodeficiency virus-infected patients in South-South Nigeria. Saudi J Kidney Dis Transpl 2016;27:129-34

How to cite this URL:
Okafor U H, Unuigbe E I, Chukwuonye E. Prevalence and clinical and laboratory characteristics of kidney disease in anti-retroviral-naive human immunodeficiency virus-infected patients in South-South Nigeria. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2019 Nov 22];27:129-34. Available from: http://www.sjkdt.org/text.asp?2016/27/1/129/174155

   Introduction Top


Multiple organs including the kidneys are common targets in infection with the human immunodeficiency virus (HIV). A variety of renal syndromes have been reported during the course of HIV infection. [1] These present as acute, chronic or acute on chronic kidney disorders.

Rao et al [2] first reported in 1984 that renal lesions were found in HIV-infected patients. He went further to describe a glomerulopathy, which was characterized by heavy proteinuria, biochemical features of nephrotic syndrome and azotemia, which rapidly progressed to end-stage renal disease (ESRD). Since then, many types of renal disorders have been encountered, ranging from mild transient renal impairment to ESRD. These renal disorders can occur at all stages of HIV infection. [3],[4]

Furthermore, kidney disorders can also result from opportunistic infections, toxicity from anti-retroviral therapy and other drugs used in the management of HIV infection. [5],[6]

The actual global incidence and prevalence of renal disease in HIV infection is not known thus rendering epidemiologic assessment difficult. In Africa, where majority of the patients with HIV infection live, there is paucity of data regarding renal involvement. However, the prevalence of renal disease in HIV/ acquired immune deficiency syndrome (AIDS) patients has been variously reported to be 30- 60%. [1],[3],[7]

Most of the renal manifestations of HIVinfected patients represent complications of concurrent infection in a severely immunocompromised host or side-effects of the plethora of treatment required to manage them. [8],[9],[10]

Defining the precise role of the HIV virion and its gene products in instigating pathology within the nephron has been difficult, and most of the proposed pathogenic mechanisms remain controversial. Attempts to define the pathogenesis of HIV-driven renal disease, including in vivo and in vitro studies of HIV infection in various cell components of the nephron, have not produced a consensus mechanism. [11]

The virus has been reported to affect the kidneys directly, causing various glomerular and interstitial kidney diseases. This is achieved by attacking the glomerular epithelial and renal tubular cells. [9] Diabetic nephropathy, hypertensive nephrosclerosis, malignant hypertension, chronic glomerulonephritis, lupus nephritis and chronic pyelonephritis had been variously reported in HIV-infected patients. [12],[13],[14]

Early detection and intervention in HIV patients with renal disorder may delay the progression or reverse the impairment in renal function. [9],[10]

The aim of this study was to determine the prevalence and clinical and laboratory characteristics of naive HIV-infected patients with kidney disorders presenting at a tertiary hospital in South-South Nigeria.


   Subjects and Methods Top


This was a cross-sectional study of naive HIV-infected patients presenting at the University of Benin Teaching Hospital (UBTH), Benin City, a tertiary health-care center in South-South Nigeria. The study was conducted over a six-month period.

Adult HIV-seropositive patients presenting during the study period were recruited for the study after receiving informed consent. However, patients with diabetes mellitus, hypertension, congestive cardiac failure, sickle cell anemia, malignancies not related to HIV infection, urinary tract infection and history of renal disease were excluded from the study. Pregnant patients and those on anti-retroviral therapy were also excluded.

Consecutive naive HIV-infected patients presenting in the accident/emergency unit or admitted into the medical wards within the study period and meeting the eligibility criteria were recruited for the study.

Ethical clearance from the Ethical and Research Committee of the hospital was obtained. The details of the study, including collection of urine and blood specimens, were explained to all patients participating in the study and signed consent was obtained from each patient before proceeding with the study.

The demographic data and the clinical details of each patient were documented. Blood specimen was collected for assessment of packed cell volume (PCV), serum electrolytes, urea and creatinine. Spot urine was collected for assessment of protein and creatinine.

The glomerular filtration rate (GFR) was calculated using the six formula equation of the Modification of Diet in Renal Disease (MDRD), and the urine protein excretion was calculated using the urine protein:creatinine ratio (PCR).

Kidney disorder was defined as impairment in kidney function, detected when the estimated GFR (eGFR) is <60 mL/min/1.73 m 2 and/or evidence of kidney injury as detected when the PCR (mg/g) was ≥200.

