Clinicopathological manifestations of kidney disease in hiv/aids patients with proteinuria at Kenyatta National Hospital
Abstract
Renal involvement in HIV /AIDS is well documented with up to 60% of patients with
AIDS presenting with some form of renal pathology. The incidence of asymptomatic
proteinuria in HIV individuals varies in different studies. Urinalysis remains a cheap and
available important tool for screening for renal disease in these patients for early
diagnosis and intervention. In some patients however renal biopsy remains an important
tool for appropriate diagnosis so as to institute appropriate treatment as different
pathologies may appear similar clinically but have different interventions and prognosis.
METHODOLOGY
Study design Cross-sectional prospective study.
Study area Kenyatta National Hospital medical wards and HIV clinic.
Study duration November 2003 to May 2004
Study population HIV /AIDS patients over 14 years of age with an informed signed
consent. Patients excluded were those with chronic diseases with known glomerular
involvement e.g. Diabetes, hypertension and connective tissue diseases, patients on drugs
affecting proteinuria e.g. ACE inhibitors, patients with fever and moribund patients.
Sample size Minimum sample size was 43 patients. However 56 patients were recruited.
Clinical Methods Dipstick measurements of urine for proteins was done on patients
fitting the above study criteria. Urine was taken for UACR and microscopy and blood
taken for CD4+ cell count, urea, electrolytes and creatinine. Those with proteinuria more
than Ig by UACR estimation had a renal ultrasound, blood taken for HBsAg, HCV ab
and VDRL and a renal biopsy performed on them.
Results
From November 2003 to May 2004,56 patients were recruited. 55% of patients were
female while 45% were male giving a F: M of 1.2: 1. The majority, 49%, of patient were
married while 36% were single. 77% of patients resided in Nairobi province. Respiratory
system was the commonest affected at admission and found in 32% of patients. 32%
patients had renal/urinary complaints at presentation. No patient had previously been
diagnosed with or treated for a renal disease.
Of the 56 patients recruited, 76.8% had a proteinuria of 30-300mg/g, 10.7% had 301-
1000mglg and 12.5% had >1000mglg proteinuria on UACR. Oedema was found in 88%
of those with proteinuria of >1000mg/g,50% of those with 301-1000 mg/g and 14% of
those with 30-300mglg proteinuria. BP was elevated in 71%, 17% and 3% of those with
>1000,3011300 and 30-300mglg proteinuria respectively. The increase in BP and
oedema with higher degrees of proteinuria was statistically significant with P values
<0.001. However the numbers analyzed were small.
Urine microscopy findings included, WBC casts found in 27%, RBC casts in 52%,
epithelial cells in 15% and granular/hyaline casts in 27% of patients. Granular cast were
found in 86% of patients with proteinuria >1000mglg and RBC casts were also found in
86% of the same patients. The increase in these active casts with increase in proteinuria
was statistically significant with P value <0.001.
CD 4+ cell counts ranged from 3-549/1 with a mean of 121.98 ± 125.211L. Forty seven
(84%) patients had CD4+ cell counts less than 200/1. Most patients, 32%, were in stage
C3 disease. The GFR ranged from 3.1-113.6 ml/min with a mean of38.8 ± 26.8 ml/min.
Four (7%) of patients had normal GFR and all had proteinuria of30-300mg!g. The
majority of patients, 38% had stage 3 renal disease with GFR between 30-59mVmin. 19%
of patients with stage 2, 17% of those with stage 3 and 29% of those with severe
proteinuria had ESRD. There was no statistically significant difference between the CD
4+ cell counts and renal function and the degree of proteinuria.
Six biopsies were performed and of these, 5 had histological features suggestive of
HIVAN. One patient had MCGN and was negative for HCV ab, HBsAg and VDRL.
Three of the 5 with HIV AN had other pathologies in addition, diffuse glomerulonephritis
TIN and ATN. All patients had elevated BP other than 2 with features of HIVAN alone
while only I patient who had features of HIV AN had no oedema.
Conclusion Renal disease among HIV /AIDS patients is common and should be screened
for in even in the absence of symptoms or HIV stage. Dipstick screening of urine for
proteinuria is simple and cheap. Those with proteinuria should have their 24 hour urine
protein determined for determination of further management or need for renal biopsy.
GFR estimation should be used to assess renal function and need also for biopsy
independent of or along with proteinuria. HIV AN is found in our population but more
studies are needed with bigger samples of biopsies. Renal biopsy remains the gold
standard for appropriate diagnosis of pathology as managements and prognosis of these
pathologies differ.
Citation
degree of Master of Medicine in Internal Medicine, University of Nairobi. 2004Publisher
University of Nairobi. Faculty of Medicine