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ORIGINAL ARTICLE
Year : 2018  |  Volume : 21  |  Issue : 1  |  Page : 42-46

Prevalence of chronic kidney disease among antiretroviral naïve human immunodeficiency virus-infected patients


Department of Medicine, Jos University Teaching Hospital, Jos, Plateau State, Nigeria

Date of Web Publication21-May-2018

Correspondence Address:
Dr. Esala E Abene
Department of Medicine, Renal Unit, Jos University Teaching Hospital, PMB 2076, Jos, Plateau State
Nigeria
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DOI: 10.4103/smj.smj_53_16

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  Abstract 


Background: Chronic kidney disease (CKD) is one of the important complications of human immunodeficiency virus (HIV) infection. The prevalence of CKD in HIV-infected Nigerians at presentation is currently unknown. Materials and Methods: This was a comparative study of 400 antiretroviral drug naïve HIV-infected patients attending the HIV clinic of a teaching hospital in North Central Nigeria and 140 apparently healthy individuals. CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min and/or proteinuria ≥1+ according to standard guidelines. Results: Proteinuria was found in 119 (29.8%) of the HIV group compared to only eight (5.7%) of the control group (P< 0.0001). eGFR <60 ml/min was found in 12 (3%) of the HIV group compared to none of the control group (P< 0.0001). CKD (eGFR < 60 ml/min/+proteinuria) was found in 123 (30.8%) of the HIV group compared to eight (5.7%) in the control group (P< 0.0001). A multivariate analysis showed that male sex, low body mass index, low CD4 + T cell counts, and higher viral load copies in the HIV population correlated independently with CKD. Conclusion: The burden of renal disease in drug naïve HIV-infected patients is high. Early diagnosis and treatment of HIV may stem this tide.

Keywords: Acquired immunodeficiency syndrome, chronic kidney disease, glomerular filtration rate, HIV, proteinuria


How to cite this article:
Abene EE, Gimba ZM, Agbaji OO, Agaba EI. Prevalence of chronic kidney disease among antiretroviral naïve human immunodeficiency virus-infected patients. Sahel Med J 2018;21:42-6

How to cite this URL:
Abene EE, Gimba ZM, Agbaji OO, Agaba EI. Prevalence of chronic kidney disease among antiretroviral naïve human immunodeficiency virus-infected patients. Sahel Med J [serial online] 2018 [cited 2018 Sep 24];21:42-6. Available from: http://www.smjonline.org/text.asp?2018/21/1/42/232784




  Introduction Top


Human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS) is a health catastrophe globally.[1] At present, HIV infection affects 35 million people worldwide of which 24.7 million (70.5%) of this population live in sub-Saharan Africa.[2] Nigeria contributes significantly to this number having the second largest number of people living with HIV in the world.[3]

Chronic kidney disease (CKD) is one of the important complications of HIV infection [4] with the most common cause being HIV-associated nephropathy.[5] Other causes include immune complex glomerulonephritis and thrombotic microangiopathy.[6],[7] Proteinuria has been recognized as a risk factor for initiation and progression of kidney disease even before any significant fall in glomerular filtration rate (GFR) and has been reported as the initial manifestation of kidney disease in HIV.[8],[9] In the USA, HIV is the third leading cause of end-stage renal disease in African Americans aged 20–64 years.[10] A study in the USA among HIV patients reported a CKD prevalence of 15.5%.[11] A large study conducted in Europe reported a prevalence of 3.5%[12] while another in Hong Kong reported a prevalence of 16.8%.[13]

Studies in Africa have reported a wide range in the prevalence of CKD in HIV patients. In Southern Africa, a prevalence of 6% was reported by Han et al.[14] Studies done in southern Nigeria, by Emem et al.,[15] reported a prevalence of 30.8% while Umeizudike et al.[16] found a prevalence of 20.1% among highly active antiretroviral therapy (HAART) naive patients in South West Nigeria. In an earlier study conducted over a decade ago in North central Nigeria, we had reported a high prevalence of CKD of 51.8% among HAART naive patients.[17] Similarly, in a retrospective study conducted from the same region, we reported a prevalence of 23.8%.[18] While the earlier study was limited by a relatively small sample size and use of azotemia and proteinuria as markers for CKD, the latter study used only low GFR without recourse to the prevalence of proteinuria.