The data obtained were entered into a Microsoft Excel electronic spreadsheet and analyzed using the SPSS version 15.0 statistical package. Distribution of variables and defining criteria for kidney disorder were computed. The Student's t test and the chi-square test were used to compare the means and proportions of the variables, respectively. A Pvalue <0.05 was considered to be significant.


   Results Top


Three-hundred and eighty-three eligible HIVinfected patients were recruited for the study, and, of these, 204 patients (53.3%) had an evidence of kidney disorder as defined above.

Demographics

Patients studied were aged between 18 and 81 years, with a mean age of 36.03 ± 9.08 years. The mean age of patients with normal and impaired renal function were 35.39 ± 8.78 and 36.67 ± 9.38 years, respectively (P = 0.66).

[Table 1] shows the age distribution of the patients according to renal function. Majority (89.8%) of the patients were aged <50 years. HIV infection and impaired kidney function were most commonly seen in the 30-39 years age-group.
Table 1: Age distribution of the study subjects.

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Sex distribution of patients studied according to kidney function is shown in [Figure 1]. Females made up 58.5% of the study population. Normal kidney function was demonstrated in 67.5% and 32.5% of females and males, respectively, while the prevalence of impaired kidney function was similar in both sexes (50% each).
Figure 1: Sex distribution of the study population.

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The important clinical characteristics of the study patients are shown in [Table 2] and the salient laboratory features are shown in [Table 3].
Table 2: Clinical characteristics of the study population.

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Table 3: Laboratory parameters of the study population.

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   Discussion Top


A large proportion (53.3%) of the HIVinfected patients studied had impaired kidney function (IKF) defined as GFR <60 mL/min/1.73 m 2 and/or daily urinary protein excretion >200 mg. Previous studies have reported a lower prevalence rate of kidney disorder in HIV infection. [5],[8],[9] These studies excluded patients with low-grade proteinuria as this parameter was assessed by the dipstick method; also, the study population had better socioeconomic status and easier access to early diagnosis and treatment of HIV. However, Agaba et al, [7] in a study of HIV patients with renal disease in North Central Nigeria, reported a prevalence rate of 52%, which is consistent with the results of this study.

HIV and renal disease have been reported as diseases affecting young adults more than the other age-groups in developing countries, [7],[12],[15] and this trend is thought to be associated with poverty, low socioeconomic status and higher sexual activity in the younger age groups. Majority (89.8%) of the HIV patients studied were aged <50 years, which was in agreement with earlier reports. [12],[15] In consonance with an earlier report, females constituted a larger proportion (58.5%) of the study population; indeed, females are more predisposed to HIV infection because of various social and anatomic make up that result in a higher prevalence of infection in them. [16] However, despite the female preponderance in this study population, 50% of patients with IKF were male thus suggesting that renal disease is more common in the male gender. This is consistent with other studies. [7],[8],[15]

Various clinical features are common to both HIV infections and renal diseases. These features include easy fatigability, weakness, anorexia, nausea, vomiting, change in bowel habits, pruritus, pallor, fluffy hair and weight loss. Hypertension and body swelling have been reported to be uncommon in HIV patients with renal disorder, especially in those with HIV-associated nephropathy. However, this study reported that fluid retention was more common in patients with IKF. This could have resulted from other co-morbid conditions prevalent in these patients, including malnutrition, vasculopathy and hepatic or cardiac disorder, and this study included patients with non-HIV kidney disorders as well. Central nervous system manifestations were more common in patients with IKF in this study, and this conforms to the fact that such features are commonly seen in HIV and CKD patients with co-morbidities/complications.

Anemia is a common presentation in HIV infection and in patients with renal impairment. The co-existence of HIV infection and renal impairment worsens the burden of anemia in these patients in terms of morbidity and mortality. [17],[18] Thus, it is not surprising that anemia was more severe in patients with IKF in this study. The cause of anemia in both clinical conditions is multi-factorial and includes malnutrition, hemolysis, hemorrhage and bone marrow suppression, among others. The mean CD4 cell count in patients with IKF was lower than that in patients with normal kidney function, and this is consistent with earlier reports of a positive correlation between the prevalence/severity of renal disorder and CD4 cell count. [7],[8],[19] Immunosuppression, which is the hallmark of HIV infection, is also common in patients with IKF; thus, HIV patients with IKF are more prone to infection, and this might explain the higher white blood cell count in patients with IKF in this study.

