HIV-associated nephropathy in children: challenges in a resource-limited setting

HIV infection remains one of the leading causes of morbidity and mortality worldwide, especially in children living in resource-limited settings. Although the World Health Organization (WHO) recently recommended antiretroviral therapy (ART) initiation upon diagnosis regardless of the number of CD4, ART access remains limited, especially in children living in sub-Saharan Africa (SSA). HIV-infected children who do not receive appropriate ART are at increased risk of developing HIV-associated nephropathy (HIVAN). Although due to genetic susceptibility, SSA is recognized to be the epicenter of HIVAN, limited information is available regarding the burden of HIVAN in children living in Africa. The present review discusses the information available to date on the prevalence, pathogenesis, risk factors, diagnosis, and management of HIVAN in children, focusing on related challenges in a resource-limited setting.

High risk APOL1 genotypes and kidney disease among treatment naïve HIV patients at Kano, Nigeria

Introduction

Racial disparities are known in the occurrence of kidney disease with excess risks found among people of African descent. Apolipoprotein L1 (APOL1) gene variants G1 and G2 are associated with kidney disease among HIV infected individuals of African descent in the USA as well as among black population in South Africa. We set out to investigate the prevalence of these high-risk variants and their effects on kidney disease among HIV infected patients in Northern Nigeria with hitherto limited information despite earlier reports of high population frequencies of these alleles from the Southern part of the country.

Methods

DNA samples obtained from the whole blood of 142 participants were genotyped for APOL1 G1 and G2 variants after initial baseline investigations including assessment of kidney function. Participants comprised 50 HIV positive patients with no evidence of kidney disease, 52 HIV negative individuals with no kidney disease and 40 HIV positive patients with chronic kidney disease (CKD) evidenced by persistent proteinuria and/or reduced eGFR, who also had a kidney biopsy. All the HIV positive patients were newly diagnosed and treatment naïve.

Results

The distribution of the APOL1 genotypes among the study participants revealed that 24.6% had a G1 risk allele and 19.0% a G2. The frequency of the High Risk Genotype (HRG) was 12.5% among those with CKD compared to 5.8% in the HIV negative group and zero in the HIV positive no CKD group. Having the HRG was associated with a higher odds for developing HIV Associated Nephropathy (HIVAN) (2 vs 0 risk alleles: OR 10.83, 95% CI 1.38–84.52; P = 0.023; 2 vs 0 or 1 risk alleles: OR 5.5, 95% CI 0.83–36.29; P = 0.07). The HRG was also associated with higher odds for Focal Segmental Glomerulosclerosis (FSGS) (2 vs 0 risk alleles: OR 13.0, 95% CI 2.06–81.91; P = 0.006 and 2 vs 0 or 1 risk alleles: OR 9.0, 95%CI 1.62–50.12; P = 0.01) when compared to the control group.

Conclusion

This study showed a high population frequency of the individual risk alleles of the APOL1 gene with higher frequencies noted among HIV positive patients with kidney disease. There is high association with the presence of kidney disease and especially FSGS and HIVAN among treatment naive HIV patients carrying two copies of the HRG.

HIV at 40: kidney disease in HIV treatment, prevention, and cure

Four decades after the first cases of HIV were reported, kidney disease remains an important comorbidity in people with HIV (PWH). Both HIV-associated nephropathy and immune complex kidney disease were recognized as complications of HIV infection in the early years before treatment was available. Although the introduction of effective antiretroviral therapy in the late 1990s resulted in dramatic improvements in survival and health in PWH, several commonly used antiretroviral agents have been associated with kidney injury. HIV infection and treatment may also promote the progression of comorbid chronic kidney disease due to traditional risk factors such as diabetes, and HIV is one of the strongest "second hits" for the high-risk APOL1 genotype. Unique considerations in the management of chronic kidney disease in PWH are largely related to the need for lifelong antiretroviral therapy, with potential for toxicity, drug-drug interactions, and polypharmacy. PWH who develop progressive chronic kidney disease are candidates for all modalities of kidney replacement therapy, including kidney transplantation, and at some centers, PWH may be candidates to serve as donors for recipients with HIV. Transplantation of kidney allografts from donors with HIV also offers a unique opportunity to study viral dynamics in the kidney, with implications for kidney health and for research toward HIV cure. In addition, HIV-transgenic animal models have provided important insights into kidney disease pathogenesis beyond HIV, and experience with HIV and HIV-related kidney disease has provided important lessons for future pandemics.

Prevalence and risk factors of chronic kidney disease in an HIV positive Mexican cohort

BACKGROUND

HIV subjects have several kidney pathologies, like HIV-associated nephropathy or antiretroviral therapy injury, among others. The global prevalence of Chronic Kidney Disease (CKD) is 8-16%; however, in HIV subjects, the prevalence varies between geographic regions (2-38%). The aim was to determine the prevalence of CKD and identify the associated risk factors.

METHODS

A longitudinal descriptive study was carried out at the 'Hospital Civil de Guadalajara' Feb'18 - Jan'19. Basal clinical, demographic, opportunistic infections (OI), and laboratory data were obtained at months 0 and 3; inclusion criteria were ≥ 18 years old, naïve HIV + , urine albumin/creatinine ratio, serum creatinine & urine test, and signed informed consent. Descriptive and multiple logistic regression statistical analyses were made.

RESULTS

One hundred twenty subjects were included; 92.5% were male, 33 ± 9.5 years, 60% consumed tobacco, 73% alcohol, and 59% some type of drug. The CKD prevalence was 15.8%. CKD patients had a higher risk of hepatitis C virus coinfection, Relative Risk (RR):5.9; HCV infection, RR:4.3; ≥ 30 years old, RR:3.9; C clinical-stage, RR:3.5; CD4+ T cells count < 200 cells/μL, RR: 2.4; and HIV-1 viral load ≥ 100,000 cop/mL, RR: 2.7.

CONCLUSIONS

Our study showed a higher CKD prevalence in patients with HIV; higher CKD development with coinfections as Hepatitis C Virus and Mycobacterium tuberculosis. The identification and prompt management of CKD and coinfections should be considered to avoid the progression and to delay renal replacement therapy as long as possible.

HIV-Associated Nephropathy among Children with Renal Disease in Port Harcourt, Nigeria

INTRODUCTION

Human Immunodeficiency Virus (HIV) infects multiple tissues of the body, including the renal parenchyma, with HIV-associated Nephropathy (HIVAN) being the most common form of the HIV-related renal disease and an important cause of End Stage Renal Disease (ESRD) in HIV infected patients. There is paucity of studies on HIVAN among children with renal diseases, most studies on HIVAN focused on prevalence among HIV patients with vertical transmission being the commonest route. We undertook this study to determine the prevalence and impact of HIVAN among our renal patients and to highlight the new route of HIV transmission observed in these group of patients in Port Harcourt, Southern Nigeria.

MATERIALS AND METHODS

The study was conducted among renal patients managed in the Paediatric department of the University of Port Harcourt Teaching Hospital from December 2016 to March 2019. The information on the HIVAN patients were stored and retrieved from the renal register where all cases of renal diseases were enrolled. The diagnosis of HIVAN was made based on presence of significant proteinuria (≥ 1+), with one or more of the following: abnormal microscopic examination of urinary sediments, rising serum creatinine, renal ultrasound finding of enlarged echogenic kidneys and histology finding of focal segmental glomerulosclerosis. The patient's sociodemographic data, clinical presentation, route of transmission of HIV, laboratory investigations, treatment, and clinical outcome were obtained and analysed using SPSS version 25.0.

