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Beng H, Rakhmanina N, Moudgil A, Tuchman S, Ahn SY, Griffith C, Mims MM, Ray PE. HIV-Associated CKDs in Children and Adolescents. Kidney Int Rep 2020; 5:2292-2300. [PMID: 33305123 PMCID: PMC7710839 DOI: 10.1016/j.ekir.2020.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Limited information is available describing the current prevalence of proteinuria and HIV-associated CKDs (HIV-CKDs) in children and adolescents living with HIV and receiving antiretroviral therapy in the United States. METHODS To address this issue, we performed a retrospective study of children and adolescents living with HIV who received medical care at Children's National Hospital in Washington, DC, between January 2012 and July 2019. Demographic data, clinical parameters (mode of HIV transmission, viral loads, CD4 cell counts, serum creatinine, glomerular filtration rate [GFR], plasma lipid levels, proteinuria, blood pressure, renal biopsies), and medical treatments, all done as a standard of clinical care, were collected and analyzed. RESULTS The majority of the 192 patients enrolled were of African descent (88%) and acquired HIV through vertical transmission (97%). The prevalence of all HIV-CKDs was 6%. Of these patients, 39% had intermittent or persistent proteinuria, and 7% percent had proteinuria with a mild decline in GFR (60-80 ml/min per 1.73 m2), and 6% had a mild decline in GFR without proteinuria. Documented hypertension was present in 6% of the patients, mainly in association with HIV-CKD. Patients with persistent proteinuria (3%) and biopsy-proven HIV-CKD had a slow but constant progression of their renal diseases. CONCLUSIONS The prevalence of persistent proteinuria and HIV-CKD was lower than that reported in previous studies conducted in the United States. However, intermittent proteinuria, mild reductions in GFR, and progression of established HIV-CKD were common findings in this group of patients with predominantly vertically acquired HIV who were receiving antiretroviral therapy.
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Affiliation(s)
- Hostensia Beng
- Division of Nephrology, Children’s National Hospital, Washington District of Columbia, USA
| | - Natella Rakhmanina
- Division of Infectious Diseases, Children’s National Hospital, Washington District of Columbia, USA
- Department of Pediatrics, George Washington University School of Medicine, Washington, District of Columbia, USA
- Elizabeth Glaser Pediatrics AIDS Foundation, Washington, District of Columbia, USA
| | - Asha Moudgil
- Division of Nephrology, Children’s National Hospital, Washington District of Columbia, USA
- Department of Pediatrics, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Shamir Tuchman
- Division of Nephrology, Children’s National Hospital, Washington District of Columbia, USA
- Department of Pediatrics, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Sun-Young Ahn
- Division of Nephrology, Children’s National Hospital, Washington District of Columbia, USA
- Department of Pediatrics, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Caleb Griffith
- Division of Infectious Diseases, Children’s National Hospital, Washington District of Columbia, USA
- Department of Pediatrics, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Marva Moxey Mims
- Division of Nephrology, Children’s National Hospital, Washington District of Columbia, USA
- Department of Pediatrics, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Patricio E. Ray
- Division of Nephrology, Children’s National Hospital, Washington District of Columbia, USA
- Child Health Research Center, Department of Pediatrics, University of Virginia, School of Medicine, Charlottesville, Virginia, USA
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Tariq A, Kim H, Abbas H, Lucas GM, Atta MG. Pharmacotherapeutic options for kidney disease in HIV positive patients. Expert Opin Pharmacother 2020; 22:69-82. [PMID: 32955946 DOI: 10.1080/14656566.2020.1817383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Since the developmentof combined antiretroviral therapy (cART), HIV-associated mortality and the incidence of HIV-associated end-stage kidney disease (ESKD) has decreased. However, in the United States, an increase in non-HIV-associated kidney diseases within the HIV-positive population is expected. AREAS COVERED In this review, the authors highlight the risk factors for kidney disease within an HIV-positive population and provide the current recommendations for risk stratification and for the monitoring of its progression to chronic kidney disease (CKD), as well as, treatment. The article is based on literature searches using PubMed, Medline and SCOPUS. EXPERT OPINION The authors recommend clinicians (1) be aware of early cART initiation to prevent and treat HIV-associated kidney diseases, (2) be aware of cART side effects and discriminate those that may become more nephrotoxic than others and require dose-adjustment in the setting of eGFR ≤ 30ml/min/1.73m2, (3) follow KDIGO guidelines regarding screening and monitoring for CKD with a multidisciplinary team of health professionals, (4) manage other co-infections and comorbidities, (5) consider changing cART if drug induced toxicity is established with apparent eGFR decline of ≥ 10ml/min/1.73m2 or rising creatinine (≥0.5mg/dl) during drug-drug interactions, and (6) strongly consider kidney transplant in appropriately selected individuals with end stage kidney failure.