There was no significant difference between the biochemical parameters of both groups in this study; however, the serum creatinine and urea were higher and the GFR was lower in patients with IKF. Various electrolyte abnormalities, including hyponatremia, hypokalemia, hypouricemia, hypocalcemia, hypomagnesemia and acid/base imbalance, have been reported in HIV/AIDS patients. [20],[21]

Proteinuria is an important parameter in the diagnosis and prognosis of kidney diseases. Nephrotic-range proteinuria is part of the diagnostic criteria for renal diseases in HIV infection, especially in HIV-associated nephropathy. Proteinuria in this study was higher in patients with IKF, but was not in the nephrotic range. This level of proteinuria may be due to the fact that some patients studied had other forms of renal disorder responsible for the IKF.

In conclusion, IKF is a common presentation in patients with HIV infection. HIV patients with IKF have poorer clinical, hematological and biochemical characteristics. Early detection of kidney disorder is imperative in HIVinfected patients; there is a need for screening of all HIV patients for renal function even at the time of diagnosis of HIV infection.

The limitations of this study include the small sample size and the fact that it is a crosssectional study. There is need for a multicenter cohort study to enable proper characterization and to identify the nature of the IKF in HIV-infected patients in developing countries.

 
   References Top

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2.
Rao TK, Filippone EJ, Nicastri AD, et al. Associated focal and segmental glomerulosclerosis in the acquired immunodeficiency syndrome. N Engl J Med 1984;310:669-73.  Back to cited text no. 2
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Winston JA, Klotman PE. Are we missing an epidemic of HIV-associated nephropathy? J Am Soc Nephrol 1996;7:1-7.  Back to cited text no. 3
    
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Seney FD Jr., Burns DK, Silva FG. Acquired immunodeficiency syndrome and the kidney. Am J Kidney Dis 1990;16:1-13.  Back to cited text no. 4
    
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Szczech LA, Gupta SK, Habash R, et al. The clinical epidemiology and course of the spectrum of renal diseases associated with HIV infection. Kidney Int 2004;66:1145-52.  Back to cited text no. 8
    
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Szczech LA. HIV related renal diseases. Med Gen Med 2005;3:1.  Back to cited text no. 10
    
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Gerntholtz TE, Goetsch SJ, Katz I. HIVrelated nephropathy: A South African perspective. Kidney Int 2006;69:1885-91.  Back to cited text no. 12
    
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Valeri A, Neusy AJ. Acute and chronic renal disease in hospitalized AIDS patients. Clin Nephrol 1991;35:110-8.  Back to cited text no. 13
    
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Rosenberg ZF, Fauci AS. The immunopathogenesis of HIV infection. Adv Immunol 1989;47:377-431.  Back to cited text no. 14
    
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Emem CP, Arogundade F, Sanusi A, Adelusola K, Wokoma F, Akinsola A. Renal disease in HIV-seropositive patients in Nigeria: An assessment of prevalence, clinical features and risk factors. Nephrol Dial Transplant 2008;23:741-6.  Back to cited text no. 15
    
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Onyemelukwe GC, Musa BO. CD4+ and CD8+ lymphocytes and clinical features of HIV seropositive Nigerians on presentation. Afr J Med Med Sci 2002;31:229-33.  Back to cited text no. 16
    
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Okafor UH, Unuigbe EI, Wokoma FS. Spectrum of clinical presentations in human immunodeficiency virus (HIV) infected patients with renal disease. Afr J Infect Dis 2011;5:28-32.  Back to cited text no. 17
    
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Horwich TB, Fonarow GC, Hamilton MA, MacLellan WR, Borenstein J. Anemia is associated with worse symptoms, greater impairment in functional capacity and a significant increase in mortality in patients with advanced heart failure. J Am Coll Cardiol 2002;39:1780-6.  Back to cited text no. 18
    
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Okafor UH, Unuigbe EI, Ojogwu I, Oviasu E, Wokoma FS. Renal disease in HIV infected patient: What relationship with level of CD4 cell count. Afr Health Sci 2011;11:S28-33.  Back to cited text no. 19
    
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Agarwal A, Soni A, Ciechanowsky M, Chander P, Treser G. Hyponatremia in patients with the acquired immunodeficiency syndrome. Nephron 1989;53:317-21.  Back to cited text no. 20
    
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Earle KE, Seneviratne T, Shaker J, Shoback D. Fanconi's syndrome in HIV+ adults: Report of three cases and literature review. J Bone Miner Res 2004;19:714-21.  Back to cited text no. 21
    

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Correspondence Address:
U H Okafor
Renal Unit, Department of Medicine, Enugu State University Teaching Hospital Parklane, Enugu
Nigeria
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DOI: 10.4103/1319-2442.174155

PMID: 26787579

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