A STUDY OF HIV-ASSOCIATED NEPHROPATHY

AMONG NIGERIANS: CLINICO-PATHOLOGICAL

CORRELATION

BY

DR. KWAIFA SALIHU IBRAHIM (MBBS, 1991)

A Dissertation submitted to the National

Postgraduate Medical College of Nigeria in partial fulfilment of the requirement for the award of the

Fellowship of the College in INTERNAL MEDICINE (NEPHROLOGY SUBSPECIALTY)

Department of Medicine

Obafemi Awolowo University Teaching Hospital

Ile-Ife

May 2007

ii

DECLARATION

It is hereby declared that this work is original unless

otherwise acknowledged. The work has not been

presented to any other college for the award of fellowship

nor has it been submitted elsewhere for publication.

…………………………………………………

DR. KWAIFA, SALIHU IBRAHIM

iii

CERTIFICATION

I certify that this research was conducted by DR. KWAIFA

SALIHU IBRAHIM under my supervision. I have also

supervised the writing of this dissertation.

…………………………………………………………………

Prof. Wale Akinsola

Head of Nephrology Unit

Dept. of Medicine

Obafemi Awolowo University Teaching Hospitals Complex,

(OAUTHC) Ile-Ife, Nigeria.

………………………………………………………….

DR. A. A. Sanusi

Senior Lecturer/Consultant Nephrologist

Renal Unit,

Dept. of Medicine

Obafemi Awolowo University Teaching Hospitals Complex,

(OAUTHC) Ile-Ife, Nigeria

iv

CERTIFICATION

I certify that this research was conducted by Dr. Kwaifa Salihu

Ibrahim at the Renal Units of ABUTH-Zaria/OAUTHCs Ile-Ife.

………………………………………………………….

Prof. G. E. Erhabor

Head of Department

Dept. of Medicine

Obafemi Awolowo University Teaching Hospitals Complex,

(OAUTHC) Ile-Ife, Nigeria

v

DEDICATION

This work is dedicated to my late grand-parents, Abdullahi

Dan-Kwaifa and Fatimah Abdullahi Karofi; and to my late

parents Muhammad Salisu Abdullahi and Salamatu Salisu.

May their gentle souls rest in perfect peace. Amin.

vi

ACKNOWLEDGEMENT

First and foremost, I would like to express my appreciation and indebtedness

to my supervisor and mentor Professor Wale Akinsola, “a season

academician” and administrator “par-excellence” for training me in

Nephrology and also for supervision of this dissertation. I also want to

extend my appreciation to his family especially his wife for her hospitality.

Thank you Ma.

My gratitude also goes to my co- supervisors Dr. A.A. Sanusi and Dr.

F.A. Arogundade who have contributed immensely to my training. They

have shown great interest in my progress throughout my stay and made me

feel at home.

To the head of Department of medicine OAUTH, Prof. G.E. Erhabor,

I am most grateful for your encouragement and support. I also want to

express my gratitude to my head of department at ABUTH- ZARIA Prof. S.

S Danbauchi. Thank you sir, for the support and guidance. My appreciation

and gratitude goes to the entire Consultants in the Department of Medicine

ABUTH/OAUTH for their support.

The immense contributions of my Unit Head Dr.I. B Bosan, Dr. A.

Ibrahim, Dr. J.U. Okpapi and Dr. M.S Isa could not be overemphasized.

Thank you very much for the support, encouragement and guidance. I would

vii

like to acknowledge with gratitude the contributions of renal nurses at

ABUTH ZARIA (Renal family), especially for patients preparation during

renal biopsies.

Furthermore, i would like to express my profound gratitude and

appreciation to the CMD ABUTH Zaria Prof. I.A Aguye and his entire

management team for sponsoring my course at OAUTH Ile-Ife.

The following colleagues and friends are of memorable value and

importance especially during the struggle. These include: Rilwanu G.S, Alh.

S.F Mohammed, Nasir Umar D/G, Dr.M. Baba, Dr.O.R. Obiakor, Dr.L.E

Ojo, Dr. M. Ndakotsu, Dr.P.T Mbaave, Dr. (Mrs.) F.A Soyinka, Dr. U. Aziz,

Dr.M. Tasiu, Dr. S. B. Muazu, Dr.O.S David, Dr.P. Azuh, Dr.M.A

Akolawole, Dr.D. Ogoina, Dr.J. Sheyin, and all the residents in the

Department of Medicine in OAUTHCs and ABUTH- Zaria.

My brother Prof. U.T Mohammed, who have supported me

throughout the period. Thank you very much for your encouragement and

guidance.

I would also like to acknowledge with gratitude the contribution of

Dr.A. Adelusola of Department of Morbid Anatomy for the preparation and

reporting of the slides.

viii

My special acknowledgement goes to my beloved wife Asma’u Sada

Sodangi for her endurance, patience, encouragement and support throughout

the residency period.

To my children Sadiq, Fatima, Sumayyah and Mustapha, I love you

all.

Finally, I would like to conclude with the praise of Almighty Allah

the Lord of the worlds, who teaches by the pen and from whom all

knowledge flows.

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TABLE OF CONTENTS

Title page……………………………………………………………….i

Declaration……………………………………………………………ii

Certification…………………………………………………………iii-iv

Dedication…………………………………………………………….v

Acknowledgement……………………………………………………vi

Table of contents…………………………………………………….ix

List of abbreviations………………………………………………….x

Abstract……………………………………………………………..xii

Chapter 1: Introduction…………………………………………….1

Chapter 2: Literature review……………………………………….5

Chapter 3: Materials and Methods……………………………….26

Chapter 4: Results……………………………………………….38

Chapter 5: Discussion……………………………………………67

Conclusion and recommendation……………………….. ………75

Limitations……………………………………………………….77

References…………………………………………………………81

Appendix………………………………………………………..102

x

ABBREVIATION

ABUTH - Ahmadu Bello University Teaching Hospital

ACE - Angiotensin Converting Enzyme

ACR - Albumin Creatinine ratio

AIDS - Acquired Immune Deficiency

ARF - Acute renal failure

ARV - Antiretroviral

BMI - Body Mass Index

DARC - Duffy antigen receptor Chemokine

CAPD - Continuous Ambulatory Peritoneal Dialysis

CD4 - Cluster of differentiation

CKD - Chronic Kidney Disease

CRF - Chronic Renal Failure

ELISA - Enzyme-linked Immunosorbent assay

ENV - Envelope protein

ESRD - End Stage renal disease

FBC - Full blood count

FH - Factor H

FSGS - Focal segmental glomeruloscelorosis

Gag - Group Specific antigen

GFR - Glomerular Filtration rate

HAART - Highly active antiretroviral therapy

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HBSAg - Hepatitis B surface antigen

HD - Haemodialysis

HCV - Hepatitis C virus

HIVAN - HIV – associated nephropathy

HUS - Haemolytic Uraemic syndrome

IVDU - Intravenous drug use

LTR - Long terminal repeat

MCD - Minimal change disease

MCP - Membrane co-factor protein

Nef - Negative factor

NSAIDS - Non-Steroidal anti-inflammatory drugs

OAUTHC - Obafemi Awolowo University Teaching

Hospitals Complex

PCR - Polymerase chain reaction

PCV - Packed cell volume

PD - Peritoneal dialysis

POL - Polymerase

RRT - Renal replacement therapy

SHIV - Simian human immune deficiency virus

USRDS - United State renal data systems

WBC - White blood cell count

WT-1 - Wilm’s tumour antigen -1

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ABSTRACT

BACKGROUND: The burden of HIV/ AIDS pandemic remains huge in

Africa and Nigeria in particular, being Africa’s most populous nation. HIV

associated renal diseases constitute enormous morbidity and mortality in

people living with HIV/AIDS worldwide. HIV – associated nephropathy,

one of the grave consequences of HIV systemic manifestations was

adjudged to be the 3rd leading cause of ESRD in African- Americans aged

20-64 years. Although this disease entity has been widely studied in the

developed countries, there is a dearth of data in Nigeria about its prevalence.

AIMS AND OBJECTIVES: Therefore, this prospective cross sectional

study was aimed at providing data on the prevalence and factors associated

with development of HIVAN.

METHODS

Four hundred HIV – infected patients were screened over one year period

for the presence of proteinuria and/or elevated serum creatinine.

Thirty consecutive HIV – patients with nephropathy were later

compared with another thirty consecutive HIV – patients without

nephropathy (controls). Exclusion criteria included diabetes mellitus,

hypertension, fever, pregnancy, congestive cardiac failure and urinary tract

infection. Their early morning urine samples were tested for protenuria using

albustix and spot urine sample was used to estimate 24hrs urine protein by

xiii

calculating protein to creatinine ratio. Their full blood count (FBC), CD4

cell count, serum electrolytes, urea, creatinine, serum proteins and total

cholesterol were also estimated. Renal biopsy was done on 10 of the patients

with nephropathy. Statistical analysis was done using SPSS version 11.5

RESULTS:

The prevalence of renal disease was 127 (31.8%) of the 400 patients

that were screened. The mean age was 37.5±10.3 years and ranged was 20 to

70yrs. The prevalence was higher in males 72(56.7%) than females 55

(43.3%). The commonest symptoms seen were nocturia 43(33.8%), low

urine output, 43(33.8%) frothy urine 38(30%), pruritus 29(22.38%)

vomiting, 17 (13.4%), leg swelling 17 (13.4%), and facial swelling 13

(10.2%). The common signs were weight loss 80(63.0%) pallor 43 (33.8%),

hepatomegaly 1(0.8%), and ascites1(0.8%).The BMI ranged from 16.0 to

33.8kg/m2 with mean of 22.9 ± 3.8kg/m2. Thirteen (10.2%) of the subjects

had a BMI of less than 18.5kg/m2.