RESULTS

There were 112 cases of renal diseases seen during the study period of which 10 (8.9%) had HIVAN. The HIVAN patients were aged between 4-17years. Four (40%) of these HIVAN cases had CKD of which 2 (20%) had ESRD. The route of transmission of HIV was vertical (mother-to-child) in 8 patients and via sexual route in two older male patients aged 17years who were homosexuals. Mortality rate among the HIVAN patients was 30%, with 2 (20%) lost to follow up.

CONCLUSION

There is a rising prevalence of HIVAN among paediatric patients with renal diseases in our environment, with homosexuality being a new route of HIV transmission observed in the older patients.

HIV-associated nephropathy: Protocol and rationale for an exploratory genotype-phenotype study in a sub-Saharan African population

BACKGROUND

HIV-positive persons of African descent are disproportionately affected by chronic kidney disease (CKD). Deterioration to end-stage kidney disease (ESKD) also occurs in this population at a higher frequency. There remains a lot to learn about the genetic susceptibility to CKD in HIV positive patients, and the pathophysiology of progression to ESKD.

OBJECTIVES

We will conduct an exploratory genotype-phenotype study in HIV-positive persons with CKD in Aminu Kano Teaching Hospital, Nigeria, to determine blood-based differential gene expression biomarkers in different kidney risk groups according to the KDIGO 2012 criteria.

METHODS

We will consecutively screen 150 HIV-positive adults (≥18 years of age) attending the HIV clinic of Aminu Kano Teaching Hospital, Kano, Nigeria, for CKD based on proteinuria and elevation of estimated glomerular filtration rate. Among these, two separate groups of 16 eligible participants each (n = 32) will be selected in the four (4) KDIGO 2012 kidney risk categories. The groups will be matched for age, sex, viral suppression level and antiretroviral (ARV) regimen. In the first group (n = 16), we will determine differential gene expression markers in peripheral blood mononuclear cells using mRNA-sequencing (RNA-Seq). We will validate the differential expression markers in the second group (n = 16) using reverse transcription quantitative polymerase chain reaction (RT-qPCR). Using a systems-based approach, we will construct, visualize and analyze gene-gene interaction networks to determine the potential biological roles of identified differential expression markers based on published literature and publicly available databases.

RESULTS

Our exploratory study will provide valuable information on the potential roles of differential expression biomarkers in the pathophysiology of HIV-associated kidney disease by identifying novel biomarkers in different risk categories of CKD in a sub-Saharan African population. The results of this study will provide the basis for population-based genome-wide association studies to guide future personalized medicine approaches.

CONCLUSION

Validated biomarkers can be potential targets for the development of stage-specific therapeutic interventions, an essential paradigm in precision medicine.

Viral-Associated GN: Hepatitis C and HIV

Viruses are capable of inducing a wide spectrum of glomerular disorders that can be categorized on the basis of the duration of active viremia: acute, subacute, or chronic. The variable responses of the adaptive immune system to each time period of viral infection results mechanistically in different histologic forms of glomerular injury. The unique presence of a chronic viremic carrier state with either hepatitis C (HCV) or HIV has led to the opportunity to study in detail various pathogenic mechanisms of viral-induced glomerular injury, including direct viral infection of renal tissue and the development of circulating immune complexes composed of viral antigens that deposit along the glomerular basement membrane. Epidemiologic data show that approximately 25%-30% of all HIV patients are coinfected with HCV and 5%-10% of all HCV patients are coinfected with HIV. This situation can often lead to a challenging differential diagnosis when glomerular disease occurs in this dual-infected population and requires the clinician to be familiar with the clinical presentation, laboratory workup, and pathophysiology behind the development of renal disease for both HCV and HIV. Both of these viruses can be categorized under the new classification of infection-associated GN as opposed to being listed as causes of postinfectious GN as has previously been applied to them. Neither of these viruses lead to renal injury after a latent period of controlled and inactive viremia. The geneses of HCV- and HIV-associated glomerular diseases share a total dependence on the presence of active viral replication to sustain renal injury so the renal disease cannot be listed under "postinfectious" GN. With the new availability of direct-acting antivirals for HCV and more effective combined antiretroviral therapy for HIV, successful remission and even regression of glomerular lesions can be achieved if initiated at an early stage.

Emtricitabine/rilpivirine/tenofovir disoproxil fumarate for the treatment of HIV-1 infection in adults

This paper reviews the current literature and information on the combination drug Complera(™) (rilpivirine/emtricitabine/tenofovir disoproxil fumarate) that was approved by the Food and Drug Administration (FDA) in August 2011. PubMed, Cochrane and Embase (2001-2014) were searched for primary and review articles on rilpivirine, emtricitabine, and tenofovir disoproxil fumarate, individually or in combination. Data from drug manufacturer and product label was also used. Clinical trial reports were selected, extracted and analyzed to include relevant and recent ones. Selected English-language trials were limited to those with human subjects and included both safety and efficacy outcomes. Results from two phase 3 randomized double blind trials (ECHO and THRIVE) showed that rilpivirine is non-inferior to efavirenz in suppressing viral load below 50 copies/mL in anti-retroviral therapy (ART) naïve human immunodeficiency virus (HIV) infected patients. In addition, psychiatric disturbances, rash and increase in lipid levels occurred less frequently with rilpivirine when compared to efavirenz. However, virological failure and drug resistance were higher with rilpivirine in patients with baseline viral load >100,000 copies/mL. Rilpivirine showed cross resistance to efavirenz and etravirine. Efavirenz, on the other hand, did not demonstrate cross resistance to rilpivirine and etravirine, leaving the latter drugs as options for use in case of virological failure with efavirenz. Complera(™) remains an acceptable alternative treatment to Atripla(™) in ART naïve patients who have a pre-ART plasma HIV RNA <100,000 copies/mL and CD4 count >200 cells/mm(3) with non-inferior efficacy and better safety and tolerability.

HIV-related metabolic comorbidities in the current ART era

Despite effective antiretroviral therapy (ART), HIV-infected individuals have residual chronic immune activation that contributes to the pathogenesis of HIV infection. This immune system dysregulation is a pathogenic state manifested by very low naïve T-cell numbers and increased terminally differentiated effector cells that generate excessive proinflammatory cytokines with limited functionality. Immune exhaustion leaves an individual at risk for accelerated aging-related diseases, including renal dysfunction, atherosclerosis, diabetes mellitus, and osteoporosis. We highlight research that clarifies the role of HIV, ART, and other factors that contribute to the development of these diseases among HIV-infected persons.

Pain, sleep disturbances, and functional limitations in people living with HIV/AIDS-associated distal sensory peripheral neuropathy

BACKGROUND

Pain, sleep, and functional disturbances are a common occurrence in people living with HIV/AIDS-related distal sensory peripheral neuropathy (PLWHA-DSPN) yet lack group classification and quantification.