We hypothesized that the prevalence of CKD in HAART naïve HIV-infected patients may be lower than we had previously reported. In this comparative study conducted in a teaching hospital in North central Nigeria, we describe the prevalence of CKD in HAART naïve HIV-infected patients.


  Materials and Methods Top


This was a comparative study of HAART naïve HIV-infected patients attending the HIV clinic of the Jos University Teaching Hospital in North Central Nigeria and apparently healthy controls between May 2011 and January 2012. HIV-infected subjects who were older than 15 years but <65 years presenting for HIV counseling and testing were recruited in a consecutive manner using convenience sampling technique. Subjects who had fever, symptoms of urinary tract infection, congestive cardiac failure, known history of diabetes mellitus, hypertension, urinary tract obstruction, and chronic use of analgesics were excluded from the study. Individuals who tested negative were taken as controls.

The Human Research Ethics Committee of the hospital approved this study 3rd August 2010. Written informed consent was obtained from the study participants. The data were kept anonymous by removing all patient identifiers and all records were kept safe until analysis.

An interviewer-administered questionnaire was used to collect data from all participants. Demographic and clinical information obtained from each subject included age, sex, marital status, occupation, and level of education and family history of hypertension, diabetes mellitus, and kidney disease. Height and weight were measured in meters and kilograms, respectively, using a stadiometer and weighing scale with the participants wearing light clothing with no head gear. Body mass index (BMI) was calculated using the Quetelet index.[19] Blood pressure was measured according standard guidelines.[20] Urine was then collected from each subject using standard protocols and combi 10 dipstix was used to determine proteinuria. Ten milliliters of venous blood was then obtained for serum creatinine and random blood glucose. Serum creatinine was estimated using the kinetic enzymatic method and estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI formula.[21] CD4+ T cell count and HIV-1 RNA viral load were measured in the HIV positive subjects using CyFlow (Partec, Germany) and Roche Ampliclor (version 1.5, Brancburg, NJ, USA) machines, respectively.

CKD was defined as eGFR <60 ml/min and/or proteinuria ≥1+. The various stages of CKD were determined using the latest guidelines.[22] Statistical analysis was done using Epi-info, version 3.5.1. (CDC, Atlanta, GA) Continuous variables were expressed as means +/- SD while categorical variables as proportions. Student's t-test was used to compare group means while Chi-square was used to compare proportions. Kruskal–Wallis test was used to compare nonuniformly distributed continuous variables such as CD4+ T-cell counts and viral loads between HIV-positive subjects with and without CKD. Variables with P < 0.25 were entered into a multivariate equation to identify the independent correlates of CKD. A P< 0.05 was considered statistically significant.


  Results Top


Sociodemographic and clinical characteristics of the study population

A total of 400 HAART naïve HIV-infected subjects and 140 HIV-negative controls were recruited for this study. [Table 1] shows the demographic, clinical, and laboratory parameters of the study population. Women constituted majority of the study population (66.5% of the subjects and 67.1% of the controls, P = 0.89). The mean age of the HIV-positive subjects, serum creatinine, and eGFR was comparable with the control group as shown in the table.
Table 1: Demographic, clinical, and laboratory characteristics of the study population

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Prevalence of chronic kidney disease

Proteinuria was found in 119 (29.8%) of the HIV group while only 8 (5.7%) of the control group had proteinuria (P< 0.0001). Reduced eGFR was found in 12 (3%) of the HIV group while none of the control group had reduced eGFR (P< 0.0001). CKD (eGFR <60 ml/min/+proteinuria) was found in 123 (30.8%) of the HIV group compared to 8 (5.7%) in the control group (P< 0.0001). The various stages of CKD of the study population are presented in [Figure 1].
Figure 1: Distribution of chronic kidney disease among human immunodeficiency virus-positive patients and controls at the Jos University Teaching Hospital

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Factors associated with chronic kidney disease