The mean PCV was 33.9±6.7% with 34(26.8%) of the subjects having

a PCV of less the 30%. The mean CD4 cell counts was 219.57 + 89.22

cells/µL. Mean serum creatinine was 113.77 + 72.89μmol/l and mean

creatinine clearance was 68.77 + 21.22 mls/min. The mean ACR was 427.67

+267.66mg/g

Forty seven (37.0%) had nephrotic range proteinuria .The mean serum

cholesterol and albumin were 5.20±1.73 mmol/l and 32.66±4.98g/l

xiv

respectively. Renal disease had no correlation with, CD4 cells count or

creatinine clearance. There was significant difference in creatinine

clearance, CD4 cells count, duration of ARVs therapy and serum

albumin levels between subjects and controls. HBSAg seropositivity was

present in 23.3% of the subjects compared with 6.7% of the controls

(fisher’s test=0.073), while HIV –2 seropositivity of 13.3% was seen

(fisher’s test=0.056), although not statistically significant, there was

tendency towards some significance. No significant difference in BMI,

blood pressure, and family history of hypertension or diabetes mellitus

between the subjects and controls. Focal segmental glomerulosclerosis

(FSGS) was the predominant finding in the histology.

CONCLUSION

The prevalence of renal disease in HIV-patients is high in Nigeria with male

preponderance. Low creatinine clearance, CD4 cell counts differentiates

HIV patients with nephropathy from those without nephropathy. The

histopathological feature of patients with HIVAN is similar to that of blacks

reported elsewhere. Therefore, routine screening for the presence of renal

disease in all HIV patients is recommended for early detection and

appropriate intervention.

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CHAPTER ONE

INTRODUCTION

More than 42 million people have been infected with HIV

world wide, with an estimated 5 million new infection each

year. Sub-Saharan Africa carries most of the burden of HIV

infection with an estimated prevalence of more than 80% of

the world cases1.

Renal manifestations are important component of

HIV disease, and renal diseases significantly contribute to

morbidity and mortality in patients with HIV-Infection2, 3.

Great progress has been made towards identifying specific

glomerular lesions and their pathogenesis, and newer highly

active antiretroviral drugs therapy (HAART) offer great promise

in preventing and/or retarding progression of established

renal disease and also in patients with HIV-associated

nephropathy4, 5-6. At the inception of HIV pandemic in the early

1980s, it appeared that the kidney might be spared from

major complication of the disease. However, it was in 1984,

that, the association between HIV and renal disease was first

reported by researchers in New York and Miami; they reported

xvi

series of HIV-I patients with renal syndrome characterized by

proteinuria and progressive renal failure3-8.This finding was

later found to be commoner in the population of African-

Americans. Currently, HIV-related renal diseases are the third

leading cause of end-stage renal disease (ESRD) among

African-Americans aged 20-64years7,8,9-11. Human

immunodeficiency virus associated Nephropathy (HIVAN)

appears to be the most common manifestation of renal

diseases in HIV seropositive patients and invariably progress

to end stage renal disease.10-13.The HIV-associated

nephropathy was predominantly seen among people of black

race in the USA and has high prevalence in intravenous drugs

abusers3-9.

Although some researchers suggest that HIV associated

nephropathy comprises spectrum of mesangial diseases, and

matrix production disorders7, the most common histological

variant is focal segmental glomerulosclerosis (FSGS) with,

collapsing glomerulopathy. 3-4,5-9.

Human immunodeficiency virus associated nephropathy

though, characterized by “Pan Nephropathy,” histologically

xvii

manifests as focal segmental glomerulosclerosis with

collapsing features with frequent tubular and interstitial

degenerative and inflammatory changes9,11,13; and this

histological variant accounts for more than 50% of all renal

lesions seen among HIV infected individuals9,14.

Other lesions seen include Amyloidosis, Minimal Change

Disease(MCD), cryoglobulinaemia and various forms of

immune-complex glomerulonephritides, such as IgA

nephropathy, membranous nephropathy and

membranoproliferative glomerulonephritis5-9,11-14.

Since HIV associated nephropathy is associated with

inexorable and relentless progression to end-stage renal

disease, understanding of its associated risk factors and

clinico-pathological course are imperative to be able to mount

effective preventive and treatment strategies. Nigeria with

estimated population of 140 million has 5.4% prevalence of

HIV seropositivity and this large population of HIV

seropositivity imposes a potential huge burden of chronic

kidney disease on the nation. There are fewer studies that

have looked at the prevalence of proteinuria and raised serum

xviii

creatinine levels among Nigerians with HIV-infection also, no

large studies conducted to classify the histological variants of

renal lesions among HIV/AIDS infected patients in our setting

thus creating the need for such study. This study is therefore

aimed at providing a base line data on the prevalence of renal

lesions in HIV/AIDS seropositivity and various histological

variants in our setting, this, hopefully will form data base for

further research on this subject.

xix

CHAPTER TWO

LITERATURE REVIEW

(1) EPIDEMIOLOGY:

The acquired Immune Deficiency syndrome (AIDS),

caused by the human Immunodeficiency virus types 1 and 2

(HIV-1 and HIV-2) was recognized in the 1980s and is

presently the leading cause of death in Africa1. The HIV/AIDs

pandemic has spread very rapidly in Africa. The prevalence of

HIV- infection was indeed less than 1% in most of African

countries in 1991; rising to more than 8% by 19971.Of the 42

million people living with HIV/AIDs worldwide, about 28.5

million resides in the sub-Saharan Africa, where AIDs has

already killed more than 14 million adults and children.1

Patients with HIV-1 infection are at risk of developing

renal diseases with diverse aetiologies. Acute renal failure

occurs in up to 20% of hospitalized patients with HIV

infections, and chronic renal diseases of diverse aetiologies

have been reported11-14, 15-18 and these accounts for 3-10%.

The single most common cause of chronic renal insufficiency

in HIV-I patients is HIV-associated nephropathy. HIVAN

xx

usually presents as nephrotic-range proteinuria with a

progressive loss of renal function within an interval of less

than 10 months from the time of diagnosis to ESRD.This is

typically not accompanied with Hypertension as a common

feature6. Typical morphologic and histologic features include

enlarged kidneys, microcystic tubule dilatation,

tubulointerstitial inflammation, and focal and segmental

glomerulosclerosis of collapsing variety3-10.

During the 1980s, and early 1990s, the incidence of end-

stage renal disease due to HIVAN increased more rapidly than

any other aetiology of renal disease.3, 10 In 1999, HIVAN

became the third leading cause of ESRD in African Americans

aged 20-64years and HIVAN is also the leading cause of

chronic renal failure in HIV-I sero-positive patients3,14.

In the USA the prevalence of HIVAN is 3-10% among HIV

infected people and intravenous10,11,19,20 drug users accounted

for more than 50% of patients with HIVAN9,10,12,18.In contrast

to the abundant literature documenting HIVAN in the United

States, little is known about the frequency and prevalence of

this disease in Europe. Nevertheless, the fragmentary

xxi

information that is available suggests that this nephropathy is

not rare. However, in their series Nochy et al.20reported a

prevalence of 5.3% of HIVAN in 206 patients and 83% of the

patients were of African or Afro Caribbean descent. However,

in contrast to the series of US, intravenous drugs users

(IVDUs) accounted for only 16% of their patients. Also,

Vigneau et al .21 reported a rise in the prevalence of HIV –

infection (from 0.38% to 0.67%) among French dialysis

patients.

In Africa, the true incidence of people living with HIVAN

is not known.6, 22, 23 However, studies conducted by Muloma

and Pepper in central Kenya and Uganda found a prevalence

of 25-50% of HIVAN among HIV-infected antiretroviral naive

patients attending HIV/AIDS clinics.24, 25 In another cross-

sectional study among HIV-seropositive patients with varying

degrees of proteinuria. Han et al. 22 found HIVAN in 25(83%) of

the 30 patients that underwent renal biopsy in South Africa.

Also, Gerntholtz et al. 23 in a retrospective review of biopsies

done on HIV – patients in different hospitals in South Africa

xxii

found HIVAN to constitute 27% of all the renal lesions

reviewed.

In Nigeria, the prevalence of HIV-infection continues to

rise from 1.8% in 1991, to 5.8 in 2001; and about 3.5 million

Nigerians were reported to be infected with HIV virus in

200226. This high prevalence put Nigeria as the 2nd in the

world with the national sero-prevalence of 5.4% of HIV

infection26, 27.

Before the advent of HIVAN, the commonest causes of

chronic renal disease in Nigeria included chronic

glomerulonephritides, systemic hypertension, Diabetes

Mellitus and obstructive uropathy27-31. However, Agaba et al.

32 in Jos Central Nigeria in a hospital based prospective case

control study of 79 AIDS patients and 57 HIV negative healthy

controls reported that renal disease, defined as proteinuria of

1g/day or more and/or azotaemia was present in 51.8% of

AIDS patients compared to 12.2% of controls. In another

hospital based study among ESRD patients on Haemodialysis,

Anteyi et al.33 in Abuja reported HIVAN in four (28.5%) of 14

HIV-positive patients on the programme. Also Pedro in Ife

xxiii

reported Kidney disease in 152(38%) of 400 patients who were

diagnosed HIV positive34.

Although studies conducted by Nigerian authors 32-

34described varying degree of renal abnormalies in the form of

proteinuria and raised creatinine levels in the HIV-infected

patients only one of them conducted biopsy and HIVAN was

revealed in 70 %( 7 patients) of the cases on histology.

However, these studies do not provide adequate information

on the true prevalence of HIVAN in Nigerian HIV infected

patients because of low biopsy rate. Therefore, there is a need

to embark on another study with the aim of providing data on

the histopathological pattern of renal lesion in HIV infected

Nigerians.