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Affiliation(s)
- Anam Tariq
- Division of Nephrology, Johns Hopkins University , Baltimore, MD, US
| | - Hannah Kim
- Division of Pediatric Nephrology, Johns Hopkins University , Baltimore, MD, US
| | - Hashim Abbas
- Division of Nephrology, Johns Hopkins University , Baltimore, MD, US
| | - Gregory M Lucas
- Division of Infectious Disease, Johns Hopkins University , Baltimore, MD, US
| | - Mohamed G Atta
- Division of Nephrology, Johns Hopkins University , Baltimore, MD, US
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Gupta G, Hemal A, Saha A, Kapoor K, Goyal P, Upadhyay AD. Proteinuria in HIV-infected Indian children. Trop Doct 2016; 47:230-233. [PMID: 27655943 DOI: 10.1177/0049475516668963] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chronic kidney disease (CKD) is a major cause of morbidity and mortality among individuals with HIV infection. Screening for proteinuria in HIV-infected children will help in early detection and treatment, and thus prevention and progression to CKD to end-stage kidney disease (ESRD). We screened 139 HIV-infected children aged 18 months to 18 years for proteinuria by urinary dipstick and confirmed by spot urine protein-to-creatinine ratio. If proteinuria was absent by the above methods, patients were screened for microalbuminuria by urinary albumin to creatinine ratio. We found proteinuria in 11.5% and microalbuminuria in 10.6% of our study population. The prevalence of proteinuria was higher in the advanced stages; 8.05% in stage 1, 12.12% in stage 2 and 26.32% in stages 3 + 4.
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Affiliation(s)
- Gopila Gupta
- 1 Postgraduate Student, Department of Paediatrics, Postgraduate Institute of Medical Education & Research and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Alok Hemal
- 2 Professor of Paediatrics, Department of Paediatrics, Postgraduate Institute of Medical Education & Research and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Abhijeet Saha
- 2 Professor of Paediatrics, Department of Paediatrics, Postgraduate Institute of Medical Education & Research and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Kanika Kapoor
- 3 Senior Resident, Department of Paediatrics, Postgraduate Institute of Medical Education & Research and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Parul Goyal
- 4 Associate Professor of Biochemistry, Department of Biochemistry, Postgraduate Institute of Medical Education & Research and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Ashish Datt Upadhyay
- 5 Statistican, Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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Dettmar AK, Oh J. Infection-Related Focal Segmental Glomerulosclerosis in Children. BIOMED RESEARCH INTERNATIONAL 2016; 2016:7351964. [PMID: 27294131 PMCID: PMC4886048 DOI: 10.1155/2016/7351964] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 04/07/2016] [Accepted: 04/21/2016] [Indexed: 01/16/2023]
Abstract
Focal segmental glomerulosclerosis (FSGS) is the most common cause of steroid resistant nephrotic syndrome in children. It describes a unique histological picture of glomerular damage resulting from several causes. In the majority of patients the causing agent is still unknown, but in some cases viral association is evident. In adults, the most established FSGS causing virus is the human immune-deficiency virus, which is related to a collapsing variant of FSGS. Nevertheless, other viruses are also suspected for causing a collapsing or noncollapsing variant, for example, hepatitis B virus, parvovirus B19, and Cytomegalovirus. Although the systemic infection mechanism is different for these viruses, there are similarities in the pathomechanism for the induction of FSGS. As the podocyte is the key structure in the pathogenesis of FSGS, a direct infection of these cells or immediate damage through the virus or viral components has to be considered. Although viral infections are a very rare cause for FSGS in children, the treating pediatric nephrologist has to be aware of a possible underlying infection, as this has a relevant impact on therapy and prognosis.
