Renal impairment in HIV infected patients receiving tenofovir-based antiretroviral therapy in a South African hospital
Date
2017
Authors
Seedat, Faheem
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Abstract
Objective: There is limited data describing acute kidney injury (AKI) in HIV-infected
adult patients in resource-limited settings where increasingly, tenofovir (TDF), which
is potentially nephrotoxic, is prescribed. We describe risk factors for, and prognosis of
AKI in HIV-infected individuals receiving and naïve to TDF.
Methods: This was a prospective case cohort study of hospitalized HIV-infected
adults with AKI (as defined by the 2012 KDIGO Clinical Practice Guideline for AKI)
stratified by TDF exposure. Adults (≥18 years) were recruited: clinical and
biochemical data was collected at admission; their renal recovery, discharge or
mortality was ascertained as an in-patient and, subsequently, to a scheduled 3-month
follow-up.
Results: Amongst this predominantly female (61%), almost exclusively black African
cohort of 175 patients with AKI, 93 (53%) were TDF exposed; median age was 41
years (IQR 35-50). Median CD4 count and VL and creatinine at baseline was 116
cells/mm3 and 110159 copies/ml, respectively. A greater proportion of the TDF group
had severe AKI on admission (61% v 43% p=0.014); however, both groups had
similar rates of newly diagnosed tuberculosis (TB) (52%) and NSAID (32%) use.
Intravenous fluid was the therapeutic mainstay; only 7 were dialyzed. Discharge
median serum creatinine (SCr) was higher in the TDF group (p=0.032) and fewer in
the TDF group recovered renal function after 3-months (p=0.043). 3-month mortality
was 27% in both groups but 55% of deaths occurred in hospital. Those that died had a
higher SCr and more severe AKI than survivors; TB was diagnosed in 33 (70%) of
those who died.
Conclusions: AKI was more severe and renal recovery slower in the TDF group; comorbidities,
risk factors and prognosis were similar regardless of TDF exposure.
Because TB is linked to higher mortality, TB co-infection in HIV-infected patients
with AKI warrants more intensive monitoring. In all those with poor renal recovery,
our data suggests that a lower threshold for dialysis is needed.
Description
A research report submitted to the Faculty of Health Sciences, University of
Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree
of Master of Medicine in the branch of Internal Medicine
Johannesburg, 2017