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.