Kidney disease in Africans with HIV and tuberculosis

Abstract

Objective: To describe the spectrum of kidney disease in African patients with HIV and tuberculosis (TB). Methods: We used data from three cohorts: consecutive patients with HIV/TB in South London (UK, 2004-2016; n=95), consecutive patients with HIV/TB who underwent kidney biopsy in Cape Town (South Africa, 2014-2017; n=70), and consecutive patients found to have HIV/TB on autopsy in Abidjan (Cote d'Ivoire, 1991; n=100). Acute kidney injury (AKI) was ascertained using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. In the Cape Town cohort, predictors of recovery of kidney function at six months were assessed using Cox regression. Results: In the London cohort, the incidence of moderate/severe AKI at 12 months was 15.1 (95%CI 8.6-26.5) per 100 person-years, and the prevalence of chronic and end-stage kidney disease (ESKD) 13.7% and 5.7% respectively. HIV-associated nephropathy (HIVAN) was diagnosed in 6% of patients in London, and in 6% of autopsy cases in Abidjan. Evidence of renal TB was present in 60% of autopsies in Abidjan and 61% of kidney biopsies in Cape Town. HIVAN and acute tubular necrosis (ATN) were also common biopsy findings in Cape Town. In Cape Town, 40 patients were dialyzed, of whom 28 (70%) were able to successfully discontinue renal replacement therapy. Antiretroviral therapy status, CD4 cell count, eGFR at biopsy and renal pathology, other than ATN, were not predictive of eGFR recovery. Conclusions: Kidney disease was common in Africans with HIV/TB. Monitoring of kidney function, and provision of acute dialysis to those with severe kidney failure, is warranted.

The Evolving Spectrum of Kidney Histology in HIV-Positive Patients in South Africa

“…The substantially higher proportion of cases with TID in our series may reflect the exceptionally high prevalence of TB (42%), which can result in granulomatous interstitial nephritis in the kidney, TB drug-induced interstitial nephritis, or ATI from kidney hypoperfusion in those with severe systemic illness. 25 , 26 Furthermore, the greater degree of immunodeficiency in our patients may have resulted in increased susceptibility to other infections and increased exposure to nephrotoxic agents. Of note, about half of the patients with HIV/TB had initiated ART within 3 months of kidney biopsy, raising the possibility that some kidney pathology may have been the result of immune reconstitution inflammatory syndrome in the kidney.…”

“…Of note, about half of the patients with HIV/TB had initiated ART within 3 months of kidney biopsy, raising the possibility that some kidney pathology may have been the result of immune reconstitution inflammatory syndrome in the kidney. 25 …”

Host factors predisposing to kidney disease in people with HIV

“…Hence, it is possible that HCV is a surrogate marker for shared factors of HIV and HCV transmission, such as intravenous drug use, that have a larger effect on the kidney than HCV itself. Besides hepatitis, bacterial (including mycobacterial infections [32]), fungal infections and syphilis may all result in kidney injury.…”

"Acute Kidney Injury predictive models: advanced yet far from application in resource-constrained settings."

“…As a result, research into HIV as a risk factor and its impact on AKI development in patients with severe acute illness requiring ICU admission in such settings is critical. Several researchers have identified HIV infection as an independent risk factor for AKI 11 ; the risk is associated with HIV progression as measured by CD4 count and viral load, tenofovir disoproxil fumarate treatment, and hepatitis C co-infection. Other risk factors include the use of herbal and traditional medications with unknown nephrotoxic potential, as well as the high prevalence of infectious disease, traumatic injuries, and pregnancy-related hypertensive disorders.…”

“…As a result, research into HIV as a risk factor and its impact on AKI development in patients with severe acute illness requiring ICU admission in such settings is critical. Several researchers have identified HIV infection as an independent risk factor for AKI 11 ; the risk is associated with HIV progression as measured by CD4…”