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Affiliation(s)
- Anne Katrin Dettmar
- Department of Pediatric Nephrology, University Children's Medical Clinic, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Jun Oh
- Department of Pediatric Nephrology, University Children's Medical Clinic, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
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Fredrick F, Francis JM, Ruggajo PJ, Maro EE. Renal abnormalities among HIV infected children at Muhimbili National Hospital (MNH)-Dar es Salaam, Tanzania. BMC Nephrol 2016; 17:30. [PMID: 27000018 PMCID: PMC4800772 DOI: 10.1186/s12882-016-0242-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/16/2016] [Indexed: 02/06/2023] Open
Abstract
Background Human Immunodeficiency Virus infection is a multisystem disease that contributes to significant morbidity. Renal involvement is reported to be common among patients with HIV. This study was carried out to determine renal involvement using simple bedside tests combined with ultrasonography examination. Methods We recruited 240 children from the HIV clinic at Muhimbili National Hospital. Data were collected using structured questionnaires and included demographic, clinical information, radiological tests; renal ultrasound and laboratory tests; serum creatinine, white blood cells, CD4+ counts and percent, urine for microalbuminuria and proteinuria. Results Microalbuminuria and proteinuria were present in 20.4 % and 7.1 % respectively. Significantly higher prevalence of microalbuminuria (p < 0.01) and proteinuria p < 0.01) were noted with low CD4 percent (<25 %). Lower mean CD4+ count were noted among children with microalbuminuria [937.4 ± 595.3 cells/μL vs 1164.7 ± 664.3 cell/μL, (p < 0.05)] and proteinuria [675.5 ± 352.3 cells/μL vs 1152 ± 662 cells/μL (p < 0.001)]. Fourteen (5.8 %) HIV infected children had estimated glomerular filtration rate (eGFR of 30–59) consistent with severe renal impairment. Increased cortical echogenicity was noted in 69/153 (39.2 %) of participants who had ultrasound examination. Conclusion Microalbuminuria, proteinuria and renal dysfunction were noted to be prevalent among HIV infected children indicating the need to consider routine screening of renal complications in these children.
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Affiliation(s)
- Francis Fredrick
- Department of Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), P. O. Box 65001, Dar es Salaam, Tanzania. .,Renal Unit, Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania.
| | - Joel M Francis
- National Institute of Medical Research (NIMR), Mwanza-Centre, Mwanza, Tanzania
| | - Paschal J Ruggajo
- Renal Unit, Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania.,Department of Internal Medicine, School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Eden E Maro
- Department of Internal Medicine, School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
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Vreeman RC, Scanlon ML, McHenry MS, Nyandiko WM. The physical and psychological effects of HIV infection and its treatment on perinatally HIV-infected children. J Int AIDS Soc 2015; 18:20258. [PMID: 26639114 PMCID: PMC4670835 DOI: 10.7448/ias.18.7.20258] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/25/2015] [Accepted: 09/02/2015] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION As highly active antiretroviral therapy (HAART) transforms human immunodeficiency virus (HIV) into a manageable chronic disease, new challenges are emerging in treating children born with HIV, including a number of risks to their physical and psychological health due to HIV infection and its lifelong treatment. METHODS We conducted a literature review to evaluate the evidence on the physical and psychological effects of perinatal HIV (PHIV+) infection and its treatment in the era of HAART, including major chronic comorbidities. RESULTS AND DISCUSSION Perinatally infected children face concerning levels of treatment failure and drug resistance, which may hamper their long-term treatment and result in more significant comorbidities. Physical complications from PHIV+ infection and treatment potentially affect all major organ systems. Although treatment with antiretroviral (ARV) therapy has reduced incidence of severe neurocognitive diseases like HIV encephalopathy, perinatally infected children may experience less severe neurocognitive complications related to HIV disease and ARV neurotoxicity. Major metabolic complications include dyslipidaemia and insulin resistance, complications that are associated with both HIV infection and several ARV agents and may significantly affect cardiovascular disease risk with age. Bone abnormalities, particularly amongst children treated with tenofovir, are a concern for perinatally infected children who may be at higher risk for bone fractures and osteoporosis. In many studies, rates of anaemia are significantly higher for HIV-infected children. Renal failure is a significant complication and cause of death amongst perinatally infected children, while new data on sexual and reproductive health suggest that sexually transmitted infections and birth complications may be additional concerns for perinatally infected children in adolescence. Finally, perinatally infected children may face psychological challenges, including higher rates of mental health and behavioural disorders. Existing studies have significant methodological limitations, including small sample sizes, inappropriate control groups and heterogeneous definitions, to name a few. CONCLUSIONS Success in treating perinatally HIV-infected children and better understanding of the physical and psychological implications of lifelong HIV infection require that we address a new set of challenges for children. A better understanding of these challenges will guide care providers, researchers and policymakers towards more effective HIV care management for perinatally infected children and their transition to adulthood.