CHRONIC RENAL DISEASE IN HIV-PATIENTS

Three types of chronic kidney disease are directly caused

by HIV infection: HIV–associated thrombotic

microangiopathies, HIV–Immune mediated renal diseases, and

classic HIV associated nephropathy.3, 35

HIV-ASSOCIATED THROMBOTIC MICROANGIOPATHY

xxiv

Renal thrombotic microangiopathy (TMA) was first

described in an AIDs patient by Broccia et al. 35 in 1984.

Subsequently TMA has been reported in several hundred HIV

infected patients worldwide, and may be the second most

common renal injury associated with HIV infection. 36

The thrombotic microangiopathies, haemolytic uraemic

syndrome and thrombotic thrombocytopenic purpura, are

thought to occur because of endothelial cell dysfunction

partially mediated by HIV proteins.6,7,37 Renal cellular

apoptosis as well as inhibition of Von-Willebrand factor-

cleaving protease may play pathogenic key roles. 38Mutations

in the genes for complement factor H (FH), factor (FI) and

membrane co-factor protein (MCP), also known as CD46, are

associated with the development of haemolytic uraemic

syndrome (HUS). Also, genetic disorders of Von-Willebrand

factor cleaving protease(ADAMS-13)have been associated with

thrombotic thrombocytopaenic purpura(TTP).39 The disease

spectrum is characterized by a pentad of findings with variable

expression: fever, neurologic dysfunction, thrombocytopenia,

microangiopathic haemolytic anaemia and renal insufficiency

xxv

with haematuria.7,38 High – level proteinuria is uncommon,

which helps to differentiate these syndromes from Immune-

mediated diseases and HIVAN.7 However, nephrotic range

proteinuria may occur in these patients and is often ascribed

to coexistence of two diseases. 38, 40 The renal lesions often

resist treatment, glucocorticoids, plasma and immunoglobulin

infusions, plasma pharesis, anti platelet drugs, vincristine and

splenectomy have all been tried with variable success.40

HIV-ASSOCIATED IMMUNE-MEDIATED GLOMERULONEPHRITIDES

The prevalence of proliferative glomerulonephritis in HIV

infected patient is between 10% and 80%. 7, 20, 21 Immune

complex glomerulonephritis associated with HIV infection has

several different histologic manifestations, including

proliferative, lupus-like and mixed proliferative and sclerotic

forms. 7 Other types of glomerulonephritis such as

membranoproliferative glomerulonephritis, membranous

nephropathy, fibrillary and immunotactiod glomerulonephritis

and post infectious glomerulonephritis, 20-22,41 also occur in

HIV infected patients. It’s been argued that these various renal

diseases may not have direct causal relationship with HIV

xxvi

because of various coexisting infections such as Hepatitis B

or C that are frequently seen in these patients and these

infections are known causes of the various renal diseases seen

in patients without HIV. 42, 43

IgA nephropathy also occurs in HIV infected patients 7, 20.

Its incidence and prevalence are unknown but seems to be

relatively common in men of European descent but uncommon

in people of African descent.21, 44The clinical course of IgA

nephropathy is generally indolent, characterized by

proteinuria, haematuria and mild to moderate fall in GFR.7,

42,44 Generally the incidence of IgA nephropathy in the CKD

black population without HIV infection is very low. The reason

for this is not known. And in the population of HIV/AIDS

Black African, IgA nephropathy has not been reported either.

The low incidence may be perhaps due to genetic variation and

low level of Immunohistological evaluation of renal tissue.

CLASSIC HIV-ASSOCIATED NEPHROPATHY (HIVAN)

HIV-associated nephropathy is characterized by large,

echogenic kidneys on Ultrasonography, nephrotic-range

proteinuria, and renal insufficiency. 2-5 Although it has been

xxvii

argued that HIV-associated nephropathy is late complication

of HIV, 17 it can clearly occur at any stage of HIV-infection and

is occasionally the presenting feature. 29, 43 It is also the most

common variant of all the renal lesions seen in HIV induced

renal diseases.3,14

PATHOGENESIS OF HIVAN

The exact pathogenesis of HIV-associated nephropathy is unknown,

but three lines of evidence link the disease to viral infection: (1) the finding

of HIV-associated nephropathy in infants of HIV-infected mothers,44 (2) the

reproduction of the disease in HIV-1 transgenic mice, rats and simian

models of retroviral infections; 38-46 and (3) reports of reversal of renal

histologic and laboratory abnormalities in a small set of patients with biopsy

proven HIV-associated nephropathy after highly active antiretroviral

therapy.47-63

Several studies have shown marked racial predilection of

HIVAN for blacks and Hispanic, 2, 3, 18 but recent analysis of

data from the United States Renal Data Systems (USRDS)

revealed that HIVAN is more strongly associated with black

race than any other cause of renal failure with the exception of

sickle cell disease.16, 47, 48 The marked racial disparity in HIVAN

suggests that genetic factors are important determinants of

HIVAN pathogenesis. Nearly 25% of patients with HIVAN have

first degree or second degree family members with ESRD, and

black patients with HIVAN are 5.4 times more likely to have a

xxviii

first degree or second – degree relative with ESRD than are

black patients without renal disease. 46 The Duffy antigen /

receptor Chemokine (DARC) has been proposed as a candidate

gene involved in HIVAN pathogenesis. The DARC promoter has

a high prevalence of polymorphism in black patients, and Liu

et al.45 has demonstrated increased DARC expression in renal

specimens from children with HIVAN and haemolytic uraemic

syndrome.

Until recently, it was unknown whether HIV-1 infection of

renal parenchymal cells caused HIVAN directly or whether

HIVAN was an indirect response to HIV-induced immune

dysregulation.48, 49 The primary reason for this uncertainty

was due to some published studies demonstrating the

presence of HIV in the HIVAN specimen while other studies did

not show this. However, the weight of evidence is in support of

direct infection of the kidney tissue by Human

immunodeficiency virus (HIV).8-11

In 1989, Cohen et al.49 reported detection of HIV-1 in

renal epithelial cells by DNA in- situ hybridization. Other

investigators reported also detecting HIV-1 by PCR in tubules

xxix

microdisected from HIVAN biopsies specimens50. And in

contrast to this, other groups did not find HIV-1 in renal

parenchymal cells in HIVAN biopsy specimens51-53. Studies

using HIV-1 transgenic mice model of HIVAN have provided

important insight into HIVAN pathogenesis. Mice transgenic

for a replication defective HIV-1 reconstruct lacking the gag

and pol genes, expressed under control of the viral promoter

(long terminal repeat or LTR), developed proteinuria, renal

failure, and histologic renal disease identical to HIVAN.54

Bruggeman et al.53 later demonstrated that HIV-1 transgene is

expressed in renal glomerular and tubular epithelial cells and

that transgene expression in renal epithelial cells was required

for the development of the HIVAN phenotype. Further support

for the role of direct infection of renal parenchymal cells in

HIVAN pathogenesis was provided by a Macaque model of HIV-

induced renal disease56-57 Stephens et al.58 reported that,

passage of chimeric simian-human immunodeficiency virus

(SHIV) containing sequence from HIV-1 and simian

immunodeficiency virus (SIV) was capable of causing severe

glomerulosclerosis and tubular disease. Infection with

xxx

different strains of SHIV resulted in varying severity of renal

disease, suggesting differences in viral strains mediated renal

pathogenesis58.

Accumulating data from animal models of HIVAN led to

renewed attempts to determine definitively whether HIVAN

results from direct infection of renal tissue by HIV-1.The

answer to this was provided by Bruggeman and his colleagues

in 2000; when they reported the detection of HIV-1 Virus in 11

of 15 HIVAN patients in renal epithelial cells by RNA in-situ

hybridization59. The pattern of HIV-1 infection of renal

tubules is focal and may involve epithelial cells from multiple

nephron segments, including proximal tubule, thick ascending

loop of Henle and collecting duct.59 The distribution of HIV-1

infection of renal tubule is similar to the pattern of microcystic

tubular disease in HIVAN.60

The mechanism by which HIV-1 gains entry into renal

epithelial cells is unknown. CD4, the receptor for HIV-1, and

CCR5 and CXCR4, the major co-receptors for HIV-1 are not

expressed in most normal renal epithelial cells.61However,

Some authors have in-vitro demonstrated CD4 and other

xxxi

major co-receptors in cultured epithelial cells, these findings

have not been reported in in-vivo studies .35, 60-63 Several other

co-receptors (CXCR6/Bonzo and CCR8) for HIV-1 have been

recently identified, but whether they are expressed in renal

epithelial cells remains to be determined64.

PATHOLOGY OF HIVAN

The constellation of collapsing focal glomerulosclerosis

combined with extensive tubular microcystic disease was

previously thought to be relatively specific to HIVAN, but

Markowitz et al.65 recently reported a series of seven white

HIV-negative patients who developed renal failure, proteinuria

and histopathologic disease identical to HIVAN after treatment

with high dose pamidronate for metastatic breast cancer.

One of the pathologic hallmarks of HIVAN is focal

glomerulosclerosis, often of the collapsing type.3, 7, 11, 12 These

collapsing lesions are associated with vigorous podocyte

proliferation and loss of podocyte differentiation markers,

including synaptopodin, podocalyxin and WT –166. These

podocytes abnormalities have been demonstrated in HIV-1

transgenic mouse model of HIVAN.66 In vitro studies have

xxxii

demonstrated that podocytes derived from HIV-1 transgenic

mice demonstrate a lack of contact inhibition and increased

anchorage- independent growth in culture.66-67Hanna et al. in

their study demonstrated the key role nef gene plays in the

pathogenetic mechanism of renal disease in HIV patients.