METHODS

A total of 46 PLWHA-DSPN were recruited, as part of a 2-group intervention study, to complete the Neuropathic Pain Scale and the Pittsburgh Sleep Quality Index (PSQI) questionnaires. The participant's performance during a forward reach task and walking distance in 6 minutes was recorded as a measure of function.

RESULTS

The pain (60.77 +/- 17.85) and sleep (14.62 +/- 4.28) scores denote marked pain and sleep disturbances, compared to seronegative, age-matched individuals. The ambulation distance was limited (243.99 +/- 141.04 m) and inversely associated with the PSQI-sleep efficiency subscale (rs = -.35, P < .05). The average reaching distances measured (36.07 +/- 7.37 cm) were similar to seronegative, age-matched individuals. Pain, sleep, and functional measures exhibited significant associations.

CONCLUSIONS

The data collected suggest that PLWHA-DSPN report moderate-to-severe pain and significant sleep disturbances and exhibit limited ambulation distances.

The kidney in HIV infection: beyond HIV-associated nephropathy

Acute kidney injury (AKI) and chronic kidney disease (CKD) are more common in HIV-infected persons than in the general population. AKI is associated with poor health outcomes, including increased risk of heart failure, cardiovascular events, end-stage renal disease (ESRD), and mortality. The most common causes of AKI in HIV-infected persons are systemic infections and adverse drug effects. The prevalence of CKD is rising in the HIV-infected population and CKD is increasingly likely to be caused by comorbid conditions, such as diabetes and hypertension, that frequently cause CKD in the general population. Guidelines for CKD screening in HIV-infected patients are being revised. It is currently recommended that all patients be screened for creatinine-based estimates of glomerular filtration rate and for urine protein at the time of HIV diagnosis. Annual screening is recommended for high-risk patients. Hemodialysis, peritoneal dialysis, and kidney transplantation are all options for treating ESRD in HIV-infected patients. Hemodialysis and peritoneal dialysis offer similar survival in HIV-infected patients with ESRD. In selected patients with well-controlled HIV infection, kidney transplantation is associated with survival intermediate between that in the overall transplant population and that among transplant recipients older than 65 years. This article summarizes a presentation by Christina M. Wyatt, MD, at the IAS-USA continuing medical education program held in Chicago in May 2012, describing AKI and CKD using case illustrations.

Determining the prevalence of human immunodeficiency virus-associated nephropathy (HIVAN) using proteinuria and ultrasound findings in a Nigerian paediatric HIV population

BACKGROUND

HIV associated nephropathy (HIVAN) is the most common form of chronic kidney disease resulting directly from HIV infection. The true prevalence of HIVAN in the paediatric population of West Africa is unknown, largely due to lack of surveillance and reporting of kidney disease in HIV positive patients.

METHODS

This was a prospective study over a six month period( July to December 2008) conducted in the Infectious Disease Unit of the Department of Paediatrics, University of Uyo Teaching Hospital, Uyo, Nigeria involving all confirmed cases of paediatric HIV infection. Urine microalbuminuria using calculated urine albumin - creatinine ratio was determined and repeated in 4 weeks interval. CD4 count and renal ultrasonography was done for all the patients. The correlation of urine albumin - creatinine ratio with CD4 count, duration of treatment with highly active antiretroviral therapy (HAART) and association with clinical staging of the disease was also examined.

RESULTS

Fifty - nine (60.2%) were males, thirty - nine (39.8%) were females with male to female ratio of 1.5:1. The prevalence rate of 31.6% HIVAN was found, out of which 3.1% had abnormal ultrasound findings. There was a significant correlation between CD4 count and urine albumin - creatinine ratio (r=-0.22, p=0.03). There was no correlation between urine albumin - creatinine ratio and duration on HAART (r=-0.10, p=0.31).

CONCLUSION

Screening for microalbuminuria is essential for the early diagnosis and treatment of HIVAN in this age group.

[Glomerular diseases in HIV-infected patients: clinical and morphological evaluation]

AIM

To evaluate the clinical and morphological variants of kidney abnormalities in HIV-infected patients.

SUBJECTS AND METHODS

Thirty HIV-infected patients (60% men and 40% women) aged 26 to 54 years (mean age 31.6 +/- 4.7 years) who had undergone diagnostic needle renal biopsy were examined. The indication for the biopsy was nephrotic syndrome (NS) (isolated or concurrent acute nephritic syndrome) and/or decreased renal function. The morphological study of biopsy specimens included light microscopy and immunofluorescence assay.

RESULTS

In the examined HIV-infected patients, the histological variants of kidney abnormalities presented with immune complex glomerulonephritis (ICGN) in 26 cases and with focal segmental glomerulosclerosis (FSGS) in 4 cases. The clinical manifestations of ICGN were as follows: NS (61.5%), acute nephritic syndrome (in more than one third of the patients) concurrent with hematuria, as well as mainly grades 2-3 arterial hypertension (AH) (12/14) and renal dysfunction. Immune complex glomerulopathies were marked by polymorphism in the renal morphological pattern with fluorescence during immunofluorescence microscopy in most cases of virtually all classes of immunoglobulins (IgA, IgM, IgG) and complement system fragments (C3, C1q). FSGS was clinically characterized by NS concurrent with AH, hematuria. The morphological subtypes of FSGS were exhibited by apical, perihilar, and nonspecific variants in 1, 1, and 2 cases, respectively. By the time the signs of renal dysfunction appeared, the HIV-infected patients with glomerulopathy were found to have a high viral load (HIV RNA >100 000 copies/ml) and low CD4 lymphocyte levels (< or = 200 in 1 microl).

CONCLUSION

In our study, the morphological pattern of chronic glomerulonephritis showed a preponderance of immune complex nephropathies with the clinical manifestations of acute nephritic syndrome and/or NS concurrent with hematuria. High viremia and depressed immune system may be risk factors for nephropathy.

Renal complications in HIV disease: between present and future

The recent introduction of new antiretroviral drugs, characterized by high efficiency and improved safety profiles, has not reduced the incidence of long-term adverse effects, in some cases manifested as selective organ damage. The presence of organ damage in patients receiving antiretroviral treatment is not only the expression of treatment toxicity, but also a complex interaction between individual risk factors, HIV-correlated effects, and antiretroviral drug toxicity. Kidney damage belongs to these adverse events. Renal function abnormalities are present in a large percentage of patients with HIV infection. Moreover, HIV-associated renal disease seems to be associated with progression to AIDS and death. In this review we address the various aspects of the epidemiology of renal damage, the interaction and the convergent effect of HIV and antiretroviral drugs in the onset of kidney injury, the interplay between kidney function and other organ systems, early clinical management, the monitoring of renal function, and a proposal of clinical approach to kidney disease in daily practice. Finally, we discuss future perspectives of renal damage in HIV patients and evaluate the patient's perspective.

Absence of APOL1 risk variants protects against HIV-associated nephropathy in the Ethiopian population

BACKGROUND

Susceptibility to end-stage kidney disease (ESKD) among HIV-infected Americans of African ancestral heritage has been attributed to APOL1 genetic variation. We determined the frequency of the APOL1 G1 and G2 risk variants together with the prevalence of HIV-associated nephropathy (HIVAN) among individuals of Ethiopian ancestry to determine whether the kidney disease genetic risk is PanAfrican or restricted to West Africa, and can explain the previously reported low risk of HIVAN among Ethiopians.