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Affiliation(s)
- Rachel C Vreeman
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Child Health and Paediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya;
| | - Michael L Scanlon
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Megan S McHenry
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Winstone M Nyandiko
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Child Health and Paediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
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Perazzo S, Soler-García ÁA, Hathout Y, Das JR, Ray PE. Urinary biomarkers of kidney diseases in HIV-infected children. Proteomics Clin Appl 2015; 9:490-500. [PMID: 25764519 PMCID: PMC4530778 DOI: 10.1002/prca.201400193] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 02/01/2015] [Accepted: 03/09/2015] [Indexed: 01/06/2023]
Abstract
A significant number of children infected with the human immunodeficiency virus 1 (HIV-1) virus all over the world are at risk of developing renal diseases that could have a significant impact on their treatment and quality of life. It is necessary to identify children undergoing the early stages of these renal diseases, as well as the potential renal toxicity that could be caused by antiretroviral drugs, in order to prevent the development of cardiovascular complications and chronic renal failure. This article describes the most common renal diseases seen in HIV-infected children, as well as the value and limitations of the clinical markers that are currently being used to monitor their renal function and histological damage in a noninvasive manner. In addition, we discuss the progress made during the last 10 years in the discovery and validation of new renal biomarkers for HIV-infected children and young adults. Although significant progress has been made during the early phases of the biomarkers discovery, more work remains to be done to validate the new biomarkers in a large number of patients. The future looks promising, however, the new knowledge needs to be integrated and validated in the context of the clinical environment where these children are living.
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Affiliation(s)
| | | | | | | | - Patricio E. Ray
- Center for Genetic Medicine Research and Division of Nephrology, Children’s National Medical Center, and Department of Pediatrics, The George Washington University, Washington DC
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Lucas GM, Ross MJ, Stock PG, Shlipak MG, Wyatt CM, Gupta SK, Atta MG, Wools-Kaloustian KK, Pham PA, Bruggeman LA, Lennox JL, Ray PE, Kalayjian RC. Clinical practice guideline for the management of chronic kidney disease in patients infected with HIV: 2014 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:e96-138. [PMID: 25234519 PMCID: PMC4271038 DOI: 10.1093/cid/ciu617] [Citation(s) in RCA: 205] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 07/25/2014] [Indexed: 12/15/2022] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Paul A. Pham
- Johns HopkinsSchool of Medicine, Baltimore, Maryland
| | - Leslie A. Bruggeman
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | | | | | - Robert C. Kalayjian
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
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Foster C, Fidler S. Optimizing antiretroviral therapy in adolescents with perinatally acquired HIV-1 infection. Expert Rev Anti Infect Ther 2014; 8:1403-16. [DOI: 10.1586/eri.10.129] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Kidney disease in children and adolescents with perinatal HIV-1 infection. J Int AIDS Soc 2013; 16:18596. [PMID: 23782479 PMCID: PMC3687339 DOI: 10.7448/ias.16.1.18596] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 04/14/2013] [Accepted: 04/16/2013] [Indexed: 12/20/2022] Open
Abstract
Introduction Involvement of the kidney in children and adolescents with perinatal (HIV-1) infection can occur at any stage during the child's life with diverse diagnoses, ranging from acute kidney injury, childhood urinary tract infections (UTIs), electrolyte imbalances and drug-induced nephrotoxicity, to diseases of the glomerulus. The latter include various immune-mediated chronic kidney diseases (CKD) and HIV-associated nephropathy (HIVAN). Discussion The introduction of highly active anti-retroviral therapy (HAART) has dramatically reduced the incidence of HIVAN, once the commonest form of CKD in children of African descent living with HIV, and also altered its prognosis from eventual progression to end-stage kidney disease to one that is compatible with long-term survival. The impact of HAART on the outcome of other forms of kidney diseases seen in this population has not been as impressive. Increasingly important is nephrotoxicity secondary to the prolonged use of anti-retroviral agents, and the occurrence of co-morbid kidney disease unrelated to HIV infection or its treatment. Improved understanding of the molecular pathogenesis and genetics of kidney diseases associated with HIV will result in better screening, prevention and treatment efforts, as HIV specialists and nephrologists coordinate clinical care of these patients. Both haemodialysis (HD) and peritoneal dialysis (PD) are effective as renal replacement therapy in HIV-infected patients with end-stage kidney disease, with PD being preferred in resource-limited settings. Kidney transplantation, once contraindicated in this population, has now become the most effective renal replacement therapy, provided rigorous criteria are met. Given the attendant morbidity and mortality in HIV-infected children and adolescents with kidney disease, routine screening for kidney disease is recommended where resources permit. Conclusions This review focuses on the pathogenesis and genetics, clinical presentation and management of kidney disease in children and adolescents with perinatal HIV-1 infection.