They generated several transgenic lines with mutations in one

or more HIV genes and found that expression of nef was

necessary and sufficient to produce their renal

phenotype.71Nef was also shown to be capable of building to

Hck as well as several other Src families of tyrosine kinases in

vitro72 To determine whether Hck was important in modulating

the renal disease in the nef transgenic mice, Collette et al72

cross bred the transgenic mice with Hck knocked out mice and

found that the development of renal disease was delayed;

suggesting Hck may play a role in the pathogenesis of HIV-

related renal disease.72, 73Conversely, inhibition of HIV-1 viral

transcription using synthetic cyclin-dependent kinase-9

(CDK9) inhibitors to inhibit Tat trans – activation of LTR

inhibits podocyte proliferation and cause re-expression of

podocyte differentiation markers in vitro69

xxxiii

TREATMENT OF HIVAN

HIGHLY ACTIVE ANTIRETROVIRAL THERAPY (HAART)

After the introduction of HAART in the USA, however

there was an abrupt drop in the incidence of HIVAN

progressing to ESRD.11,13 It is likely that, this change reflects

the efficacy of HAART in either preventing HIVAN or slowing

progression to end-stage renal failure in patients with HIVAN

6,9, 11,13. Several studies have evaluated the use of antiretroviral

medications for the treatment of HIVAN74 75Ifudu et al76

studied 23 HIV-1 patients, 14 of whom had at least 2+

proteinuria who were offered treatment with zidovudine. They

found remarkable difference in outcome between those who

were compliant with the drug (Zidovudine) and those who were

non-compliant. None of the 15 patients who were compliant

had deterioration of renal function after a mean follow-up of

20.4months as against 8 patients who were not compliant

with zidovudine treatment who all progressed to ESRD after

mean of 8 weeks. In another study demonstrating the

usefulness of antiretroviral drug, Szezech et al.77evaluated the

xxxiv

association of HIV-1 protease inhibitors usage with change in

creatinine clearance in 19 patients with HIV and renal disease.

They found using multivariate analysis a significant

association between protease inhibitor usage and reduced

progression of renal disease as evidenced by marked reduction

in the rate of decline of GFR. And again Winston et al.17 and

Kirchner78 in their case reports demonstrated clinical

improvement in patients who were on haemodialysis due to

HIVAN and also on HAART showed clinical improvement in

renal function necessitating discontinuation of haemodialysis

treatment. The clinical import of these studies in

demonstrating the salutary effects of ART particularly HAART.

However these drugs could also induce kidney damage.

ANGIOTENSIN CONVERTING ENZYMES INHIBITORS (ACEIS)

Kimmel et al.79reported an increase in renal survival

associated with Captopril usage in a retrospective case-control

study of 18 patients with biopsy proven HIVAN. Also Wei et

al.80rospectively evaluated 40 patients with HIVAN and mild

renal insufficiency. All patients were offered 10mg/day

xxxv

Fosinopril and they were follow-up for 1890days (5.1yrs).They

found a median renal survival of 479.5days in the treated

group with only one developing ESRD and all untreated

controls progressed to ESRD, with mean renal survival of

146.5days. These findings support the argument for ACEI as

an important drug in the armamentarium of drugs in the

management of CKD whether due to HIVAN or other causes.

CORTICOSTEROIDS

Prednisolone has been found in several studies to be

associated with reduced risk of progressive renal failure in

patients with HIVAN. Smith et al.81reported an observational

study of 20 patients with HIVAN who had advanced renal

disease with heavy proteinuria and were treated with

Prednisolone.Most of the patients had advanced renal failure

and heavy proteinuria at the time of diagnosis. They found

that 17 of the patients experienced a decrease in serum

creatinine and/or proteinuria after treatment with

prednisolone. However several of the patients relapsed,

requiring repeated courses of Prednisolone. The study also

xxxvi

reported that 11 patients died during the period, and 6

developed serious infectious complication while on

prednisolone and 17 patients were still free of dialysis at a

mean of 25weeks of follow-up81 Another study82 a case control,

evaluated the outcome of 21 patients with HIVAN and

advanced renal failure, 13 of who were treated with

Prednisolone. The odds ratio for progression to ESRD in

Prednisolone treated patients was 0.2; supporting the

usefulness of prednisolone in the management of HIVAN.The

argument for the use of prednisolone in HIVAN are derived

from these case reports and one should be aware of limitations

of case reports in adopting the finding universally. DIALYSIS

Although limited studies found a low survival rate in

haemodialysed HIV-infected patients, recent studies

segregating the patients by the stage of HIV infection have

found better results. 6,11-15 A study from New York found a 1

yr survival rate of 16% for dialysis patients with AIDS versus a

77% survival rate for HIV patients without AIDS. 6,83Likewise,

another New York study found that of 160 HIV-patients

xxxvii

haemodialysed over 8 yrs period, 115 had HIV nephropathy,

whereas 45 had other causes of ESRD. 84

The initially dismal results observed in maintenance HD

in AIDS patients, along with an increasing concern for

transmission of HIV infection to staff during HD procedures,

prompted many to suggest that CAPD may be a better

alternative.14 Theoretically, there is less exposure of staff to

HIV with PD than with HD because peritoneal fluid is much

less infectious than blood; there is likelihood of needle sticks,

and the nature of staff to patient contact is different. Also

glucose load from PD fluid may provide additional obligatory

calories for patients with AIDS, helping to prevent the

inanition and failure to thrive so commonly observed in

maintenance HD.14 Peritoneal dialysis had been used in HIV-

infected patients with mixed results. 85In general, HIV infected

patients have a shorter survival than non HIV-infected

patients, also rate of peritonitis have been found to be higher

than in control populations. 85However, Kimmel et al.85 in their

series observed survival rates of 14.7±8.5 months in 23 HIV

patients treated by maintenance HD were similar to the

xxxviii

17.9±10.3 months observed in 8 others receiving CAPD.

Another retrospective analysis of 39 HIV patients treated by

CAPD revealed 1 and 2 years survival rates of 58% and 54%

respectively.86On the other hand, Schoenfeld et al.87reported a

mean survival of 33 months in their CAPD patients compared

to 12 months in those on maintenance HD. Recent advances

in the management of HIV infected patients, however, have

improved the prognosis of HIV patients on HD. Ahuja et al.88

reviewed the USRDS data on 6166 HIV-infected patients on

HD from 1990 to 1999 and found that, the 1 year survival

increased from 56 to 74%.

From these available data, both maintenance HD and

CAPD are effective modalities of RRT in HIV patients with

ESRD. The choice of therapy should depend on individual

patient’s lifestyle, preference, and availability of family and

other support, and not based on HIV seroposivity.

TRANSPLANTATION

Generally the information on transplantation in HIV

patients can be divided into pre-HAART (before1996) and post-

xxxix

HAART (after1996). The Pre-HAART transplant experience is

mostly retrospective with little or no information regarding

pre-transplant severity of disease, CD4 counts or viral load.89

In these cases HIV infected patients were transplanted

inadvertently, or HIV was acquired either peri or post-

transplant. The few patients with unrecognised HIV infection

who received a transplant had variable courses often

characterised by rapid progression of HIV infection. In 1989,

the earliest data regarding organ transplantation in HIV

infected patients was published in 1043 transplant recipients.

About 1.3% of patients were found to be seropositive. Fifty

percent of the seropositive patients died 6 months following

transplantation.90 Also; Erice et al.91 reported five cases of

solid organ transplants in HIV infected patients and reviewed

the literature on 11 kidney transplant recipients. Seventy five

percent of the kidney transplant recipients had normal graft

function at a mean follow up of 30.7 months. Twenty seven

percent of the patients had developed AIDS at a mean of 13

months post-transplantation. However, Myosore et

al.92transplanted 40 HIV patients on dialysis between 2001

xl

and 2004.All the patients were on HAART, with plasma HIV-1

RNA of less than 400copies/ml and absolute CD4 counts of

200cells/uml or more. The one year and 2years patient

survival post transplant was 85% & 82% respectively and graft

survival was 75% and 71% respectively.

CHAPTER THREE

PATIENTS AND METHODS

This cross-sectional descriptive study was carried out, at

Ahmadu Bello University Teaching Hospital, Zaria. The study

methodology and plan for data analysis is classified into three

major subheadings.

xli

(I) STUDY SUBJECTS

For the purpose of this study, four hundred HIV positive

(I & II) confirmed by Double Elisa were screened for the

presence of proteinuria (1+ve) on at least two occasions using

dipstick and/or decreased GFR by estimation equation using

Cockroft and Gault formula.93,94 Thirty (30) of those who

have decreased GFR (<90-15ml/min) or significant proteinuria

with no contraindication to biopsy and who consented had

renal biopsy on them to determine the histopathological

pattern.

This group was then compared with another 30 HIV-

patients without proteinuria or decreased GFR, age, sex

matched to determine the factors associated with the

development of renal involvement.

Sample size

(i) The sample size (N) was determined using the formula:-

N = Z x P (I – P)

xlii

22 d2

Where:

Z = (1.96)2

22

N = Minimum sample size

Z = Normal standard deviation (which corresponds to the

desired confidence level of the study for 95% confidence

interval, Z = 1.96%)

P = Prevalence rate of disease (25%) 25

d = Tolerable sampling error which is usually set at

0.05

= (1.96)2 x 0.25 x 0.75 = 288

0.0025

(ii) Inclusion criteria: - To qualify for inclusion into the

study:

xliii

(a) HIV – seropositivity (confirmed by Double Elisa)

(b) Dipstick proteinuria of at least +1 on early morning

urine sample on two occasions

(c) Serum creatinine > 176mol/L (2mg/dL)

(d) Absence of Hypertension or Diabetes mellitus prior to

the diagnosis of HIV infection.