METHODS

We studied a cohort of 338 HIV-infected individuals of Ethiopian ancestry treated in one Israeli and one Ethiopian center. We sought clinical evidence for HIVAN (serum creatinine >1.4 mg/dl or proteinuria >30 mg/dl in a spot urine sample). Genetic analyses included the genotyping of the APOL1 G1 and G2 variants, and a panel of 33 genomic ancestry-informative markers. Statistical analysis compared clinical and genetic indices for HIV-infected individuals of Ethiopian ancestry and overall Ethiopians to those reported for HIV-infected African-Americans, overall African-Americans, West Africans and non-Africans.

FINDINGS

Three (0.8%) of 338 HIV-infected patients of Ethiopian ancestry showed clinical criteria compatible with renal impairment. Two of these 3 patients also have severe poorly controlled diabetes mellitus. The third nondiabetic patient underwent renal biopsy which ruled out HIVAN. This absence of clinically apparent HIVAN was significantly different from that reported for African-Americans. The APOL1 G1 and G2 risk variants were found, respectively, in 0 and 2 (heterozygote state) of the 338 HIV-infected individuals. Global ancestry and the frequencies of the APOL1 G1 and G2 variants are not statistically different from their frequencies in the general Ethiopian population, but are significantly and dramatically lower than those observed among HIV-infected African-Americans, African-Americans and West Africans.

INTERPRETATION

The coinciding absence of HIVAN and the APOL1 risk variants among HIV-infected individuals of Ethiopian ancestry support a Western rather than Pan-African ancestry risk for ESKD, and can readily explain the lack of HIVAN among individuals of Ethiopian ancestry.

Complications of HIV infection: a systems-based approach

Patients with human immunodeficiency virus (HIV) infection often develop multiple complications and comorbidities. Opportunistic infections should always be considered in the evaluation of symptomatic patients with advanced HIV/AIDS, although the overall incidence of these infections has decreased. Primary care of HIV infection includes the early detection of some complications through screening at-risk and symptomatic patients with routine laboratory monitoring (e.g., comprehensive metabolic and lipid panels) and validated tools (e.g., the HIV Dementia Scale). Treatment of many chronic complications is similar for patients with HIV infection and those without infection; however, combination antiretroviral therapy has shown benefit for some conditions, such as HIV-associated nephropathy. For other complications, such as cardiovascular disease and lipoatrophy, management may include switching antiretroviral regimens to reduce exposure to HIV medications known to cause toxicity.

[Renal abnormalities in HIV infected patients]

Several renal complications may occur during HIV infection, especially in advanced stages related to HIV, to other infectious agents and/or drugs. Little is known about the prevalence of renal diseases that may occur as a complication of or related to HIV infection in asymptomatic patients. This is a single center cross-sectional study of asymptomatic HIV(+) patients referred to a nefrology care service at an Argentine hospital to look for the presence of renal abnormalities. Fifty two consecutive patients were studied between April and November 2008. Patients underwent plasma and urine analysis, ultrasound, and kidney biopsy as needed. Mean age was 39.9 +/- 10.6 years, 88% were male, time from HIV diagnosis 53.2 +/- 41.2 months (2-127); 71% had HIV-disease and 77% were on antiretroviral therapy. Mean plasma HIV-RNA copies number was 7.043 +/- 3.322 and CD4+ cell count: 484 +/- 39. Pathologic findings in urine analysis were present in 30.7% of patients: albuminuria 16.6%, microscopic hematuria 11.5%, hypercalciuria 10.8% and crystalluria 6%. Mean glomerular filtration rate was 102.2 +/- 22.95 ml/min (34-149) and 41% of patients could be classified in stages 1 to 3 of chronic kidney disease. Renal abnormalities prevaled in older patients without relationship with presence of HIV-disease. Two patients were biopsied and the findings included: tubulointerstitial nephritis with presence of crystal deposition in one and IgA nephropathy in the other. No HIV-associated nephropathy was detected. The broad spectrum and the high prevalence of lesions found in this series suggest that asymptomatic HIV-infected patients should routinely undergo renal evaluation.

Incidence of persistent renal dysfunction in human immunodeficiency virus-infected children: associations with the use of antiretrovirals, and other nephrotoxic medications and risk factors

BACKGROUND

Survival of HIV-infected children continues to increase and the use of antiretrovirals (ARVs) is expanding; however there are few data regarding the incidence of renal dysfunction and associated risk factors among HIV-infected children and youth.

METHODS

A total of 2102 children enrolled in Pediatric AIDS Clinical Trials Group Study 219/219C, were followed and assessed prospectively for >30 months. Occurrence of clinical events and laboratory abnormalities were recorded using standardized criteria and forms. Therapeutic decisions were made by clinicians at each site. Occurrence of persistent renal laboratory abnormalities was the main outcome measure.

RESULTS

Four hundred forty-six (22%) enrollees exhibited at least one persistent renal laboratory abnormality. Elevated serum creatinine (Cr) was more common than persistent proteinuria (15% vs. 8%). The incidence of new renal laboratory abnormalities was 3.7 events per 100 person-years with rates increasing between 1993 and 2005. Older age (>or=6 years vs. <6 years), Hispanic ethnicity, and Black non-Hispanic race were associated with increased risk of renal dysfunction, but CDC clinical class and plasma HIV RNA levels were not. Subjects exposed to ARV regimens containing tenofovir and/or indinavir had approximately twice the risk of developing renal dysfunction compared with persons exposed to other ARVs. The risk of renal dysfunction was also elevated for other antivirals (hazard ratio = 5.4) and amphotericin B (hazard ratio = 28).

CONCLUSIONS

Persistent renal function abnormalities occur frequently in HIV-infected children. Improved survival, Black race and Hispanic ethnicity, and exposure to tenofovir, indinavir, and other antimicrobial agents increase the risk for renal dysfunction. All HIV-infected children should be monitored closely for evidence of renal disease.

Chronic renal failure in Jamaican children--an update (2001-2006)

OBJECTIVE

This study evaluated the incidence, epidemiology, aetiology and outcome of chronic renal failure (CRF) in Jamaican children < 12 years old between 2001 and 2006.

METHODS

The required data on all children who fulfilled inclusion criteria were obtained from their medical records at the University Hospital of the West Indies, Bustamante Hospital for Children and from practitioners in hospitals serving children islandwide.

RESULTS

Eighteen new children (72.2% male) presented with CRF. The cumulative annual incidence was 4.61/million child population under age 12 years or 1.14/million total population. Congenital urological disease (44.5%) was the commonest cause of CRF, followed by glomerulonephritis (33.3%). Half of the cases of glomerulonephritis were secondary to HIV-associated nephropathy. Although all children with posterior urethral valves were diagnosed before age 6 months and promptly treated, renal failure present at birth proved irreversible. The mean age at diagnosis of CRF was 6.72 years. Ten children (55.6%) were already in CRF at first presentation with renal disease. Of these, the five with non-urological disease were already in End Stage Renal Disease (ESRD). Mortality was 44.4%. Five children died in ESRD without the benefit of dialysis.

CONCLUSION

The incidence of CRF has increased from the 1985-2000 local study and is mainly due to urological pathology which progresses despite early diagnosis and treatment. Non-urological renal disease is presenting too late for therapeutic intervention. Greater public awareness of symptoms of renal disease is needed. Children's access to dialysis is unpredictable. A paediatric dialysis and transplantation programme is needed.

