Comparison of glomerular filtration rate estimates vs. 24-h creatinine clearance in HIV-positive patients

Predictors of chronic kidney disease among HIV-infected patients on highly active antiretroviral therapy at the University of Calabar Teaching Hospital, Calabar, South-South Nigeria

Background: The burden of the people living with human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS) is largely borne by communities in Sub-Saharan Africa. The rate of kidney disease is increasing amongst HIV patients and occurs more often in patients with advanced stage of the disease with lower CD₄ counts and associated with a high rate of morbidity and mortality. The objective of this study is to determine the prevalence and predictors of chronic kidney disease (CKD) amongst HIV patients on highly active antiretroviral therapy (HAART) at the University of Calabar Teaching Hospital, Calabar.

Materials and methods: This was a cross-sectional study that was carried out over a 4-month period from May to August 2018. In all, a total of 118 patients with HIV on HAART were recruited into the study in a consecutive manner and their serum creatinine measured with the calculation of estimated glomerular filtration rate (eGFR). Other data collected were sex, age, weight, height, body mass index (BMI), waist hip ratio (WHR), packed cell volume, CD4 count etcetera. Data collected were inputted and analyzed with SPSS version 18, and statistical significance was taken to be p<0.05.

Results: There were more females (69.5%) amongst the HIV participants and the prevalence of CKD was 15.3%. The risk factors seen to be associated with CKD were lower levels of CD4 count below 200 cells/µl, lower PCV, weight, BMI, and eGFR. Also, higher levels of WHR and creatinine were associated with CKD. Factors directly correlated with CKD were weight, BMI and CD4 count levels, while creatinine level was inversely correlated with CKD. However, a logistic regression model showed only creatinine to be a predictor of CKD.

Conclusion: HIV patients on antiretroviral therapy, mainly the highly active antiretroviral therapy (HAART) have a relatively high prevalence of CKD of 15.3% and high level of serum creatinine was predictive of CKD in the logistic regression model in our study.

Individualizing pharmacotherapy in patients with renal impairment: the validity of the Modification of Diet in Renal Disease formula in specific patient populations with a glomerular filtration rate below 60 ml/min. A systematic review

Background

The Modification of Diet in Renal Disease (MDRD) formula is widely used in clinical practice to assess the correct drug dose. This formula is based on serum creatinine levels which might be influenced by chronic diseases itself or the effects of the chronic diseases. We conducted a systematic review to determine the validity of the MDRD formula in specific patient populations with renal impairment: elderly, hospitalized and obese patients, patients with cardiovascular disease, cancer, chronic respiratory diseases, diabetes mellitus, liver cirrhosis and human immunodeficiency virus.

Methods and Findings

We searched for articles in Pubmed published from January 1999 through January 2014. Selection criteria were (1) patients with a glomerular filtration rate (GFR) < 60 ml/min (/1.73m²), (2) MDRD formula compared with a gold standard and (3) statistical analysis focused on bias, precision and/or accuracy. Data extraction was done by the first author and checked by a second author. A bias of 20% or less, a precision of 30% or less and an accuracy expressed as P₃₀% of 80% or higher were indicators of the validity of the MDRD formula. In total we included 27 studies. The number of patients included ranged from 8 to 1831. The gold standard and measurement method used varied across the studies. For none of the specific patient populations the studies provided sufficient evidence of validity of the MDRD formula regarding the three parameters. For patients with diabetes mellitus and liver cirrhosis, hospitalized patients and elderly with moderate to severe renal impairment we concluded that the MDRD formula is not valid. Limitations of the review are the lack of considering the method of measuring serum creatinine levels and the type of gold standard used.

Conclusion

In several specific patient populations with renal impairment the use of the MDRD formula is not valid or has uncertain validity.

The validity of the modification of diet in renal disease formula in HIV-infected patients: a systematic review

RATIONALE, AIMS AND OBJECTIVES

Renal dysfunction is highly prevalent in HIV-infected patients and may require dose adjustment of renally excreted antiretroviral drugs. The Modification of Diet in Renal Disease (MDRD)-4 formula is frequently used in daily practice to estimate patients' renal function. The aim of this systematic review was to assess the validity of the MDRD-4 formula in HIV-infected patients.