(iii) Exclusion criteria: The following patients were excluded

from the study

(a) Pregnant patients

(b) Congestive heart failure, hypertension or Diabetes

mellitus

(c) Urinary tract infection

(d) Presence of fever (temp.≥37.40c)

(iv) Ethical Approval – This was obtained from Ethics and

Research Committee of the Ahmadu Bello University

Teaching Hospital Zaria. And all patients signed an

informed consent form before being recruited into the

study.

(v) Inclusion criteria for controls

xliv

(a) HIV positive serology test

(b) Absence of dipstick proteinuria on early morning urine.

(c) Serum creatinine less than 176umol/l(2mg)

(d) Those that have consented to participate in the study.

(e) No historical evidence of features suggestive of chronic

renal disease such as frothy urine, body swelling etc.

(vi) Exclusion criteria for controls

(a) Patients who are pregnant

(b) The presence of congestive cardiac failure

(c) The presence of urinary tract infection

(d) Presence of fever (temp. ≥37.40c)

(e) A known Diabetic or Hypertensive

(f) Lack of written consent.

II STUDY METHODOLOGY

A questionnaire was administered to all the participants

(subjects and controls). This contained the biodata of the

study subjects. Laboratory results, family history of renal

disease, diabetes mellitus, hypertension and drug history.

xlv

All patients were physically examined. The weight (kg)

was recorded to the nearest 0.5kg using Hanson’s standard

bathroom (standing) weighing scale with subjects wearing light

clothing. Height (meters) was measured against a calibrated

vertical wall with shoes removed. The body mass index (BMI)

was calculated using the formula: BMI = Wt (kg)/Ht2 (m2).

Malnutrition is defined as a BMI of less than 18.5kg/m2.

Blood pressures were taken in both the sitting and erect

positions on the dominant arm of the patient using Accoson’s

mercury sphygmomanometer, manufactured by A.C. Cossor

and Sons Ltd, Accoson works, London, with an appropriate

standard cuff of 12-13cm by 55cm size. The following

investigations were performed on all the study subjects. Viz:

Full blood count, platelet count, prothrombin time, serum

electrolytes, creatinine, uric acid, fasting blood sugar, 2 hrs

postprandial, urine macro and microanalysis,

HIV seropositivity was determined by Double Enzyme

Linked Immunosorbent Assay (ELISA) test. Determine HIV-1

and 2 kits, Abbot Laboratories, USA; and Immunocomb HIV-1

and 2 kits, Organics, Israel were used. Hepatitis B surface

xlvi

antigen, antibody to Hepatitis C-RNA, and CD4 cells count.

The CD4+ lymphocytes count was carried out by the staff of

the hospital at the Haematology Department using commercial

kits (DynalR T4 Quarant Kit –Dynal Biotech ASA, Oslo

Norway).The following steps were followed:

(i) Sample preparation-The K2EDTA blood sample

was incubated for 5minutes at room

temperature with gentle tilt and rotation using

mechanical rotator.

(ii) Monocytes depletion-To <1ml test tube the

following was added: 350uL washing/diluents

buffer, 125uL whole blood and 25uL of re-

suspended Dynabeads M-450 CD14 (specific

for monocytes). The tube was carefully capped

and mixed and then incubated with gentle

tilting and rotation as above for 10minutes at

room temperature.

(iii) CD4 lymphocytes isolation -200uL of

monocytes depleted blood was transferred to a

micro-centrifuge tube and then 200uL

xlvii

washing/dilution buffer was added. Re-

suspended Dynabeads were added again, the

tube capped and carefully mixed. The CD4+

cells were isolated attached to the walls of the

tube by Dynal MPC-S.

(iv) Cells washing-: The isolated CD4+ cells were

then washed by removing the magnetic slides

from the Dynal MPC-S and then added 500uL

of washing/dilution buffer to the tube. The

washing procedure was carried out twice.

(v) CD4+ counting (manual method)-: 50uL of

lysis solution was added and left for 5minutes.

The counting was done in a counting

chamber. The numbers of cells in one

counting area of 1mm by 1mm with a depth of

0.1mm were counted. The volume of one

counting area is equal to 0.1mm3.The

concentration of CD4+ cells in the sample is

equal to half that in the whole blood. The

number of cells counted was converted to the

xlviii

concentration of CD4+ cells in the whole blood

with the formula below:

Cells/uL =n×2/v

N=no. of cells counted

V=volume counted in uL

Abdominal ultrasound was carried out in all the subjects

to determine the kidney size, echogenicity, cortical and

medullary thickness and cortico-medullary differentiation and

other markers of kidney disease. Urinary protein excretion was

obtained using spot urine protein to creatinine ratio (ACR).93

ACR of <30mg/gm was considered normal, 30-300mg/gm was

considered as micro- albuminuria, 300-500mg/gm as

macroalbuminuria, ACR of >500mg/gm as nephrotic

protienuria.95

Glomerular Filtration Rate (GFR) was calculated using

prediction equation devised by Gault & Cockcroft, 93 which

also validated in Nigerians by Sanusi et al. 94

xlix

GFR = [140 – Age (yrs) x Wt (kg)

0.810 x serum creatinine (mol/l)

= (140 – Age (yrs) x Wt (kg) x 0.85 if female

72 x serum creatinine (mg/dl)

All patients with proteinuria on dipstick and those with

abnormal estimated GFR had their total urine protein

estimated by using spot urine protein/creatinine ratio to

ascertain the degree of proteinuria. They also had renal biopsy

done, in order to characterize the pattern of the renal

involvement.

RENAL BIOPSY

Before the biopsy, all patients were counselled on the

procedure and had signed the consent forms. Full blood

counts, platelets, clotting profiles of each patient were checked

to rule out, bleeding tendencies.

x 0.85 if female

l

Renal scan was done on all the patients to ascertain the

kidney size and also for renal mapping to locate the lower pole

of the kidney and also to estimate the depth.

Patient was placed on prone position upon a firmly rolled

pillow to compress the upper abdomen and lower ribs thereby

fixing the kidneys. IV Normal saline was set and Pre-biopsy

vital signs were taken.

After scrubbing and draping the patient, 6mls of 2%

plain xylocaine was used to infiltrate the area, already

mapped.

Automated spring loaded tissue biopsy needle size 16-

gauge (Monopty brand) was used to obtain the kidney tissue

percutaneously after instructing the patients to hold his

breath in full inspiration.

Post-biopsy vital signs were taken and patient was

confined in prone position for at least 30 minutes, to secure

good pressure haemostasis. Patients were then admitted for 24

hrs observation. Intermittent vital signs check-up were done,

and all the 24hrs urine was collected for inspection for

li

possible haematuria. All the patients had uneventful biopsies.

Only one complained of persistent back pain for a week after

the procedure. Repeat Renal scan did not yield any

abnormality. The pain was controlled using analgesics. All

patients were advised not to partake in any strenuous activity

for the next four weeks.

Biopsy tissue obtained was immediately fixed using

buffered formalin solution. Subsequently the biopsy specimens

were processed at the histopathology laboratory of Morbid

Anatomy of OAUTHC. The staining was done by the laboratory

technical staff using Haematoxylin and Eosin, Methenamine

and periodic acid Schiff (PAS) stains and histopathological

examination was conducted by the consultant histopathologist

with the investigator in attendance.

IV. STATISTICAL ANALYSIS

All the data obtained was analysed using the statistical

package for social science (SPSS) for windows software version

lii

11.5. All values were expressed as means standard deviation

and qualitative data as percentage. Student’s t-test, Chi-

square, and Fisher’s exact tests were used to asses the

difference between the various groups as appropriate.

Pearson’s test of correlation was used to check for the

association between HIVAN and some clinical variables.P-

value of 0.05 or less was taken as statistically significant and

confidence intervals reported were at 95% intervals.

STUDY DESIGN

400 HIV PATIENTS

liii

CHAPTER FOUR

127 patients

with proteinuria

273 patients

without

proteinuria

15 patients with

4+ proteinuria

26 patients with

3+ proteinuria

34 patients with

2+ proteinuria

52 patients with

1+ proteinuria

75 patients with proteinuria

2+ and above

30 consecutive age,

sex, matched

(controls)

30 consecutive

10 - biopsied

liv

RESULTS

EPIDEMIOLOGY

Four hundred HIV-positive patients that fulfilled the

inclusion criteria were screened for proteinuria or decreased

GFR. The age ranged from 20 to 70 years with a mean of

37.5±10.3 years. The 40-49 years age group accounted for the

highest percentage of patients in the study subjects with 156

(39%).This was followed by those aged 30-39 years with 148

(37%), 20-29 years 62 (15.5%),50-59 years 29(7.3%) and 60

years and above 5 (1.3%).There were 234 (58.5%) males and

166(441.5) females. Fifty one (12.8%) were widowed, 215

(53.8%) were married, 106 (26.5%) were single and 28 (7.1%)

were divorced. Fifty six (14%) had no formal education, 201

(50.3%) had primary education, 132 (33%) had secondary

education, while 11 (2.8%) had post secondary education. All

the subjects studied were heterosexuals and none had the

history of intravenous drug abuse (IVDU), or use of non-

steroidal anti-inflammatory drugs (NSAIDS). A total of 332

(83%) of the studied subjects were on antiretroviral drugs

(ARVS), with a mean duration of 19.3±18.1 months. All these

lv

patients were on triple therapy comprising of Lamivudine,

Stavudine and Nevirapine.