HIV-associated nephropathy: clinical presentation, pathology, and epidemiology in the era of antiretroviral therapy

The classic kidney disease of human immunodeficiency virus (HIV) infection, HIV-associated nephropathy, is characterized by progressive acute renal failure, often accompanied by proteinuria and ultrasound findings of enlarged, echogenic kidneys. Definitive diagnosis requires kidney biopsy, which shows collapsing focal segmental glomerulosclerosis with associated microcystic tubular dilatation and interstitial inflammation. Podocyte proliferation is a hallmark of HIV-associated nephropathy, although this classic pathology is observed less frequently in antiretroviral-treated patients. The pathogenesis of HIV-associated nephropathy involves direct HIV infection of renal epithelial cells, and the widespread introduction of combination antiretroviral therapy has had a significant impact on the natural history and epidemiology of this unique disease. These observations have established antiretroviral therapy as the cornerstone of treatment for HIV-associated nephropathy in the absence of prospective clinical trials. Adjunctive therapy for HIV-associated nephropathy includes angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, as well as corticosteroids in selected patients with significant interstitial inflammation or rapid progression.

[The methods of therapy ESRD patients infected with the human immunodeficiency virus-HIV]

The human immunodeficiency virus (HIV) pandemic has spread to every country in the world and has infected about 60 million persons worldwide, including 20 million who have already died. In Poland are infected 11,181 people. Highly active antiretroviral therapy (HART) has significantly prolonged the survival of HIV-positive patient. HIV infection can cause end-stage renal disease (ESRD) through both HIV-associated nephropathy (HIVAN) and antiretroviral drug toxicity. Until recently, chronic dialysis (HD or PD) was the only form of treatment available for these patients. Kidney transplantation is an alternative method to dialysis and improve the quality of life in HIV-positive ESRD patients. In this article authors present the general information about HIV infection (epidemiology, diagnosis and treatment) as well as methods of therapy ESRD like hemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation.

HIV-1 and HIV-Associated Nephropathy 25 Years Later

Twenty-five years after the first published description of AIDS, HIV-associated nephropathy (HIVAN) remains an important cause of kidney disease in HIV-infected patients. The pathogenesis of HIVAN involves direct HIV infection of the kidney, with both viral and host genetic factors playing an important role. The widespread use of antiretroviral therapy has influenced the epidemiology of HIV-related kidney disease, and the nephrology community should support efforts to improve access to therapy and limit HIV transmission in susceptible minority populations. This article reviews the history of HIV and HIVAN, focusing on advances in the understanding of pathogenesis, epidemiology, and treatment.

[Prevalence of neurological complications in Japanese patients with AIDS after the introduction of HAART]

We investigated trends in neurological complications of infection with human immunodeficiency virus (HIV) in Japan after the introduction of highly active antiretroviral therapy (HAART). Two questionnaire surveys were performed in hospitals treating acquired immunodeficiency syndrome (AIDS) to compare two periods: immediately after the introduction of HAART (1999-2001); and a few years later (2002-3). Neurological complications accompanied 15.9% in 1999-2001 and 9.8% in 2002-3. Neurological complications developed without HAART in about 80% of cases. Neurological complications developed as the first AIDS-defining disease for 8.3% of AIDS patients in 1999-2001 and for 5.4% in 2002-3. Prevalences of HIV encephalopathy and myelopathy decreased markedly over the study period, as reported in other developed nations. However, prevalences of cytomegalovirus encephalitis, PML and primary brain lymphoma did not decrease. PML and primary brain lymphoma occurred in patients who received HAART and whose CD4 counts were relatively high during the study period. This is probably related to the extended survival of HIV-infected individuals after the introduction of HAART as a worldwide therapy, and the reactivation of viremia or latent infection persisting within the central nervous system.

Renal disorders in HIV-infected patients

BACKGROUND

HIV infection affects all body organs including kidney. Since the frequency of HIV-related renal disorders is unknown in Iran and the number of HIV-infected patients is increasing, this study was conducted for the first time in Iran to assess the frequency of electrolyte imbalance, renal failure, and proteinuria among HIV-infected patients.

METHODS

Between April and December 2005, 65 HIV-infected patients who were receiving care at an outpatient counseling center in Tehran, participated in this study. Blood samples were collected to measure serum levels of sodium, potassium, calcium, phosphorus, blood urea nitrogen, and creatinine. Urine samples were analyzed to detect protein, red blood cells, white blood cells, and cast.

RESULTS

Of the 65 HIV-infected patients, 86.2% were males. The mean age of the patients was 37+/-8.7 years, and 58.5% of the patients had a history of injecting illicit drugs. Urinalysis was normal in all patients, and serum levels of electrolytes, blood urea nitrogen, and creatinine were all in normal range.

CONCLUSION

We found no electrolyte imbalance, proteinuria, or renal failure in HIV-infected patients. It seems that renal disorder is infrequent in Iranian HIV-infected patients.

HIV-related nephropathy: a South African perspective

Human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) is an important cause of renal failure in those of African origin. A number of other kidney diseases occur in HIV-positive patients. We conducted a retrospective review of renal biopsies in HIV-positive Black African patients to determine the prevalence of both 'classic HIVAN' and non-HIVAN pathologies in this group. Clinical and laboratory data from HIV-positive patients who underwent renal biopsy from 1st January 2003 to 31st December 2004 were collected. Similar information on HIV-negative patients biopsied during the same period was also recorded by way of comparison to try and assess the influence of the virus on renal histologic patterns. HIV-positive group - 99 biopsies were suitable for study. The main histologic categories were 'classic HIVAN' (27%) and HIV immune complex kidney disease ('HIVICK') (21%). The subepithelial immune deposits in 'HIVICK' induced a newly described 'ball-in-cup' basement membrane reaction. Other glomerulonephritides included membranous, post-infectious disease, mesangial hyperplasia, and immunoglobulin A nephropathy. Overlapping clinical presentations prevented pre-biopsy histologic predictions. HIV-negative group - There were no examples of collapsing focal segmental glomerulosclerosis or nonspecific immune complex disease, but increased numbers of minimal change and membranoproliferative disease. 'Classic HIVAN' accounted for less than a third of the nephropathies occurring in HIV-positive Black South Africans. 'HIVICK' is another important cause of chronic kidney disease in this group. Future research is needed into the earlier detection and treatment of these diseases, which have a high mortality in our context.

HIV-Associated Renal Diseases and Highly Active Antiretroviral Therapy--Induced Nephropathy

Renal disease is becoming an increasingly prevalent entity in human immunodeficiency virus (HIV)-infected patients; it occurs in a variety of clinical settings and is associated with histopathological changes. HIV-related renal impairment can present as acute or chronic kidney disease; it can be caused directly or indirectly by HIV and/or by drug-related effects that are directly nephrotoxic or lead to changes in renal function by inducing metabolic vaculopathy and renal damage. Acute renal failure is frequently caused by the toxic effects of antiretroviral therapy or nephrotoxic antimicrobial substances used in the treatment of opportunistic infections. Chronic renal disease can be caused by multiple pathophysiological mechanisms, leading to HIV-associated nephropathy, a form of collapsing focal glomerulosclerosis, thrombotic microangiopathy, and various forms of immune complex glomerulonephritis. The increase in life expectancy and alteration of lipid metabolism due to receipt of highly active antiretroviral therapy are expected to result in an increased prevalence of diabetes and hypertension and, thus, to secondary diabetic and hypertensive renal damage. Antiretroviral agents, such as indinavir and tenofovir, have been associated with nephrotoxic drug effects that have been shown to be reversible in most cases. In this article, we review the current knowledge about acute and chronic HIV-associated renal disease, metabolic alterations and related nephropathies, and toxic drug effects of combination antiretroviral pharmacotherapy.