METHOD

A systematic search in Pubmed and EMBASE was done to identify studies which compared MDRD-4 with measured glomerular filtration rate (mGFR) in HIV-infected patients.

RESULTS

Five studies were included, which provided data from 464 HIV-infected patients with mean mGFR ranging from 87 to 118 ml/min/1.73 m(2). In all studies, results from the MDRD-4 gave an underestimation of the mGFR. Mean bias ((MDRD-4) - mGFR) ranged from -6 to -11 ml/min/1.73 m(2) across studies. The accuracy expressed in terms of P 30 ranged from 64 to 89 %.

CONCLUSIONS

The MDRD-4 formula is as valid in HIV-positive as in HIV-negative patients. Because the available studies comprised mainly HIV-infected patients with mildly impaired to good renal function (GFR ≥ 60 ml/min/1.73 m(2)), more research is needed to validate the MDRD-4 formula in HIV-infected patients with moderate to severe renal impairment.

Does an index composed of clinical data reflect effects of inflammation, coagulation, and monocyte activation on mortality among those aging with HIV?

BACKGROUND

When added to age, CD4 count and human immunodeficiency virus type 1 (HIV-1) RNA alone (Restricted Index), hemoglobin, FIB-4 Index, hepatitis C virus (HCV), and estimated glomerular filtration rate improve prediction of mortality. Weighted and combined, these 7 routine clinical variables constitute the Veterans Aging Cohort Study (VACS) Index. Because nonroutine biomarkers of inflammation (interleukin 6 [IL-6]), coagulation (D-dimer), and monocyte activation (sCD14) also predict mortality, we test the association of these indices and biomarkers with each other and with mortality.

METHODS

Samples from 1302 HIV-infected veterans on antiretroviral therapy were analyzed. Indices were calculated closest to date of collection. We calculated Spearman correlations stratified by HIV-1 RNA and HCV status and measured association with mortality using C statistics and net reclassification improvement (NRI).

RESULTS

Of 1302 subjects, 915 had HIV-1 RNA <500 copies/mL and 154 died. The VACS Index was more correlated with IL-6, D-dimer, and sCD14 than the Restricted Index (P < .001). It was also more predictive of mortality (C statistic, 0.76; 95% confidence interval [CI], .72-.80) than any biomarker (C statistic, 0.66-0.70) or the Restricted Index (C statistic, 0.71; 95% CI, .67-.75). Compared to the Restricted Index alone, NRI resulted from incremental addition of VACS Index components (10%), D-dimer (7%), and sCD14 (4%), but not from IL-6 (0%).

CONCLUSIONS

Among HIV-infected individuals, independent of CD4, HIV-1 RNA, and age, hemoglobin and markers of liver and renal injury are associated with inflammation. Addition of D-dimer and sCD14, but not IL-6, improves the predictive accuracy of the VACS Index for mortality.

[Risk factors related to renal disorders in HIV-1 infected patients]

INTRODUCTION

Renal disease has emerged as one of the primary comorbid conditions affecting HIV-infected patients, mainly because antiretroviral therapy has improved survival. This study aimed to detect risk factors possibly associated with altered renal function in HIV-infected patients.

METHODS

A cross-sectional study was conducted involving 254 HIV-infected patients attending an outpatient clinic at Santa Casa de Vitoria< They were interviewed and blood samples were collected for CD4 cell counts, HIV-1 viral load, glucose, lipids and creatinine measurements. Urine protein was evaluated in the first voiding urine sample. Glomerular filtration was estimated by simplified modified diet in renal disease (MDRD) and Cockcroft-Gault formulas.

RESULTS

One hundred and three (40.6%) patients presented some urinary abnormality, and proteinuria was the most common finding (46; 18.1% patients). Twenty-five (9.8%) patients showed estimated glomerular filtration below 60 ml/min/1.73 m² by MDRD. Multivariate logistic regression showed that low glomerular filtration was positively correlated with black race [OR 9.6 (IC95% 1.28-23.80)], arterial hypertension [OR 3.3 (IC95% 1.28-23.81)], age over fifty-one years-old [OR 3.3 (IC95%1.11-9.90)], proteinuria [OR 5.2 {IC95% 1.67-16.25}]; hematuria [OR 3.2 (1.12-9.29)] and negatively correlated with patients using zidovudine [OR 0.2 (0.04-0.78)].