The prevalence of renal disease as defined by presence of

proteinuria of 2+ and above or raised serum creatinine of

175μmol/l and above was 127 (31.8%) of 400 HIV patients

studied. Fifty two (40.9%) had 1+ proteinuria, 34 (26.8%) had

2+ proteinuria, 26 (20.5%) had 3+ proteinuria, while 15

(11.8%) had4+ proteinuria. The mean age of these patients

was 37.5±10.3 years, with a range of 20 to 70 years. The

prevalence of renal disease was higher in the 40-49 years age

group accounting for 52 (40.9%), then followed by the 30-39

years age group 38 (30.9%), then 20-29 years age group 29

(22.8%), 50-59 years group and 60 years and above accounted

for 4 (3.3%) respectively. There were 72 (56.7%) males and 55

(43.3%) females. Fifty one (40.2%) were married, 36 (28.3%)

were widowed, 26 (20.5%) were single, while 14 (11.0%) were

divorced. Thirty one (24.4%) had no formal education, 54

(42.5%) had primary education, 35 (27.6%) had secondary

education, 7 (5.5%) had post-secondary education. A total of

103 (81.1%) of 127 patients with renal disease were on

HAART. None of the patients with renal disease was on non-

lvi

steroidal anti-inflammatory drugs (NSAIDS) or angiotensin

converting enzymes (ACE) inhibitors.

CLINICAL FEATURES OF PATIENTS WITH RENAL DISEASE

SYMPTOMS

The commonest symptoms seen in the study subjects

were nocturia 43 (33.8%), low Urine output 43 (33.8%),

frothiness of urine 38 (30%), pruritus 29 (22.8%), vomiting 17

(13.4%), leg swelling 17 (13.4%), and facial swelling is seen

only among 13 (10.2%) of the patients. The frequencies of

other symptoms are shown on table (1) below.

lvii

Table (1): Showing symptoms and history of patients with

renal disease

SYMPTOMS NUMBER/PERCENTAGE

Facial swelling 13 (10.2)

Leg swelling 17 (13.4)

Abdominal swelling 1 (0.8)

Frothiness of urine 38 (30)

Nocturia 43 (33.8)

Hiccups 13 (10.2)

lviii

Pruritus 29 (22.8)

Vomiting 17 (13.4)

Low urine output 43 (33.8)

High urine output 13 (10.2)

History of ARVS 332 (83.0)

History of body swelling 2 (1.6)

Family history hypertension 13 (10.2)

History of hypertension 13 (10.2%)

Family history of Diabetes 13 (10.2%)

SIGNS

The most predominant signs noted in these patients,

were weight loss 80 (63.0%), pallor 43 (33.8%), hepatomegaly

1 (0.8%), abdominal swelling and ascites 1 (0.8%) respectively.

Pedal oedema, periorbital oedema, and abdominal tenderness

accounted for 1 (0.8) each. Tachycardia was seen in 17

lix

(13.4%) of the patients. Systolic hypertension was seen in 17

(13.4%), while diastolic hypertension accounted for 13 (10.2%)

of the patients. The mean BMI was 22.9±3.8kg/m2, with a

range of 16.0 to 33.0 kg/m2. Thirteen (10.2%) of the patients

had a BMI of less than 18.5kg/m2, while 9 (7.1%) had a BMI of

more than 29.9kg/m2.

Table (2): Showing clinical signs of patients with renal disease

lx

SIGNS NUMBER/PERCENTAGE

Wasting 80 (63.0)

Pallor 43(33.8)

Periorbital oedema 4 (3.1)

Pedal oedema 4 (3.1)

Abdominal swelling 1 (0.8))

Abdominal tenderness 1 (0.8)

Ascites 1 (0.8)

Hepatomegaly 1 (0.8)

Tachycardia 17 (13.4)

Systolic hypertension 17 (13.4)

Diastolic hypertension 13(10.2)

lxi

LABORATORY FINDINGS

HAEMATOLOGIC PARAMETERS

Packed cell volume (PCV)

Their PCV ranged from 27.9 to 47.9% with a mean of

33.9±6.7%. Thirty four (26.8%) had PCV less than 30%, 34

(26.8%) had PCV of 30-35.9%. Fifty nine (46.5%) had PCV of

36-47.9%.

White blood cells

The mean total white blood cells count was 5492.30±2610.12

cells/mm3 with a range of 2100 to 10900 cells/mm3. The

mean Neutrophils count was 52.16±15.29% with a range of

20.20 to 80.00%, while mean Lymphocytes count was

37.75±11.52% with a range of 19.80 to 60.60%.

CD4 cells count

lxii

The CD4 cells count ranged from 100 to 464cells/μL with a

mean of 219.57±89.22cells/μL. Fifty nine (46.5%) had CD4

cells count in the range of 100 to 200cells/μL.

BIOCHEMICAL PROFILES

Serum electrolytes, creatinine and urea

The mean serum creatinine was 113.77±72.89μmol/l with a

range of 79.0 to 436.0μmol/l and the mean creatinine

clearance was 68.77±21.22mls/min and ranged from 15.20 to

100.00mls/min. Thirty eight (30%) had creatinine clearance of

60.00mls/min and below. Table (3) shows the staging and

estimates of chronic Kidney disease among the subjects.

lxiii

Table (3): Staging and estimates of CKD among the subjects

Stage Description GFR(mls/min) Number/Percentage

1 Kidney

damage with

≥90 22 (17.3)

lxiv

normal or

increased

GFR

2 Kidney

damage with

mild decrease

in GFR

60-89 67 (52.8)

3 Moderate

decrease in

GFR

30-59 34 (26.8)

4 Severe

decrease in

GFR

15-29 4 (3.1)

5 Kidney

failure(ESRD)

≤15 0

The mean spot urine albumin to creatinine ratio (ACR)

was 427.67±267.66mg/g, with a range of 29.00 to 1280mg/g.

Forty seven (37.0%) of these patients had nephrotic range

lxv

proteinuria (ACR of >500mg/g), 42(33.1%) had

microalbuminuria (ACR of 30-300mg/g), 34(26.8%) had

macroalbuminuria (ACR of 301-500mg/g), and 4(3.2%) had

normal ACR (<30mg/g). The mean serum sodium was

139.30±3.17mmol/l, with values ranging from 132.00 to

147.00mmol/l, while mean serum potassium was

3.81±0.47mmol/l with a range of 3.10 to4.90mmol/l.

Hypokalaemia (serum potassium of <3.5mmol/l) was observed

in 17 (13.4%) of the patients in this study, while no case of

hyperkalaemia (serum potassium of >6.0mmol/l) was noted.

However, hyponatraemia (serum sodium of <135mmol/l) was

seen in 8 (6.3%) of the patients, while hypernatraemia (serum

sodium of >145mmol/l) was observed in only 4 (3.2%) patient.

lxvi

Serum lipids and proteins

The mean total serum cholesterol in the study subjects

was 5.20±1.73mmol/l with a range of 2.5 to 9.60mmol/l.

Eighteen (14.2%) had Hyperlipidaemia (serum cholesterol

>6.5mmol/l).

Total serum proteins had a mean of 69.97±7.90g/l with a

range of 58.00 to 86.00g/l, mean serum globulin was

37.31±8.57g/l with a range of 23.00 to 67.00g/l, while serum

albumin had a mean of 32.66±4.98g/l with values ranging

from 17.00 to 42.00g/l. Seventy four (58.3%) of the patients

had hypoalbuminaemia with a serum albumin below 35g/l.

Kidney disease correlated negatively with SBP

[Pearson’s correlation-0.677, p-value 0.032]. There was no

correlation between Kidney disease and CD4 cells count

[Pearson’s correlation 0.081, P=0.823], and Creatinine

clearance [Pearson’s correlation= -0.319, P=0.369].

On the other hand there was a positive correlation between

Systolic Blood Pressure (SBP) and duration of ARVs usage

[Pearson’s correlation=0.318, P=0.032].

lxvii

Table (4); Correlation of Kidney disease with other variables

Variables Pearson’s

correlation

coefficient

P-Value

SBP -0.677 0.032

CD4 cells count 0.081 0.823

Creatinine

Clearance

0.319 0.369

lxviii

CASE CONTROL STUDY

A comparison of 30 consecutive HIV-positive patients

with definite (i.e 2+ proteinuria or more) nephropathy and

another 30 without nephropathy to serve as control, age and

sex matched was carried out. Both subjects and controls were

on ARVs. There were no significant differences between the

ages and sex of both groups (P =0.603) as shown on table

(5).There were however, significant differences in their

creatinine clearance, duration of ARVs usage, CD4 cells count,

urea, serum albumin and globulin levels, while there was no

significant differences in their BMI, educational status, marital

status, blood pressures, serum cholesterol levels, PCV and

total serum proteins. See tables (5-10).

lxix

Table (5): Comparision of demography of subjects and control

Variables Patients Control P-Value

No. of patients 30 30

Males 13 12

Females 17 18

Age range 20-70yrs 23-53yrs

Mean age 37.65±10.29 36.40±8.40 0.603

lxx

Table (6): Comparision of marital status

lxxi

Marital status Patients Control

Single 6 4

Married 11 17

Divorced 1 1

Widowed 12 8

Total 30 30

X2=0.478

lxxii

Table (7): Comparison of educational status

Educational status Patients Controls

None 2 4

Primary 5 4

Secondary 8 16

Post-secondary 15 6

Total 30 30

X2=0.063

lxxiii

Table (8): comparison of creatinine clearance

Creatinine clearance Patients Controls

<60mls/min 9 0

>60mls/min 21 30

Total 30 30

Fisher’s exact test=0.007)

lxxiv

Table (9): Comparision of CD4 cells count

Cd4 count patients Controls P-Value

Mean 219.57±89.22 318.63±216.09 0.024

<200cells/μL 14 11

lxxv

>200cells/μL 16 19

Total 30 30

Fisher’s exact test=0.300

lxxvi

Table (10): Comparision of clinical features

Variables Patients Control P-Value

SBP (mmHg) 124.90±19.80 122.93±15.50 0.670

DBP(mmHg) 75.27±18.25 80.27±9.09 0.186

BMI(Kg/m2) 22.93±3.85 24.55±3.86 0.111

lxxvii

Tables 11 and 12 showed a comparison of laboratory profiles.