A cross-sectional study of HIV-seropositive patients with varying degrees of proteinuria in South Africa

Human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) is the most common finding on renal biopsy in HIV-infected black patients and is also the commonest cause of end-stage renal disease in these patients. Early detection of HIVAN may be beneficial in evaluating early treatment. This study examined the pattern of renal diseases in HIV-infected South Africans and also attempted to diagnose HIVAN at an early stage. In this single-center cross-sectional study, 615 HIV-infected patients were screened for proteinuria. Thirty patients with varying degrees of proteinuria underwent renal biopsy. Patients with diabetes mellitus, uncontrolled hypertension, known causes of chronic kidney disease, and serum creatinine above 250 mumol/l were excluded. Patients in this study were not on antiretroviral therapy. HIVAN was found in 25 (83%) patients. Six of them (24%) had microalbuminuria. Altogether, seven patients with persistent microalbuminuria were biopsied and six (86%) showed HIVAN. Other biopsy findings included membranoproliferative nephropathy in two (7%) and interstitial nephritis in three (10%). Four patients with HIVAN had associated membranous nephropathy. HIVAN is the commonest biopsy finding among our study patients with HIV infection who present with varying degrees of proteinuria. Microalbuminuria is a manifestation of HIVAN in our study patients. Therefore, microalbuminuria may be an early marker of HIVAN, and screening for its presence may be beneficial. Renal biopsy may be considered in seropositive patients who present with persistent microalbuminuria, especially with low CD4 counts irrespective of good renal function. This will allow diagnosis and treatment of HIVAN at an early stage and may prevent further disease progression.

Human immunodeficiency virus-1 associated nephropathy (HIVAN): epidemiology, pathogenesis, histology, diagnosis, and medical management

Human immunodeficiency virus-associated nephropathy (HIVAN) is a very distinct, unique, clinico-pathological syndrome, and a structural type of renal failure that is the most common cause of chronic renal failure in patients who are HIV-seropositive. Early referral and a long-term, primary care approach can improve patient outcomes. Careful adjustments of prescription doses with regularly scheduled, and at times frequent, laboratory testing will yield, optimal health, improve the quality of life, and most importantly, will decrease the incidence of morbidity and mortality in those individuals afflicted with both HIV and HIVAN.

Absence of HIV-associated nephropathy in Ethiopians

BACKGROUND

Population-based epidemiological surveys in several countries have shown approximately 10- to 15-fold increased susceptibility to human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) for populations of recent African ancestry. Accordingly, we sought to determine whether a similar or different pattern of susceptibility was evident among Ethiopians followed up in an HIV clinic in Israel.

METHODS

One hundred seventy-six consecutive patients (126 Ethiopians, 50 non-Ethiopian Israelis) followed up at the HIV clinic of Rambam Medical Center in northern Israel were examined for the presence of proteinuria and/or decreased glomerular filtration rate. HIV viral load, CD4 count, and treatment modality also were determined.

RESULTS

Overall, 73% of patients were treated with highly active antiretroviral therapy, and there was no difference between Ethiopians and non-Ethiopian Israelis in this regard. Mean CD4 count in Ethiopians was 288 +/- 140/microL, significantly less than the corresponding CD4 count of 398 +/- 190/microL for non-Ethiopian Israelis. Mean viral loads were greater in Ethiopians compared with non-Ethiopian Israelis. None of 176 HIV-infected patients fulfilled clinical criteria for HIVAN as delineated in this study.

CONCLUSION

HIV-infected individuals of Ethiopian descent have a level of susceptibility to HIVAN similar to that of non-Ethiopian Israelis, which is strikingly less than that reported for other populations for recent African ancestry. This does not appear to be attributable to differences in HIV infection control or viral subtype and most likely represents population-based differences in host genetic factors. This finding emphasizes the importance of avoiding generalizations with respect to phylogeographic ancestry in disease-susceptibility studies.

HIV/AIDS--dominant player in chronic kidney disease

HIV-associated nephropathy (HIVAN) is now the third leading cause of end-stage renal disease (ESRD) in African Americans between the ages of 20 and 64 years. Statistics in the United States estimate the incidence of HIVAN to be between 3.5% and 12%. The estimated number of those living with HIV worldwide is 37.4 million, with 26 million in Africa. If the US data for HIVAN were extrapolated to Africa, between 0.9 and 3.1 million people would be predicted to have HIVAN. These figures predict an unprecedented (and possibly underestimated) burden of chronic kidney disease (CKD) in Africa, especially if we take into account the socioeconomic associations with CKD for the African continent. This potentially large number of patients poses daunting logistic, financial, and ethical issues for physicians and nephrologists practicing in Africa. Preventing chronic kidney disease due to HIV in Africa should become a major priority. This would enable early detection and treatment of HIVAN in order to prevent or delay progression to ESRD. As HIV infection is a risk factor for the development of CKD, the HIV Medicine Association of the Infectious Diseases Society of America recommends screening for CKD in HIV-infected patients; screening tests should be similar to those for patients with diabetes mellitus to detect early renal involvement. Preventive strategies need to be determined; prospective studies including antiretroviral therapy, angiotensin-converting enzyme inhibitors, and other therapeutic agents are required.

Highly active antiretroviral therapy and the epidemic of HIV+ end-stage renal disease

The rise in the number of patients with HIV-associated nephropathy and HIV-infection with end-stage renal disease (HIV+ ESRD) continues to be a substantial concern for the ESRD program. In order to assess the impact of highly active antiretroviral therapy (HAART) on the progression of patients with AIDS to the development of ESRD and to project the prevalence of HIV+ ESRD through 2020, a mathematical model of the dynamics of HIV+ infection in the ESRD population was developed. Epidemiologic data on AIDS and HIV+ ESRD among black individuals in the United States were obtained since 1991 from the Centers for Disease Control and Prevention and US Renal Data System, respectively. The model was constructed to predict the prevalence of HIV+ ESRD incorporating the current rate of growth in AIDS prevalence. Two possible trends were considered: linear AIDS growth and exponential AIDS growth. The likely effectiveness of HAART in slowing progression to HIV+ ESRD was estimated from the best fit of the model to the data after 1995, when HAART was introduced. The model was then used to evaluate recent data and to project the prevalence of HIV+ ESRD through 2020. The model suggested that HAART has reduced the rate of progression from AIDS to HIV+ ESRD by 38%. The model projected an increase in HIV+ ESRD prevalence in the future as a result of the increase in the AIDS population among black individuals. This increase was predicted even assuming a 95% reduction in the progression from AIDS to HIV+ ESRD. Despite the potential benefit of HAART, the prevalence of HIV+ ESRD in the United States is expected to rise in the future as a result of the expansion of the AIDS population among black individuals. It is concluded that prevention of progression to ESRD should focus on early antiretroviral treatment of HIV-infected patients who have evidence of HIV-associated nephropathy.