CONCLUSIONS

Traditional risk factors for renal disease, such as black race, arterial hypertension and advancing age were correlated with low estimated glomerular filtration in the present patient sample.

Monitoring of Renal Function among HIV-Infected Patients Receiving Tenofovir in a Resource-Limited Setting

The use of tenofovir disoproxil fumarate (TDF) is supposed to be increased in a resource-limited setting due to the changing of the guidelines. TDF-associated renal function declines among HIV-infected patients were defined by an increase of serum creatinine (SCr) >1.5 times, a 25% decrease in calculated creatinine clearance (CCrCl), or an estimated glomerular filtration rate (eGFR) from the baseline. Of all, 99% were antiretroviral treatment (ART)-experienced patients. At the 30th month, 19 (5.3%), 53 (14.9%), and 63 (17.7%) patients had renal function decline as defined by the above criteria with an incidence of 4.5, 12.5, and 14.6/100 person-year. A proportion of patients with a renal function decline detected by CCrCl or eGFR criteria was not different (P = .301), whereas, it differed from that detected by SCr criteria (P < .001). In conclusion, we encourage either CCrCl or eGFR calculations in monitoring renal function decline among HIV-infected patients receiving TDF in resource-limited settings.

Risk factors of chronic kidney disease in HIV-infected patients

BACKGROUND AND OBJECTIVES

The main aim of this study was determining the risk factors of chronic kidney disease (CKD) in HIV-1-infected patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients were followed from seven large HIV reference centers in France that maintain prospective databases on HIV-1-infected patients. The main outcome was the time to CKD defined as two consecutive measures of estimated GFR ≤60 ml/min per 1.73 m² over ≥3 months. A Cox's model with delayed entry was used to search predictive factors of time to CKD.

RESULTS

From 1993 to 2006, 349 out of 7378 patients were found to have CKD. Of these, 166 had hypertension, 33 had diabetes, and 26 were antiretroviral therapy-naïve. Occurrence of acute kidney injury (hazard ratio [HR] = 2.40) and hypertension (HR = 2.39) were strongly associated with an increased risk of CKD. Patients with a durable level of CD4 count >200 cells/mm³ had a lower risk of CKD (HR = 0.63). Recent exposure to indinavir (HR = 2.03), totenofovir (HR = 1.55), and abacavir (HR = 1.37) were associated with an increased risk of CKD. Past exposure to tenofovir was also associated with an increased risk of CKD (HR = 2.23), and a trend toward significance was observed for past exposure to indinavir (HR = 1.28).

CONCLUSIONS

CKD was not rare in HIV-infected patients and occurs preferentially in HIV-infected patients exposed to certain ARVs, specifically abacavir, indinavir and tenofovir. This requires closer monitoring of renal function in patients exposed to one of these drugs.

Biomarkers of impaired renal function

PURPOSE OF REVIEW

Renal disease is increasingly common as life expectancy of HIV-infected persons continues to improve. Several biomarkers are available for monitoring renal function, although no consensus exists on how best to apply these tools in HIV infection. This review describes recent findings for the more common renal biomarkers.

RECENT FINDINGS

Although widely used in clinical practice, creatinine-based estimates of glomerular filtration rate have not been validated in HIV infection. Serum cystatin C has been proposed as a more sensitive marker of renal dysfunction in HIV infection, although it may also reflect systemic inflammation. Screening for proteinuria and albuminuria allows identification of patients at higher risk of kidney disease and other adverse outcomes. Fanconi syndrome, which has been associated with tenofovir use, is associated with severe tubular proteinuria, and several low molecular weight proteins, including retinol-binding protein, β2-microglobulin, and neutrophil gelatinase-associated lipocalin have been studied as markers of tubular dysfunction. Studies have reported a high prevalence of subclinical proximal tubular dysfunction in patients receiving antiretroviral therapy.

SUMMARY

Future studies are needed to determine the optimal biomarkers for the detection and monitoring of renal disease in HIV.