Outcome of HIV positive patients presenting with renal failure at Charlotte Maxeke Johannesburg Academic Hospital
Vachiat, Ahmed Ismail
Outcome of HIV positive patients presenting with renal failure at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) Background The majority of the 33.4 million people infected with HIV worldwide reside in sub-Saharan Africa. The HIV prevalence amongst young South Africans (ages 15- 49) is 16%. HIV is the third leading cause of ESRD in African - Americans aged 20-64 in the United States. There is a paucity of data regarding the prevalence of acute kidney injury (AKI) in HIV patients in sub-Saharan Africa. Methods A retrospective review of 101 HIV positive patients presenting with renal failure at the CMJAH from 1st October 2005 until 31st October 2006 was undertaken. There were 50 HIV positive patients with presumed AKI that were compared to 90 HIV negative patients with AKI. Results A total of 684 patients presented with renal failure, 101(14.8%) of whom were HIV positive. Ninetynine of the HIV positive patients were black and 56 were male. The mean age of HIV positive patients with renal failure was 38 years. Fifty-seven patients presented with AKI (seven patients were excluded due to lack of records), 21 with acute on chronic renal failure and 23 with chronic renal failure. The causes of AKI in the HIV positive group included sepsis (62%), haemodynamic instability (20%), toxins (10%), urological obstruction (8%) and miscellaneous (10%). The common underlying aetiologies of the 90 HIV negative patients studied presenting with AKI were sepsis (43%), haemodynamic instability (17%), toxins (7%), urological obstruction (8%) and miscellaneous (23%). Forty-seven (52%) of these HIV negative patients recovered. Forty-two (47%) patients died, compared with 22 (44%) patients in the HIV positive group. Hyponatraemia, hyperkalaemia, hypochloraemia and acidosis were more common in the HIV positive patients. Dialysis was initiated in 36% of HIV positive patients with AKI. There were more HIV positive patients that recovered with supportive care, including fluid therapy when compared to HIV negative patients. Recovery was noted to be more rapid in the HIV positive group. Using survival and death as the outcome there was no difference between the HIV positive and the HIV negative group presenting with AKI (p<0.7173). Discussion HIV positive patients presented with renal failure at a younger age – a mean age of 38 years in this study. Previous studies have shown mean ages ranging from 35 years to 46.7 years. The majority of the HIV positive patients presenting with renal failure were black (98%). The racial predominance is different to that of other countries which might be due to epidemiological factors. The gender differences were similar when compared to other studies. Sepsis was the more common aetiological factor of AKI (62% of HIV positive patients compared to 43% of HIV negative patients). HIV positive patients with AKI presented at an advanced stage of immunosuppression (more than 50% had CD4<100cells/μl). Electrolyte disturbances were common in HIV positive patients with AKI. Conclusion HIV positive patients with AKI presented with advanced immunosuppression. Sepsis was the most common aetiology of AKI. Supportive management or renal replacement therapy resulted in recovery in a large number of patients.HIV positive patients should be treated acutely just as HIV negative patients and should not be excluded on the basis of their HIV status. Dialysis should be offered when indicated and aggressive fluid resuscitation should be emphasized. Outcomes were similar in HIV positive and HIV negative patients presenting with AKI.