The clinical characteristics of HIV-infected patients receiving dialysis in France between 1997 and 2002

BACKGROUND

In 1997, 0.38% of dialysis patients in France were infected by human immunodeficiency virus (HIV). No prevalence data were available in France since the widespread introduction of highly active antiretroviral therapy.

METHODS

This was a cross-sectional epidemiologic survey. A questionnaire was sent to all French dialysis centers in July 2002. The centers that did not respond were sent 3 additional mailing reminders. Finally, the nonresponding centers were called early in 2004.

RESULTS

Of the 27,577 patients on hemodialysis and 587 patients on peritoneal dialysis, 190 patients (0.67%) were infected by HIV. HIV-associated nephropathy was the cause of renal failure in 39.8% patients. Mean age was 44.6 +/- 10.9 years, the mean duration of dialysis was 4.9 +/- 5.9 years, the mean known duration of HIV infection was 8.9 +/- 5.6 years. Eighty-two percent of patients received antiretroviral therapy (ART). Fifty-eight percent of ART-treated patients had an undetectable HIV plasma viral load with a median CD4+ T-cell count 303/mm(3).

CONCLUSION

The prevalence of HIV infection among French dialysis patients was 0.67% in late 2002, a 79% increase since 1997. Possible reasons for this large increase include increased access to dialysis, better general status of HIV dialysis patients, and increasing proportion of patients originating from Africa and the Caribbean. The current efficacy of ART makes renal transplantation a realistic option for these young patients.

HIV dementia: an evolving disease

Several advances have led to improvements in the care and prognosis of HIV+ individuals. The first is an understanding of the direct relationship between HIV replication and subsequent immunological and clinical progression, reinforcing the need to completely suppress HIV replication to control disease progression. The second is the wider availability of HAART which can provide effective suppression of HIV. The third major change is the ability to monitor HAART through the reliable and widespread measurement of plasma HIV RNA levels, which has become a routine part of clinical care. Since the introduction of highly active antiretroviral therapy (HAART) in the 1990s, there have been significant declines in the incidence rates of opportunistic infections in developed countries. HAART has clearly improved survival for individuals with HIV/AIDS, and has reduced the incidence of HIV-associated dementia (HIV-D) by 40-50% (Brodt et al., 2002). The prevalence of sensory neuropathies in advanced HIV/AIDS now exceeds 20% (Schifitto et al., 2002), and may rise further with prolonged exposure to neurotoxic HAART. HIV-D and HIV-related sensory neuropathies (HIV-SN) have a combined prevalence of about 30-50% in advanced HIV disease, suggesting that HAART does not provide complete protection against neurological damage (Bouwman et al., 1998). HIV-associated dementia (HIV-D) remains a common cause of dementia worldwide, and with HIV-related sensory neuropathies (HIV-SN) represents the commonest neurological disorders associated with AIDS. Furthermore, the temporal progression of HIV-D appears to have been altered by HAART, with most patients now showing an attenuated form of dementia, which with treatment is slowly progressive or static (Dougherty et al., 2002). This overview will review some of the outstanding questions relating to HIV-dementia, including: (a) are there differing phenotypes or temporal patterns of progression in HIV-dementia? (b) what determines these temporal patterns? and (c), what has been the impact of therapy on HIV dementia?

The clinical epidemiology and course of the spectrum of renal diseases associated with HIV infection

BACKGROUND

While an understanding of the epidemiology and clinical course of HIV-associated nephropathy (HIVAN) is growing, little is known about the risk factors and clinical course of the other renal diseases that may also occur as a complication of HIV infection. This study was undertaken to compare HIVAN to the spectrum of other kidney diseases seen among HIV-infected patients.

METHODS

This retrospective cohort study included all HIV-infected patients who underwent renal biopsy during the course of their clinical care at six major medical centers. Demographic and clinical information were abstracted from each patient's clinical record. Time to initiation of renal replacement therapy was compared for patients with lesions other than HIVAN to patients with HIVAN using Cox proportional hazards regression.

RESULTS

Eighty-nine patients (47 with lesions other than HIVAN and 42 with HIVAN) were available for inclusion. Patients with lesions other than HIVAN were less likely to be black (37/47 vs. 42/42, P= 0.02), more likely to have a positive hepatitis B surface antigen (10/37 vs. 4/42, P= 0.04), less likely to have the diagnosis of hypertension (24/46 vs. 31/42, P= 0.03), more likely to have a greater creatinine clearance at time of biopsy (60.6 vs. 39.0 cc/min, P= 0.008), and have a greater CD4 lymphocyte count at time of biopsy (287 vs. 187 cells/mL, P= 0.04) compared to patients with HIVAN. Lesions other than HIVAN were associated with a longer time to initiation of renal replacement therapy compared with HIVAN (HR 0.33, 95% CI 0.15-0.71, P= 0.005). Other factors associated with a longer time to renal replacement therapy included higher creatinine clearance at time of biopsy, greater CD4(+) lymphocyte count, the absence of hepatitis C antibody, and the use of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. The type of renal disease (HIVAN vs. other) interacted significantly with HIV-1 RNA level and the use of antiretroviral therapy (P= 0.0001 and 0.006, respectively). Among patients with lesions other than HIVAN, the presence of nondetectable HIV-1 RNA was not associated with a greater risk of progression of renal disease (HR 0.27, P= 0.24). Among patients with HIVAN, because all patients had detectable virus at the time of institution of renal replacement therapy, this highly significant association could not be quantified. Among patients with lesions other than HIVAN, the use of antiretroviral therapy was not associated with the progression to renal replacement therapy (HR 3.29, P= 0.06). Among patients with HIVAN, the use of antiretroviral therapy was associated with a slower progression to renal replacement therapy (HR 0.24, P= 0.03).

CONCLUSION

Among HIV-infected patients with renal disease other than HIVAN, viral suppression and the use of antiretroviral therapy are not associated with a beneficial effect on renal function; thus, additional therapeutic strategies may need to be utilized. Because renal histology is associated with prognostic differences, these data provide outcomes information that will improve the clinical utility of renal biopsy among HIV-infected patients with renal disease.

HIV-associated nephropathy and end-stage renal disease in children in the United States

Single-center studies have reported that HIV-associated nephropathy (HIVAN) can occur in children and may have a clinical course and prognosis similar to that of adults. However, the prevalence and survival has not been reported for a national sample of children with HIVAN and end-stage renal disease (ESRD) on dialysis in the United States. We utilized the United States Renal Data System (USRDS) database to determine the prevalence, demographic information, and survival of children with HIVAN and ESRD in the United States. The Kaplan-Meier method was used to estimate survival of children with HIVAN and the log-rank test was used to compare their survival with children with focal segmental glomerulosclerosis (FSGS) and adults with HIVAN. Cox regression analysis was used to model adjusted hazard ratios (AHR) with HIVAN as a cause of ESRD and its impact on mortality during the study period, adjusted for potential confounders. Of the 7,732 patients identified with HIVAN, only 60 were younger than 21 years and were classified as children; 50% were males and the majority (88.3%) was black. The cumulative percentage survival of children with HIVAN at 12, 24, and 36 months was better than adults with HIVAN (76%, 62%, and 54% vs. 60%, 43%, and 34%). Survival of children with HIVAN who started dialysis after 1996 was significantly better than those who started dialysis in or before 1996 (log rank P value <0.043). However, the major factor associated with better survival on Cox proportional hazard analysis was female gender (male vs. female AHR 2.85, 95% confidence interval 1.04-6.73). We conclude that only a small number of children with HIVAN and ESRD have received dialysis in the United States. The prognosis of these children is better than that of adults with HIVAN and among children with HIVAN females have better survival than males.

