Proteinuria in ambulatory HIV-infected patients managed at Muhimbili national hospital

Abstract

Background: Kidney disease has emerged as an important complication of HIV infection, highly active antiretroviral therapy (HAART) and comorbidities. Thus, there is an overwhelming implication for HIV -related kidney disease in sub-Saharan Africa (SSA) since 67.7% of the world's HIV-infected individuals do reside in SSA region. However, relatively little is known regarding the burden of HIV -associated chronic kidney disease in this region.

The HIV infection in the kidney has diverse manifestations, but most of the HIV- associated nephropathies are predominantly characterised by proteinuria. However, urine screening for proteinuria is not routinely done among HIV -infected individuals in Tanzania, and the magnitude of proteinuria and associated risk factors has not been investigated among HIV-infected population attending HIV/AIDS Care and Treatment Clinics in Tanzania.

Study Objective: To determine the magnitude of proteinuria in ambulatory HIV- infected adult patients managed at the HIV / AIDS Care and Treatment Clinic, Muhimbili National Hospital, Tanzania.

Materials and methodology: Data collection included interviews using a standard structured questionnaire, physical examination and laboratory investigations (serum biochemistry, haematology, absolute CD4+ T Iymphocyte count and serology for hepatitis Band C viruses). Proteinuria was defined as a dipstick result of 1+ proteinuria or greater on the spot mid-stream urine samples.

Results: A total of 294 HIV -infected patients participated in the study; their mean age (± SD) was of 39.1 (± 6.3), range 18-69 years, and females were 68.7%. Proteinuria was detected in 11.9% (95%CI 8.5-16.3) of the study participants; with the proteinuria category being +, 2+, and:::: 3+ in 71.4%, 22.9%, and 5.7% of the cases, respectively. Fifteen percent of participants had an estimated glomerular filtration rate (eGFR) less than 60 mLlmin/1. 73m2). The presence of proteinuria was significantly associated with lower CD4+ count < 200 cells/ul, (p = 0.023), advanced WHO HIV clinical stage (p = 0.020), HAART-na'ive (p < 0.0001), lower mean haemoglobin (p < 0.019), lower eGFR (p <0.0001), and hypoalbuminaemia (p < 0.0001).

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In multivariate analysis, low eGFR « 60 mLlmin/l.73m2; OR 4.07, p = 0.019), high serum creatinine (> 200 umol/L; OR 4.94, p = 0.007), low haemoglobin « 9g/dL; OR 2.05, p = 0.030), and hypoalbuminuria « 30g/L; OR 3.05, p = 0.021) were independently associated with proteinuria. The eGFR < 60 mLlmin/1.73m2 had an independent association with low CD4+ count « 200 cell/ul.; OR 2.83, P = 0.033), high serum creatinine (OR 4.08, P = 0.001), low haemoglobin « 9 g/dL; OR l.96, p = 0.010) and WHO HIV clinical stage 3 and 4 (OR 2.65, p = 0.046).

Conclusion and recommendations: The prevalence of both proteinuria (1l.9%) and impaired renal function (15%), eGFR < 60 mLlmin/l.73m2, is high in ambulatory HIV -infected patients without specific clinical symptoms and signs. These findings underscore regular proactive screening and monitoring for proteinuria and/or kidney function among HIV -infected population as an important part of the national comprehensive strategy for HIV/AIDS care and treatment in Tanzania.

Simple, versatile and cost-effective interventions such as dipstick urinalysis can easily be done at the lowest-level health facilities that provide HIV/AIDS Treatment and Care service in Tanzania. This would result in early detection and prompt treatment or referral for patients with dipstick proteinuria to higher-level health facilities for further management; and thus facilitating early diagnosis and management of HIV -associated renal disease.