Assessment of renal function in routine care of people living with HIV on ART in a resource-limited setting in urban Zambia

Abstract

IntroductionData on renal impairment in sub-Saharan Africa (SSA) remains scarce, determination of renal function is not part of routine assessments. We evaluated renal function and blood pressure in a cohort of people living with HIV (PLWH) on antiretroviral treatment (ART) in the Renal Care Zambia project (ReCaZa).MethodsUsing routine data from an HIV outpatient clinic from 2011–2013, we retrospectively estimated the glomerular filtration rate (eGFR, CKD-Epi formula) of PLWH on ART in Lusaka, Zambia. Data were included if adults had had at least one serum creatinine recorded and had been on ART for a minimum of three months. We investigated the differences in eGFR between ART subgroups with and without tenofovir disproxil fumarate (TDF), and applied multivariable linear models to associate ART and eGFR, adjusted for eGFR before ART initiation.Results and discussionAmong 1118 PLWH (63,3% female, mean age 41.8 years, 83% ever on TDF; median duration 1461 [range 98 to 4342] days) on ART, 28.3% had an eGFR <90 ml/min, and 5.5% <60 ml/min at their last measurement. Information on other conditions associated with renal impairment was not systematically documented. Fourteen per cent of the PLWH who later switched to TDF-free ART had an initial eGFR lower 60ml/min. Nineteen percent had first-time hypertensive readings at their last visit. The multivariable models suggest that physicians acted according to guidelines and replaced TDF-containing ART if patients developed moderate/severe renal impairment.ConclusionsAssessment of renal function in SSA remains a challenge. The vast majority of PLWH benefit from long-term ART, including improved renal function. However, approximately 5% of PLWH on ART may have clinically relevant decreased eGFR, and 27% hypertension. While a routine renal assessment might not be feasible, strategies to identify patients at risk are warranted. Targeted monitoring prior and during ART is recommended, however, should not delay ART access.

Tenofovir-associated kidney disease in Africans: a systematic review

“…Fifteen report overall safety of TDF in ART regimens, recommending its continued use with monitoring [28–31, 37–40, 42, 44, 46, 48–50]. Although the definitions of renal dysfunction differed widely, the other 16 studies report either statistical or clinical association of TDF with renal dysfunction [15, 22–26, 32–35, 43, 45, 47, 51–53]. Groups at higher risk include patients with impaired renal function at baseline, older age groups and women [33, 35, 47].…”

“…Although some recommend monitoring of patients particularly those with deranged renal function parameters at baseline, there is, no consensus on recommended monitoring strategies to this end. On the other hand, 16 studies reported an association with seven of these reporting the association as significant (Table 3) [15, 22–26, 32–35, 43, 45, 47, 51–53]. Five of the seven were done in Southern Africa [25, 34, 35, 43, 45].…”

“…One study could not make an assessment of whether or not TDF was associated with renal function decline in these patients [47]. Unfortunately, of the studies included in this review, only four systematically documented other non-ART co-medications that these patients were taking thereby making it difficult to make assessments of the impact of other drugs on the results or to conclusively attribute the impact on renal function of TDF containing ART of the studies in this review [25, 26, 28, 47]. However, Cournil et al suggest that an interaction between Tenofovir and Ritonavir may be responsible for an initial decrease in eGFR observed when a patients initiates on a ritonavir boosted TDF regimen.…”

Impaired renal function in a rural Ugandan population cohort

“…Hospital-based studies from a National Referral Hospital in Uganda show that most patients with kidney disease are young and have advanced disease by the time of presentation 10 . Thus, in sub-Saharan Africa estimates of kidney disease prevalence vary widely depending on the methods used to determine renal function and the population studied, in particular the age distribution 8, 11– 19 .…”

Newer Point-of-Care Biosensors Are Expected to Permit Early Detection and Better Management of Acute and CKD

“…These advances have permitted early measurement of key biological variables (biomarkers) with great accuracy, as well as minimal cost and resource investment. 3 Such devices permit the assessment of renal function in people living with HIV in resource-limited settings in urban Zambia, 4 cost-effective screening for CKD among Canadian indigenous peoples, 5 and early detection of kidney disease in Australia. 6 Using volunteer research students and technological innovation, including GPS, digital photography, and POC biochemical analysis, these devices have measured, for the first time, the burden of CKD and other public health priorities in Rivas, Nicaragua.…”