The patients had significantly higher urea level and globulin

levels than the controls, while the controls exhibited higher

albumin level than the subjects. There was no significant

difference between their serum levels of sodium, potassium

and cholesterol.

lxxviii

Table (11): Comparision of biochemical profiles

Variables Patients Controls P-Value

Serum Creatinine 113.77±72.89 91.23±14.29 0.102

(μmol/l)

Serum Urea(mmol/l) 6.02±4.05 4.34±1.51 0.038

Serum Sodium(mmol/l) 134.89±24.99 138.43±4.67 0.448

Serum Potassium(mmol/l) 3.77±0.56 3.99±0.34 0.081

lxxix

Cholesterol (mmol/l) 5.20±1.73 4.66±0.47 0.113

Total Protein(g/l) 67.90±15.00 70.00±10.91 0.554

Serum Albumin(g/l) 32.66±4.98 38.74±7.45 0.001

Serum Globulin(g/l) 37.31±8.57 31.63±7.62 0.012

Table (12): Comparision of Haematological profiles

Variables Patients Controls P-Value

lxxx

PCV(%) 33.95±6.67 31.99±6.63 0.263

WBC(cells/mm3) 5.49±2.61 5.60±1.76 0.865

CD4 cells(cells/μL) 219.57±89.22 318.63±216.09 0.024

lxxxi

Both the subjects and controls showed no significant

difference in their HBSAg and HIV-2 status, however there was

some tendency towards significance as shown by their Fisher’s

exact tests of 0.073 and 0.056 respectively. See tables 13 and

14.

lxxxii

Table (13): Comparision of HBSAg Status

Variables Patients Controls

HBSAg

Negative 23 28

Positive 7 2

Total 30 30

Fisher’s exact test=0.073

lxxxiii

Table (14): Comparision of HIV-2 status

Variables Patients Controls

HIV-2

Positive 4 0

Negative 26 30

Total 30 30

lxxxiv

Fisher’s exact test=0.056

PATHOLOGY

lxxxv

Renal biopsy was done on ten of the subjects who

consented. Six (60.0%) of the 10 patients had Focal Segmental

Glomerulosclerosis (FSGS), While 3 (30.0%) had normal

histology on light microscopy, suggesting Minimal Change

Disease (MCD), and 1 (10%) had tubulo-interstitial nephritis.

Five (50%) of the HIVAN had nephrotic range proteinuria while

2 (20%) of those with MCD had nephrotic range proteinuria.

The details of the pathologic features are shown on tables 15-

17.

lxxxvi

Table (15): Comparison between ACR and Histologic types

ACR(mg/g)

HISTOLOGY

INTRSTITIAL

NEPHRITIS MCD FSGS

30 and below 0 0 0

31-300 1 0 0

301-500 0 1 0

501 and above 2 5 1

Total 3 6 1

lxxxvii

X2=0.537

Table (16): Shows the pathologic features found on the renal

biopsies

Type of lesion No. of patients Percentage

Glomerular capillary 6 60.0%

Thickening

Focal segmental glomerular sclerosis 6 60.0%

Mesangial expansion 6 60.0%

Microcystic dilatation 6 60.0%

Tubular casts 6 60.0%

Mononuclear cells infiltration 2 20.0%

Interstitial fibrosis 3 30.0%

lxxxviii

Table (17): Pathologic diagnosis of the 10 biopsies

Pathologic diagnosis No. of patients Percentage

FSGS 6 60.0%

Probable MCD 3 30.0%

Interstitial Nephritis 1 10%

lxxxix

CHAPTER FIVE

DISCUSSION

Sub-saharan Africa with less than 1/4 of the world’s

population carries about 70-80% of the burden of HIV-

infection; and currently there are about 28.2 million people

living with the infection in the sub-region1. Patients with HIV-

infection are at risk of developing renal diseases with diverse

aetiologies; and renal disease constitutes significant morbidity

and mortality in these patients2-11.HIVAN appears to be the

xc

most common manifestation of renal disease in HIV-

seropositive black patients and invariably progress to end-

stage renal disease12,15.

The prevalence rate of renal disease in this study was

found to be 31.8%. This was higher than the figures of 3-10%

reported in the studies conducted in the developed countries

2,5-7.This disparity might have arisen because, this study,

unlike the previous studies was conducted exclusively in black

subjects. A race with special predilection to developing HIVAN

and other renal diseases 6-10. On the other hand, the

prevalence rate in this study was lower than the prevalence

quoted by Han et al22from South-Africa, Agaba et al 32 in Jos

and Pedro34 from Ife. They found a prevalence of 83%, 51.8%,

and 38% respectively. The low prevalence in this study

compared with other African studies could be explained by the

small sample size of this study. However, the findings of this

study might not be the true reflection of prevalence of HIVAN

in this setting, because of low biopsy rate (7.9%).

The mean age of patients with renal disease was found to

be 37.7 years in this study. This is quite similar to that found

by other authors6,12,22,23,96. The prevalence of renal disease in

this study was highest among the age-range of 30-49 years

xci

(70.9%).This implies that renal disease is most prevalent

among the most productive age-group segment of the society.

In accord with reports by Rao et al5and Gerntholtz et al23

the prevalence of renal disease is higher among men (56.7%)

in this study. This can be explained by the fact that, the

burden of HIV-infection is more in men than in females in this

environment; and men tend to progress to AIDS faster than

females 46,97,98. All patients involved in this study were blacks,

heterosexuals with no history of intravenous drug usage

(IVDU), contrary to what was obtained in the USA and Europe

5,7,14,20. This has shown that homosexuality and IVDU are not

commonly practiced in this society.

In this study, over 40% of patients with renal disease had

low level of education (primary), and this is quite not

unexpected as literacy level in this environment is low; and

public hospitals are mostly patronised by those with low

socioeconomic status.

Hypertension and peripheral oedema were often absent

in patients with renal disease 2,3,4. In this study hypertension

was reported 1n 13.4% of the patients with renal disease. The

low prevalence of hypertension could be due to salt wasting

and volume depletion from recurrent diarrhoea and vomiting

xcii

prevalent in HIV- infected patients 1,6,7. Contrary to the reports

by D’Agati et al.6and Pedro 34 in which malnutrition was found

in more than 50% of their subjects; only 13 (10.2%) of the

patients with renal disease in this study had malnutrition i.e

BMI of less than 19kg/m2. This could be due to the fact that

81.1% of these patients were on highly active antiretroviral

therapy (HAART) for more than 12 months.

Anaemia was a common finding in this study and accounted

for 26.8% of the patients with renal disease, with a PCV of less

than 30%. This finding was similar to other previous reports;

in which the population of HIV-positive patients with anaemia

varied from 3.3% to 75% depending on the stage of disease99,

CD4 cells count100, and renal function. In this study 46.5% of

the patients with renal disease had CD4 cells of less than 200

cells/μL with a range of 120-160 cells/μL; and this finding

was further corroborated by Jonathan et al 15. he reported that

HIVAN was commonly seen in patients with CD4 cells count of

less than 200cells/μL. Although, HIVAN has been reported to

occur in all stages of HIV-infection including a stage of acute

sero-conversion; the patients with renal disease in this study

had a mean CD4 cells count of 216.57cells/μL. This finding is

similar to reports from South Africa22,23.

xciii

The mean serum creatinine of the patients with renal

disease in this study was 113.77±13.31μmol/l with 38/127

(30.0%) of them having creatinine clearance of less than

60mls/min. None of the patients in this study had a creatinine

clearance of less than 15mls/min. The prevalence of ESRD

from (or) due to HIVAN varied from 5.5% in pre-HAART era

(1995) to 0.8% in post-HAART era (2000) 14; and HIVAN was

the 3rd leading cause of ESRD in those aged 20-64 years in the

USA among African American2,4-6.Small sample size and

probably long duration of therapy with HAART was responsible

for the absence of ESRD in this study. Highly active

antiretroviral therapy has been shown severally, to retard the

progression of renal disease amongst HIV-infected patients74-

78.

Nephrotic range proteinuria is a frequent finding among

patients with HIVAN. In this study nephrotic range proteinuria

was present in 37.0% of the patients with renal disease. This

is in agreement with other reports in which nephrotic

proteinuria was described in 30-80% of patients with HIVAN

5,6,12,23,96. Despite this magnitude of proteinuria in these

patients only 3.1% of them presented with peripheral oedema

in this study. In the literature more than 30% of the patients

xciv

with HIVAN presented without peripheral oedema even when

serum albumin was reduced to about 22g/l98.It has been

suggested that HIV patients with HIVAN maintain high oncotic

pressure because of hypergammaglobulinaemia, resulting in

lower oedema when compared with other patients in similar

situations 96,98.

Hypercholesterolaemia is an infrequent finding in

patients with HIVAN occurring in less than 10% despite

nephrotic syndrome and hypoalbuminaemia 5,6.In this study

the prevalence of hypercholesterolaemia in patients with

HIVAN was 14.2%. This high figure could be due to HAART

these patients were on. HAART based therapy has been shown

to be associated with varying degree of dyslipidaemia 101,102.

This study also compared 30/75 consecutive HIV patients

with nephropathy (proteinuria and above),without any

evidence of renal disease other than HIV, with another 30 HIV

patients, age sex matched without nephropathy; to determine

the possible factors associated with the development of

nephropathy in these patients. The salient finding was the

observation of significant difference in their mean creatinine

clearance (p=0.007). This finding of reduced creatinine

clearance among the subjects is in agreement with the

xcv

findings of Han et al.22 and Pedro. 34 Both studies showed a

decline in creatinine clearance in patients with nephropathy

when compared with controls. And this would translate into

unfavourable outcome in these patients.

In this study there was a significant difference in the

mean CD4 cells count of the subjects when compared with the

control (p=0.024). Han et al22 reported similar observation in

their cohort in South Africa.

