Human immunodeficiency virus-associated nephropathy (HIVAN) in Nigerian children

Abstract

Human immunodeficiency virus-associated nephropathy (HIVAN) has rarely been reported in African children. In this single-center study, we analyzed ten children diagnosed with HIVAN from January 2000 to October 2006. There were eight boys and two girls, with a male:female ratio of 4:1. Their ages were from 5 months to 15 years (mean 6.8+/-6.2 years), with a peak age of 5-9 years. The presenting complaints included generalized edema (60%) and hypertension (50%). All patients had proteinuria on urine dipstick, with four (40%) at nephrotic range (proteinuria >or=500 mg/dl). Nine (90%) patients were in renal failure, with elevated serum creatinine (6.3-24 mg/dl) and serum urea (70-120 mg/dl). Renal disease was the first manifestation of HIV infection in six patients, whereas the diagnosis was made on autopsy in three. The duration from HIV infection to development of HIVAN ranged from 5 months to 10 years. CD4(+) cell count, done in only three patients due to financial constraints, was below 200/mm(3). The kidneys were hyperechoic on abdominal ultrasound in all patients, and three (30%) showed grossly enlarged kidneys. Histology of renal tissues available by autopsy in three patients showed mainly collapsing focal segmental glomerulosclerosis. Treatments given were angiotensin-converting enzyme (ACE) inhibitors and highly active antiretroviral therapy (HAART) in four and two patients, respectively, and one patient underwent peritoneal dialysis. On outcome analysis, seven (70%) patients died, two were lost to follow-up, and one was alive on HAART therapy at the writing of this article. In conclusion, HIVAN occurs in Nigeria children, and the mortality is very high from uremia.

Persistent proteinuria as an indicator of renal disease in HIV-infected children

“…Several studies have shown that duration of infection (which is described by the age of the subjects in HIV vertical transmission) significantly influenced the incidence of proteinuria. 3,11 HIV-associated nephropathy in children is different from that in adults. Children with HIVAN who had mesangial hyperplasia showed slower progression towards ESRD, so the incidence of proteinuria was more common in teenagers.…”

“…17 A retrospective cohort in 286 children with HIV showed that persistent proteinuria was more common in clinical stages III and IV. 18 Our subjects' mean CD4 count was 757.8 (SD 346) cells/ mm 3 . Regarding WHO immunological classification, 25 out of 38 subjects had no immunosuppression.…”

“…However, long-term exposure to HAART, in particular tenofovir disoproxil fumarate (TDF), is potentially nephrotoxic, and has been associated with nephropathy secondary to antiretroviral therapy (ARV). [3][4][5] Several studies regarding renal manifestation in children from American and African regions have reported HIVAN to be more common in Black races and less common among other races, including Asians. 3,6 A study in India reported that 10.7% of HIV-infected, HARRTnaive children had transient proteinuria.…”

“…[3][4][5] Several studies regarding renal manifestation in children from American and African regions have reported HIVAN to be more common in Black races and less common among other races, including Asians. 3,6 A study in India reported that 10.7% of HIV-infected, HARRTnaive children had transient proteinuria. 7 Proteinuria is an indicator of the earliest type of kidney diseases, and reflects the level of damage to the permeability of the glomerular basement membrane or tubule reabsorption.…”

Neonatal HIV-associated nephropathy

“…[3] In another series of 10 Nigerian patients, the youngest was aged 5 months. [7] To date, there have been no reports in the literature of HIVAN presenting with congenital nephrotic syndrome (CNS). We report here what we believe is the first case of a child with CNS, who was diagnosed with perinatally acquired HIV-1 infection due to vertical transmission.…”