Clinical sonographic and histological renal features of HIV seropositive patients with proteinuria at Mulago Hospital: A descriptive study
Background: A wide clinical spectrum of kidney diseases affects patients with HIV. Studies employing varying criteria for diagnosis of kidney disease have reported a variable prevalence of these diseases in patients with HIV in sub-Saharan Africa and suggest that a broader spectrum of histological lesions in HIV-associated kidney disease exists in African populations. It is often difficult to distinguish HIVAN from non HIVAN renal lesions on clinical grounds alone therefore renal sonography and renal biopsy are essential in the diagnosis of HIVAN. Objective: To describe the clinical presentation, renal sonographic and histological features of HIV seropositive patients with proteinuria in Mulago hospital. Methods: A cross-sectional descriptive study was carried out between June 2008 to January 2009 at Mulago Hospital renal clinic, ISS and CDC clinics. A total of 51 eligible patients were enrolled consecutively in to the study. Presence of significant proteinuria, defined as presence of 100mg of albumin per deciliter of urine, was assessed for by urine dipstick. Data was collected on socio-demographic, clinical characteristics and laboratory parameters measured, urine protein quantified using urine protein to urine creatinine ratios (Up/Uc), renal sonography. Kidney biopsies were done. Data analysis was performed using the SPSS 12.0 software package. Statistical significance between kidney histology variables were tested using p-values and 95% confidence intervals. A P-value of ≤ 0.05 was considered to be statistically significant. Results: Among the 51 HIV seropositive patients, the mean age was 31 (±9) years, 54.9% were women. The patients were classified according to urinary protein/creatinine ratio (Up/Uc) < 1.0 (39.2%), 1.0-3.0 (29.4%) and > 3.0 (31.4%) respectively. The mean CD4 count was 428±330 (41.2% had CD4 counts between 200-500cells/µL), 21.8% were on ART, 35.3% were on Septrin for primary PCP prophylaxis, 62.5% had oedema, 35% had hypertension and 76.7% had renal failure with eGFR less than 89ml /min/1.73m2. Forty (40) patients underwent kidney biopsies, 9 (26.5%) had classic HIVAN and 25 (73.5%) had non classic HIVAN on histology. The histological patterns described as non classic HIVAN include: FSGS 10 (40%), Collapsing glomerulopathy 4 (16%), membranous and mesangial proliferative glomerulonephritis 3 (12%), acute tubular necrosis and interstitial nephritis 2 (8%) and chronic pyelonephritis 1 (4%). Patients with non classic HIVAN had a statistically significantly greater GFR (78.4±40.1 vs.17.3±13.5ml/min/1.73m2, p=0.000) compared to patients with HIVAN and had a statistically higher CD4 cell count (557±350 vs. 204±150cells/µL, P = 0.032) compared to the HIVAN patients. These patients were less likely to be uremic (4% vs. 66.7%, p<0.001) or on antiretroviral medication (8.82% vs. 77.8%, p=0.001) compared to patients with HIVAN. Of 34 patients with definite kidney histology, 77.8% of the patients with classic HIVAN had normal kidney size with 44% having grade III echogenicity compared with 84% non classic HIVAN patients who had normal kidney size and 16% having grade III kidney echogenicity. Conclusion: This study provides evidence that, among patients with HIV and proteinuria there is a broad spectrum of kidney histology lesions other than classic HIVAN and that highest grades of sonographic echogenicity have diagnostic value in establishing a diagnosis of HIV associated nephropathy.