The mean duration of ARVs use in patients was 19.3 months

compared with controls 9.6 months (p=0.020). This significant

difference might be due to long standing infection in the

subjects compared to controls; or could be partly due to

adverse effects of HAART on the kidneys. Several studies had

shown beneficial effects of HAART on the progression of kidney

disease in HIV patients, but few had also reported

nephrotoxicity of HAART, including non nucleoside reverse

transcriptase (NNRTIs) commonly used here.

There was no significant difference in the mean total serum

proteins of the subjects compared with that of controls

(p=0.554). However, serum albumin was much lower in the

subjects than in the controls (p=0.001), while serum globulin

was much higher in the subjects than in the controls

xcvi

(p=0.012). It is believed that the high globulin in the patients

was responsible for the absence of peripheral oedema in

patients with HIVAN despite marked hypoalbuminaemia and

nephrotic range proteinuria 96, 98.Interstitial nephritis and salt

wasting are other possible explanations.

There was no difference between subjects and control with

respect to their HIV-2 status (p=0.056) and HBSAg status

(0.073), but there was some tendency towards significance as

shown by their p-values. HBV-infection is a known

compounding factor for the development of nephropathy in

HIV patients co-infected with HBV 4,5,6. Although, data on HIV-

2 nephropathy without co-infection with HIV-1 is scarce;

Izzedine et al 104 reported in a case report, of a 52 year old

woman with HIV-2 associated nephropathy without HIV-1 co-

infection.

There was no difference in educational status (x2 =0.063),

blood pressures (p=0.670), BMI (p= 0.111) and PCV (p=0.263)

between subjects and controls.

The results from this study showed involvement of all

the compartments of the nephron, i.e glomerulus, tubules and

interstitium similar to other reports 2,4,6,7-10.The characteristic

pathologic feature of collapsing glomerulopathy was not

xcvii

observed in this study. This could probably be due to long

duration of therapy (HAART) in these patients. Therapy with

HAART has been shown to retard and even improve on the

pathohistological features of HIVAN as reported by Wali 105. In

this study however, focal segmental glomerulosclerosis was

seen in 60% of the glomeruli. Also, microcystic dilatation of

the tubules with casts was seen in 60% of the biopsies. These

findings were similar to the series reported by D’Agati et al

6,106. in which focal segmental glomerulosclerosis accounted

for 73% of their biopsy findings. Also, Bourgoignie 107 in his

biopsy study reported focal segmental glomerulosclerosis in

83% of their patients.

Interstitial infiltrates which were reported in previous studies

3,4,6 was also found in this study in 20% of the biopsies.

Further studies on HIVAN in South Africa showed

contrasting reports. Han et al22. reported FSGS in 83% of their

series, while Gerntholtz et al 23. in another South African

study reported FSGS in 27% of the 99 biopsies they reviewed;

HIV- immune complex glomerulonephritis constituted 21%,

membranous glomerulonephritis (GN) 8%, and IgA

nephropathy 5%. Assounga et al 108. in Congo Central Africa

xcviii

reported low prevalence of HIVAN in which FSGS constituted

19% of their biopsy findings.

CONCLUSION AND RECOMMENDATIONS

This study has further demonstrated that, the

prevalence of renal disease is high amongst Nigerian

patients infected with HIV. The 31.8% prevalence seen in

this study was higher that what was obtained in the USA

2,4,6, but comparable with the reports from Africa 22,23,34.

HIVAN is commoner in males than females as previously

described 5, 6, 96. There was rarity of peripheral oedema

despite the nephrotic syndrome seen in 37.0% of them.

Hypertension and malnutrition were uncommon. Low

CD4 cell count and anaemia are common. Patients with

nephropathy differ from their counter part (controls) in

their CD4 cell counts, PCV and creatinine clearance.

Intravenous drugs use and homosexuality were not

seen in this study. The histologic features of the biopsies

in this study are similar to findings among blacks with

HIVAN elsewhere, with FSGS predominating.

xcix

Based on these findings the following

recommendations are proffered:-

(1) All patients with HIV/AIDS should be screened

for the presence of renal disease, irrespective of

their clinical state.

(2) A large multi-centred histopathologic

prospective study needs to be carried out to

ascertain the true prevalence of HIVAN among

Nigerians infected with HIV; and also to

determine the outcome of intervention.

(3) Patients with renal disease should be on ACE

inhibitors in addition to HAART.

(4) All patients with HIV infection should be

evaluated for HBV infection. Those who are

negative should be vaccinated; and those with

evidence of disease activity should have

appropriate intervention.

c

LIMITATIONS

The limitations of this study include:-

1) The lack of Immunoflorescence and

electromicroscopic studies.

2) Lack of facilities to demonstrate HIV or HIV-

viral proteins in renal tissues to establish

causal relationship.

3) Lack of facilities for viral load.

4) This is a cross-sectional study, there is no

opportunity for follow-up

5) Low biopsy rate.

ci

FSGS IN PATIENT WITH HIVAN

cii

Tubular dilatation with cast in patient with

HIVAN

ciii

Minimal change Disease in a patient with

Proteinuria

civ

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CONSENT FORM

Dear Respondent,

I am undertaking a research study on HIV associated Nephropathy among Nigerians.

cxxvi

This questionnaire is intended to find out the presence or absence of some

markers of Kidney damage and also the pattern of Kidney involvement to enable us adopt

appropriate intervention strategies.

The information you will supply is strictly confidential, hence you do not need to

write down your name. You will also be examined to determine the presence or absence

of those symptoms enumerated in the questionnaire.

Thank you for your co-operation and honest response to the various questions.

Yours sincerely,

.................................

DR.KWAIFA S.I

(PRIMARY INVESTIGATOR)

DEPARTMENT OF MEDICINE

RENAL UNIT

ABUTH ZARIA

I have agreed to participate in this research after the purpose has been explained to me

………………………..

Signature / thumbprint

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A STUDY OF HIV-ASSOCIATED NEPHROPATHY AMONG

NIGERIANS

CLINICO- PATHOLOGICAL CORRELATION

(PROFOMA)

Section A: Biodata

Hospital No ____________ Initials____________ Age [Years]

_________

Sex [M = 1, F = 2] _________________

Occupation___________________

Educational Status ____________

(None = 0; Primary = 1’ Secondary = 2; Post secondary = 3;

Postgraduate (Master and above) = 4)

Marital Status ___________ (Single = 1; Married = 2; Divorced =

3; Widowed =4]

Section B: Clinical Data

Do you have or have you had …..? (No = 0; Yes = 1; If Yes

indicate the duration)

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Facial swelling_______________ Duration___________; Legs

swelling________

Duration __________________

Abdominal swelling_____ Duration ______; Frothy urine ______

Duration____________Nocturia________________

Persistent hiccups_______ Duration_______; Pruritus______

Duration_______

Vomiting _________ Duration________; Convulsions_______

Duration_______

Reduction in urine output______________ Duration ___________

Increase in urine output_________________ Duration

_________________

Bloody or coke-coloured urine _________________ Duration

_____________

Any past history of body swelling ________________ Duration

________

Are you a known Hypertensive_____ Duration_______;

Diabetic____ Duration_______________

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Any family member or blood relative with history of kidney

disease___; Hypertension ___________; D/M _________________

Drug History

Are you or were you on….? (No = 0; Yes = 1; If yes indicate

type and duration

ACEIs ________________________ Duration ___________________

Steroids________________ Type_____________ Duration

______________

Antiretrovirals ___________ Duration ___________________

NSAIDS________________________

Duration__________________

Intravenous drug [Heroin] _____________ Duration

_________________

(b) Physical Examination

General: [Absent = 0; Present = 1]

Wasting __________; Pallor_______; Jaundice_________; Fluffy

hair________

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Peripheral lymph node enlargement_______; Periorbital

swelling/hallo________ Pedal oedema___________

Weight____________ kg; Height_____________ m;

BMI______________kg/m2

Chest

Crackles_________ Evidence of consolidation________ Pleural

effusion_______

CVS

Pulse: Rate__________________ BPM

BP______________________ mmHg [Sitting]

Abdomen: [Absent = 0; Present = 1]

Distension____________; Tenderness _______________;

Ascites___________

Palpable Organs: Liver _______________

Spleen ________________

Kidneys ________________

Section C: Laboratory Data

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Haematology

FBC: PCV ___________________% WBC

_________________cells/mm2

Neutrophils_____%; Lymphocytes_____%; Eosinophils____%;

Monocytes___%

CD4 count ______________________cells/L

PT_____________; PTR__________________; INR_________________

Serology: [negative= 0; Positive = 1]

HIV-1_________; HIV-2_________; HBsAg________ HCV

Antibody_______

Microbiology

Urine microscopy for WBC, RBC, Cast

Chemistry

Dipstick Proteinuria_____________ [Negative = 0; Positive = 1]

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24hrs urine protein_________ g/day FBS________ mmol/L

Spot urine protein creatinine ratio _____________________

Creatinine clearance _______ml/min; Urea clearance_______

ml/min Urine sodium__________ Urine K+____________

Urine creatinine_________ Urine urea_______________

Serum urea______ mmol/L; Serum creatinine______mol/L;

Serum K+ ________ mol/L

Serum sodium_____________ mmol/L Serum bicarbonate

__________ mmol/L

Lipid profile: Total cholesterol__________________ mmol/L

Serum Total protein____________ mg/dl; Serum

albumin__________ mg/dl; Serum globulins____________ mg/dl

Renal Ultrasonography

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For kidney size ______________ [Shrunken = 0; Normal = 1;

Large = 2]

Echogenicity _____________ [Normal = 0; Increased = 1]

Loss of corticomedullary differentiation ___________________

[Absent = 0; Present = 1]

Histopathology Report