Highly active antiretroviral therapy and the incidence of HIV-1-associated nephropathy: a 12-year cohort study

OBJECTIVE

to assess temporal changes in the incidence of human immunodeficiency virus-1-associated nephropathy (HIVAN), and the association with use of highly active antiretroviral therapy (HAART).

METHODS

HIVAN incidence and risk factors were assessed in 3976 HIV-1-infected individuals followed in clinical cohort in Baltimore, Maryland, USA from 1989 to 2001. The incidence of HIVAN, defined by biopsy or a conservative uniformly applied clinical coding protocol, was expressed in terms of person-years, and Poisson regression was used for multivariate analysis.

RESULTS

Ninety-four patients developed HIVAN over the course of the study for an incidence of 8.0 per 1000 person-years [95% confidence interval (CI), 6.5 to 9.8]. African American race and advanced immunosuppression were strongly associated with HIVAN risk. HIVAN incidence declined significantly in 1998-2001 compared with 1995-1997. Among patients with a prior diagnosis of AIDS, HIVAN incidence was 26.4, 14.4, and 6.8 per 1000 person-years in patients not receiving antiretroviral therapy, treated with nucleoside analogue therapy only, or treated with HAART, respectively (P < 0.001 for trend). In multivariate analysis, HIVAN risk was reduced 60% (95% CI, -30 to -80%) by use of HAART, and no patient developed HIVAN when HAART had been initiated prior to the development of AIDS.

CONCLUSION

HAART was associated with a substantial reduction in HIVAN incidence. Additional follow-up will be needed to determine if renal damage in susceptible individuals is halted or merely slowed by HAART, particularly when control of viremia is incomplete or intermittent.

Human immunodeficiency virus-associated nephropathy: a primary care perspective

The advent of highly active antiretroviral therapy represents a significant advance in medical care for human immunodeficiency virus (HIV)-infected persons. However, not everyone has derived the expected benefits of antiretroviral therapy and HIV-associated diseases such as nephropathy still occur in at-risk populations. Currently, there are no recommendations for screening HIV-positive patients for HIV-associated nephropathy. We propose semiannual screening for proteinuria in HIV-positive African Americans and patients with a family history of renal disease, and provide an algorithm for evaluation.

Renal disease in the acquired immunodeficiency syndrome in north central Nigeria

BACKGROUND

The brunt of the human immunodeficiency virus infection/the acquired immunodeficiency syndrome is largely borne by communities in sub-Saharan Africa. We describe renal disease in Nigerians with the acquired immunodeficiency syndrome.

METHODS

Consecutive patients with the acquired immunodeficiency syndrome (AIDS) seen in the infections unit of the Jos University Teaching Hospital and a similar group of healthy controls were evaluated for renal disease. Subjects with past history of renal disease, hypovolemia, hypertension, diabetes mellitus and/or a documented fever were excluded from the study.

RESULTS

Of the 79 patients with the acquired immunodeficiency syndrome and 57 controls studied, renal disease was present in 41 (51.8%) of the patients in the AIDS group and 7 (12.2%) of controls. While 15 (19%) of the AIDS group had azotemia alone and 20 (25.3%) had proteinuria alone, 6 (7.6%) had azotemia and proteinuria. The mean protein excretion/24 hours was significantly higher in the AIDS group compared to controls, (2.99 +/- 54 g and 0.56 +/- 0.12 g respectively, p = 0.001), while the GFR was significantly higher in controls compared to the study group (103.30 +/- 37.78 and 68.03 +/- 37.55 respectively, p = 0.004). Subjects in the AIDS group with renal disease had a significantly longer duration of illness compared to those without (12.33 +/- 8.67 months and 7.28 +/- 7.78 months respectively, p = 0.008). Age and serum CD4+ cell counts were similar in patients with and without renal disease in the AIDS group.

CONCLUSION

Renal disease is a common complication of acquired immunodeficiency syndrome, the duration of illness being strongly associated with its presence.

HIV-associated nephropathy: Epidemiology, pathogenesis, and treatment

Initially described in 1984, human immunodeficiency virus-associated nephropathy (HIVAN) has now become a common disease within the HIV-seropositive population. It is a focal segmental glomerulosclerosis causing rapid deterioration of renal function. It is the most common cause of chronic renal disease in HIV patients and occurs almost exclusively in blacks. Through murine and human studies, it is now clear that HIVAN is caused by a direct effect of infection of renal cells by HIV-1 and that the virus actively replicates within renal cells. How the virus causes disease within cells is not yet understood, but there is evidence for factors within infected cells causing both proliferation and apoptosis. Steroids, angiotensin converting enzyme (ACE) inhibitors, and highly active antiretroviral therapy (HAART) have been used for the treatment of HIVAN, with HAART, in particular, showing a dramatic improvement in both the pathologic changes and clinical course of HIVAN.

Development of proteinuria or elevated serum creatinine and mortality in HIV-infected women

BACKGROUND

Data on the incidence and prognostic significance of renal dysfunction in HIV disease are limited.

OBJECTIVE

To determine the incidence of proteinuria and elevated serum creatinine in HIV-positive and HIV-negative women and to determine whether these abnormalities are predictors of mortality or associated with causes of death listed on the death certificate in HIV-positive women.

DESIGN

The incidence of proteinuria or elevated serum creatinine and mortality was assessed in a cohort of 885 HIV-positive women and 425 at-risk HIV-negative women.

SETTING

Women from the general community or HIV care clinics in four urban locations in the United States.

OUTCOME MEASURES

Creatinine of >or=1.4 mg/dL, proteinuria 2 or more, or both. Deaths confirmed by a death certificate (92%) or medical record/community report (8%).

RESULTS

At baseline, 64 (7.2%) HIV-positive women and 10 (2.4%) HIV-negative women had proteinuria or elevated creatinine. An additional 128 (14%) HIV-positive women and 18 (4%) HIV-negative women developed these abnormalities over the next (mean) 21 months. Relative hazards of mortality were significantly increased (adjusted relative hazard = 2.5; 95% confidence interval: 1.9-3.3), and there were more renal causes recorded on death certificates (24/92 (26%) vs. 3/127 (2.7%), p<.0001) in HIV-infected women with, compared with those without these renal abnormalities.

CONCLUSIONS

Proteinuria, elevated serum creatinine, or both frequently occurred in these HIV-infected women. These renal abnormalities in HIV-infected women are associated with an increased risk of death after controlling for other risk factors and with an increased likelihood of having renal causes listed on the death certificate. The recognition and management of proteinuria and elevated serum creatinine should be a priority for HIV-infected persons.