[Table 2] shows the factors associated with CKD. The mean age was higher in those with CKD compared with those without CKD (35 ± 8 years vs. 33 ± 8 years, P = 0.018). CKD was found to be higher among males (43.3%) than females (24.4%), P < 0.0001. The BMI and CD4+ cell count were lower in those with CKD. The median viral load was, however, higher among those with CKD. A multivariate analysis showed that male sex, low BMI, low CD4+ T cell counts, and higher viral load copies in the HIV population correlated independently with CKD [Table 3].
Table 2: Factors associated with chronic kidney disease (estimated glomerular filtration rate <60 ml/min/+ proteinuria)

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Table 3: Independent predictors of chronic kidney disease in highly active antiretroviral therapy naïve human immunodeficiency virus-infected patients

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  Discussion Top


This study shows that the prevalence of CKD is high (30.8%) among HIV-infected population compared to normal population (5.7%). This concurs with a study done a decade ago in the same region where the HIV population had a prevalence of 51.8% while HIV-negative controls a prevalence of 12.2%.[17] A similar pattern has also been reported in recent studies done in Nigeria.[16],[18] Studies done in Europe, Hong Kong, and Iran, however, found lower prevalence rates of 3.5%, 16.8%, and 12.3%, respectively.[12],[13],[23] Black race,[24] poor socioeconomic status, and higher HIV burden in Nigeria may be possible reasons for the higher rates in Nigeria.

The high prevalence of CKD in the HIV-infected subjects in this study only agrees with the fact that renal disease is an important consequence of HIV infection and is common among people living with HIV.[4] Looking at proteinuria alone, this study found that its prevalence was much more in the HIV population compared to the negative controls; a pattern similar to the study by Esezobor et al. where they found a prevalence of 20.5% among HIV-positive children and 6% among HIV-negative controls.[25] The contribution of proteinuria to the prevalence of CKD in this study concurs with earlier reports that it is the initial manifestation of renal disease in HIV.[8],[9]

In our study, we observed higher mean age of the HIV subjects with CKD compared with those without CKD and this is similar to studies done in the US, China, and Nigeria,[11],[13],[15],[16],[18] where increasing age was associated with CKD. Furthermore, male sex was found to be an independent predictor of CKD in our study. A similar pattern was also observed in the Development of AntiRetroviral Therapy in Africa study done in two East African countries.[26] This confirms the knowledge that male gender is a risk factor for the development of renal disease.[27],[28] However, Agbaji et al.[18] found that female sex to be an independent variable associated with CKD. This may be a spurious epidemiological association.

Low BMI was an independent predictor of CKD in our study. A similar finding was reported in Burundi by Cailhol et al.[29] and Emem et al. in Nigeria.[15] Wasting is a feature of advanced HIV infection. This finding is further buttressed by the association of low CD4+ cell counts and higher viral load counts in our patients. The observation that low CD4+ count and high viral load are independently associated with CKD have been reported by previous workers.[13],[16]

Our study showed that majority of the HIV-infected patients (90.3%) with CKD did not have significant decrease in GFR (CKD stage G1 and G2). This pattern was also seen in a study by Yusuf et al.[30] where they found majority (72%) of the HIV-infected patients with CKD were either in Stages 1 or 2 with 26% in Stage 3. Fernando et al.[31] also in their study in an urban population in USA found majority of the patients having Stages 1–3 CKD. These studies along with ours underscore the fact that HIV-infected patients may have CKD without significant fall in GFR in the early course of their disease.

Our study was not without limitations; the major one being the fact that the indicators for CKD could not be demonstrated for at least 3 months as recommended by KDIGO. This could have overestimated the prevalence found. The relatively small sample size of our study population and the fact that this was a hospital-based study does not reflect the exact burden of CKD among HIV-infected people in the population. However, this study serves as a springboard for further research in the community to determine the impact of HIV on the kidneys.


  Conclusion Top


The prevalence of CKD is high among antiretroviral naïve HIV-infected population compared to their negative counterparts. Male HIV patients, older patients, those with low BMI, low CD4+ T-cell count, and higher viral loads are more likely to develop CKD. Decreased GFR is not seen early in HIV infection. There is the need for large multicenter studies to determine the prevalence of renal disease (CKD) in HIV-infected patients in Nigeria.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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