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Dondo V, Mujuru HA, Nathoo KJ, Chirehwa M, Mufandaedza Z. Renal abnormalities among HIV-infected, antiretroviral naive children, Harare, Zimbabwe: a cross-sectional study. BMC Pediatr 2013; 13:75. [PMID: 23663553 PMCID: PMC3654941 DOI: 10.1186/1471-2431-13-75] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 05/02/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Data on the prevalence of renal and urine abnormalities among HIV-infected children in Sub-Saharan Africa are limited. We set out to determine the prevalence of proteinuria; low estimated glomerular filtration rate (eGFR), urinary tract infection and associated factors among HIV-infected antiretroviral therapy (ART) naive children, aged 2-12 years, attending the paediatric HIV clinic at a tertiary hospital in Harare. METHODS Consecutive ART naive children attending the clinic between June and October 2009 were recruited. Detailed medical history was obtained and a complete physical examination was performed. Children were screened for urinary tract infection and for significant persistent proteinuria. Serum creatinine was used to estimate GFR using the modified Counahan-Barratt formula. The Student's t-test was used to analyse continuous variables and the chi-square or Fisher's exact test was used to analyse categorical data. Logistic regression was performed to assess the relationship between study factors and urine abnormalities, persistent proteinuria and the eGFR. RESULTS Two hundred and twenty children were enrolled into the study. The median age was 90 months (Q1=65.5; Q3=116.5). The prevalence of urinary tract infection was 9.5%. Escherichia coli was the predominant organism. There was uniform resistance to cotrimoxazole. Persistent proteinuria (urine protein to creatinine ratio greater than 0.2, a week apart) was found in 5% of the children. Seventy-five children (34.6%) had mild to moderate renal impairment shown by a low eGFR (30 to <90 ml/min/1.73 m2). Persistent proteinuria was more likely to be found in children who were wasted, weight-for-height (WHZ) z-score <-2 (p=0.0005). Children with WHO clinical stage 4 were more likely to have a low eGFR than children with less advanced stages (OR 2.68; CI 1.24-5.80). Urine abnormalities were more likely to be observed in children with WHO clinical stages 3 and 4 (OR 2.20; CI 1.06-4.60). CONCLUSION There is significant renal impairment among HIV-infected, ART naive children aged 2-12 years attending the outpatient paediatric HIV clinic at Harare Central Hospital. The abnormalities are more likely to occur in children with advanced HIV/AIDS. Screening for renal impairment and urinary tract infections in HIV-infected children before initiation of ART and regularly thereafter would be helpful in their management. KEYWORDS HIV, renal disease, persistent proteinuria, glomerular filtration rate, urinary tract infection.
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Affiliation(s)
- Vongai Dondo
- Department of Paediatrics and Child Welfare, University of Zimbabwe, College of Health Sciences, Avondale, Harare, Zimbabwe
| | - Hilda A Mujuru
- Department of Paediatrics and Child Welfare, University of Zimbabwe, College of Health Sciences, Avondale, Harare, Zimbabwe
| | - Kusum J Nathoo
- Department of Paediatrics and Child Welfare, University of Zimbabwe, College of Health Sciences, Avondale, Harare, Zimbabwe
| | - Maxwell Chirehwa
- Department of Community Medicine, University of Zimbabwe, College of Health Sciences, Avondale, Harare, Zimbabwe
| | - Zivanai Mufandaedza
- Department of Medical Laboratory Sciences, University of Zimbabwe, College of Health Sciences, Avondale, Harare, Zimbabwe
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Shah I, Gupta S, Shah DM, Dhabe H, Lala M. Renal manifestations of HIV infected highly active antiretroviral therapy naive children in India. World J Pediatr 2012; 8:252-5. [PMID: 22886199 DOI: 10.1007/s12519-012-0366-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 08/04/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are several studies on renal manifestations in human immunodeficiency virus (HIV) infected children from American and African regions, but similar studies from India are lacking. A cross-sectional study was carried out in 28 HIV infected antiretroviral therapy (ART) naïve children coming to the pediatric HIV clinic. METHODS Demographic data of the children, clinical presentations including blood pressure, detailed laboratory investigations (serum creatinine, glomerular filtration rate), urine analysis (urine morphology, urine albumin, pus cells, and red blood cells), and CD4 counts were collected. RESULTS Of the 28 children, 15 (53.6%) had renal manifestations with a male to female ratio of 1:1.5. The most common renal manifestation in our study was abnormal glomerular filtration rate (GFR) in 11 (44.0%) of 25 children. This was followed by pus cells in urine in 6 (21.4%) of the 28 children while 3 (10.7%) of them had proteinuria. The mean age of children with renal manifestations was 5.04±2.75 years as compared to those without renal manifestations who had a mean age of 7.38±2.95 years (P=0.0390). CDC class and sex were not associated with renal manifestations. CONCLUSIONS Our study suggests that reduced GFR is the common renal manifestation, particularly in younger children. Other renal manifestations are related to proteinuria. The lack of correlation of CDC classification with renal manifestations mandates screening of children with HIV for renal disease. A more detailed study of renal manifestations in HIV-infected children is needed.
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Affiliation(s)
- Ira Shah
- Department of Pediatric HIV, B.J. Wadia Hospital for Children, Mumbai, India.
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Chronic kidney disease associated with perinatal HIV infection in children and adolescents. Pediatr Nephrol 2012; 27:981-9. [PMID: 22366874 PMCID: PMC3715373 DOI: 10.1007/s00467-011-2097-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 12/01/2011] [Accepted: 12/02/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND This study describes the incidence, clinical and demographic characteristics, and spectrum of chronic kidney disease (CKD) in youths with perinatal HIV-1 infection. METHODS Retrospective analysis between May 1993 and December 2006 of subjects with renal disease followed in the Pediatric AIDS Clinical Trials Group 219/219C multicenter study examining the long-term consequences of perinatal HIV infection. Diagnosis confirmation was made utilizing a questionnaire mailed to research sites. Participants with CKD of other etiology than HIV were excluded. Outcome measures were biopsy-diagnosed CKD and, in the absence of biopsy, HIV-associated nephropathy (HIVAN) using established clinical criteria. RESULTS Questionnaires on 191 out of 2,102 participants identified 27 cases of CKD: 14 biopsy-diagnosed and 6 clinical cases of HIVAN, and 7 biopsy-diagnosed cases of immune complex-mediated kidney disease (lupus-like nephritis, 3; IgA nephropathy, 2; membranous nephropathy, 2). Incidence rates for CKD associated with HIV in pre-highly active antiretroviral therapy (HAART) (1993-1997) and HAART (1998-2002, 2003-2006) eras were 0.43, 2.84, and 2.79 events per 1,000 person years respectively. In multivariate analysis, black race and viral load ≥100,000 copies/mL (rate ratios 3.28 and 5.05, p ≤ 0.02) were associated with CKD. CONCLUSIONS A variety of immune complex-mediated glomerulonephritides and HIVAN occurs in this population. Black race and uncontrolled viral replication are risk factors for CKD associated with HIV.
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Abstract
HIV-1 associated nephropathy (HIVAN) is a clinical and renal histological disease characterized by the presence of heavy proteinuria associated with focal segmental glomerulosclerosis and microcystic tubular dilatation. These renal lesions lead to renal enlargement and rapid progression to kidney failure. People from African ancestry show a unique susceptibility to develop HIVAN. The study by Wearne and colleagues, which includes the largest group of patients of African ancestry with HIVAN studied so far, describes a novel renal histological variant of HIVAN, and suggests that antiretroviral therapies improve the clinical outcome of all HIV-associated renal diseases. These findings, when interpreted in the context of recent advances in our understanding of the molecular pathogenesis and genetics of HIVAN, will facilitate the recognition of all clinical variants of HIVAN as well the planning of better screening, prevention, and treatment programs for all HIV nephropathies.
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Ramsuran D, Bhimma R, Ramdial PK, Naicker E, Adhikari M, Deonarain J, Sing Y, Naicker T. The spectrum of HIV-related nephropathy in children. Pediatr Nephrol 2012; 27:821-7. [PMID: 22205506 DOI: 10.1007/s00467-011-2074-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 11/11/2011] [Accepted: 11/15/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite the burden of human immunodeficiency virus (HIV) disease in Southern Africa, there have been few reports of HIV-related nephropathy in children. This study outlines the spectrum of HIV-1-related kidney diseases of children in KwaZulu-Natal, South Africa. METHODS A review of the clinical presentation, laboratory and histopathological findings of children diagnosed with HIV-related nephropathy. RESULTS Forty-nine out of 71 children (1-16 years old) with HIV-1 related nephropathy underwent kidney biopsy. The most common histopathological finding was focal segmental glomerulosclerosis (FSGS), which was present in 32 (65.3%) children; 13 (26.5%) having collapsing glomerulopathy and 19 (38.8%) classic FSGS. The majority of patients showed haematological (86.4%) and electrolyte abnormalities (69.4%). Renal impairment was present in 41% of patients on initial presentation. However, end-stage kidney disease was present in only 4% of these patients. All patients were treated with highly active anti-retroviral therapy (HAART), the majority (79.6%) showed decreased proteinuria with 38.8% having complete remission. CONCLUSIONS This study, one of the largest series of children reported from Africa, demonstrates that nephrotic syndrome due to HIV-associated nephropathy (HIVAN) is the commonest presentation of HIV-related nephropathy in childhood. Highly active anti-retroviral therapy in combination with angiotensin-converting enzyme antagonists is highly effective in decreasing proteinuria and preserving renal function.
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Affiliation(s)
- Duran Ramsuran
- Optics and Imaging Centre, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
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Ray PE, Hu CAA. Advances in our understanding of the pathogenesis of HIV-1 associated nephropathy in children. Future Virol 2011; 6:883-894. [PMID: 22162721 DOI: 10.2217/fvl.11.57] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Childhood HIV-1 associated nephropathy (HIVAN) is a clinical and renal histological disease characterized by heavy proteinuria associated with focal and segmental glomerular sclerosis and/or mesangial hyperplasia in combination with microcystic tubular dilatation. These lesions lead to renal enlargement and rapid progression to kidney failure. Children of African ancestry have a unique susceptibility to developing HIVAN. It is estimated that approximately 300,000 HIV-infected children living in the sub-Saharan Africa could develop HIVAN if they do not receive appropriate antiretroviral therapy. This article discusses recent developments and controversies related to the pathogenesis of childhood HIVAN. The role of host genetic factors, including the newly identified variants in the APOL1 gene, is discussed in the context of previous studies that established the pathological paradigm for HIVAN, and our current understanding of the functional genomics analysis. Hopefully, these advances will provide new research opportunities to generate better treatments for children with HIVAN.
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Affiliation(s)
- Patricio E Ray
- Children's National Medical Center & Department of Pediatrics, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
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HIV-associated nephropathy in the setting of maximal virologic suppression. Pediatr Nephrol 2011; 26:973-7. [PMID: 21350798 DOI: 10.1007/s00467-011-1783-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 11/12/2010] [Accepted: 11/12/2010] [Indexed: 10/18/2022]
Abstract
Human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) is most frequently seen as a late manifestation in adult patients with a high viral load and low T-helper cell (CD4) counts. We report a case of HIVAN in a black Zimbabwean teenager in whom the disease activity was well suppressed for years following highly active antiretroviral therapy (HAART). Proteinuria was absent at 9 years of age when he presented with vertically transmitted HIV infection. Within a few months of HAART, the viral load became undetectable and CD4 count was normalised. Nephrotic range proteinuria, with preserved renal function, developed approximately 4 years later despite excellent HIV disease suppression. Renal biopsy showed non-collapsing focal segmental glomerular sclerosis changes compatible with HIVAN. Although the role of other unknown factors in the disease pathogenesis could not be totally excluded, this case demonstrates that HIVAN can still occur in HIV-infected children despite excellent HAART and that the disease manifestations and outcome may differ from those reported in previous studies.
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