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Table of Contents   
ORIGINAL ARTICLE  
Year : 2017  |  Volume : 10  |  Issue : 6  |  Page : 1496-1499
Prevalence of proteinuria and abnormal urinary cytology in HIV +ve asymptomatic patients


1 Department of Pathology,  School of Tropical Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
2 Department of Pathology,  School of Tropical Medicine, All Institute of Hygiene and Public Health, Kolkata, West Bengal, India

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Date of Web Publication11-Jan-2018
 

   Abstract 


Context: A variety of renal abnormalities have been described among HIV-infected patients leading to various clinical presentations. However, early renal disease in HIV +ve patients is asymptomatic. Aims: This study aims to detect the prevalence of proteinuria and abnormal urinary cytology in HIV-infected patients. Subjects and Methods: A total of 140 patients asymptomatic for renal disease and HIV infected were tested for proteinuria (dipstick method), urinary cytology, CD4 count, and serum creatinine (to determine estimated glomerular filtration rate [eGFR]). Statistical Analysis: The data were analyzed using the Chi-square test and Fisher's exact probability test (www.vassarstats.net). Results: About 30.7% of patients were detected with proteinuria. A significant proportion of patients with proteinuria had low eGFR. Low CD4 count (<200) and age (≥40) were highly associated with presence of proteinuria. However, urinary cytology was not significantly associated with low eGFR, although abnormal eGFR was more common in the presence of abnormal urinary cytology. Conclusions: A significant proportion of HIV +ve patients asymptomatic for renal disease may have proteinuria (which is an indicator of nephropathy). The test for proteinuria is simple and therefore should be regularly done in all patients. Abnormal urinary cytology is relatively common in this group and should also be tested in all patients.

Keywords: Asymptomatic, cytology, HIV, nephropathy, proteinuria

How to cite this article:
Mukherjee S, Bhattacharya PK, Hazra S, Das S. Prevalence of proteinuria and abnormal urinary cytology in HIV +ve asymptomatic patients. Ann Trop Med Public Health 2017;10:1496-9

How to cite this URL:
Mukherjee S, Bhattacharya PK, Hazra S, Das S. Prevalence of proteinuria and abnormal urinary cytology in HIV +ve asymptomatic patients. Ann Trop Med Public Health [serial online] 2017 [cited 2018 May 22];10:1496-9. Available from: http://www.atmph.org/text.asp?2017/10/6/1496/222656



   Introduction Top


Kidney disease is increasingly becoming a cause of morbidity among people with HIV infection. Statistics in the United States estimate the incidence of HIV-associated nephropathy (HIVAN) to 3.5%–12%[1] and genitourinary disease will develop in one-third of HIV +ve patients or those with AIDS.[2] If this percentage is extrapolated to the Indian population, a huge burden of HIV-related nephropathy is to be expected.

It is well known that most symptoms of kidney disease like edema or changes in urination show up when a large part of kidney function has already been lost. Other symptoms such as fatigue and loss of appetite can be confused with other health problems. Few data exist on proteinuria and urinary cytology in HIV-infected patients asymptomatic for renal disease. Given the current paucity of resources available for managing end stage renal disease, especially for the poor, early detection is very important.

In this context, this study was undertaken to determine whether simple tests for kidney function such as proteinuria, urine analysis, and serum creatinine should be regularly done in patients asymptomatic for kidney disease with HIV positivity but euglycemic, normotensive, and having no known cause of chronic kidney disease.


   Subjects and Methods Top


This is a cross-sectional study of HIV-infected patients diagnosed in an ICTC unit in a tertiary medical center. The patients who were asymptomatic for the renal disease were initially screened for blood sugar and blood pressure.

Sample size

Considering a prevalence of 29%,[3] minimum sample size = 137, taking design effect = 2, with 99% confidence, and 10% allowable error. Five patients on an average were selected per day for 28 days by linear systematic sampling so that the sample size came to 140.

Inclusion criteria

Patients above 18 years and seropositive for HIV.

Exclusion criteria

Diabetic, hypertensive, with known kidney disease, or having renal symptoms like edema.

Data collection

Data collected included age, sex, serum creatinine, presence of proteinuria, pyuria, hematuria, and CD4 cell count. Serum creatinine was measured by autoanalyzer and used to calculate estimated glomerular filtration rate (eGFR). The absolute amount of creatinine produced per day is proportional to the muscle mass of the individual and the amount of kidney function that is implied by a given level of creatinine must be normalized for the individual's size. Hence, eGFR was calculated using the MDRD formula.

eGFR = 186 × (serum creatinine)−1.154× (age)−0.203× (0.742 if female).

A GFR of <90 ml/min/1.73 m 2 was considered abnormal.

Proteinuria was measured by dipstick. Pyuria was considered if ≥10 cells/hpf were present and hematuria if ≥5 red blood cells were present per high power field.

Statistical analysis

The data were analyzed using the Chi-square test and Fisher's exact probability test (www.vassarstats.net). The presence of proteinuria and presence of at least one cytological abnormality were each correlated with eGFR to see whether they were predictors of decreased renal function. As proteinuria was found to be correlated to decreased renal function, CD4 counts and age were correlated to proteinuria to analyze if combinations of the parameters could be used to predict poor renal outcome.

One tailed and two tailed values were calculated. A P < 0.005 was considered statistically significant.


   Results Top


A total of 140 patients fitted the inclusion criteria and were investigated. The study group comprised of 70% males (n = 91) and 30% females (n = 39). A total of 43 patients (30.7%) were detected with proteinuria [Table 1]. Abnormal eGFR was found in 60% of the patients with proteinuria (χ2 = 38.95, ≤ 0.001, significant). Eleven patients (7.8%) had at least one urinary cytological abnormality [Table 2]. Abnormal eGFR was more common (36.3%) among those with abnormal urinary cytology. However, the value is not significantly greater than those with normal urinary cytology (one tailed = 0.153, two tailed = 0.2301).
Table  1: Correlation of proteinuria with abnormal estimated glomerular filtration rate in the study group

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Table  2: Correlation of “/” abnormal urinary cytology with estimated glomerular filtration rate in study group

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Proteinuria was more common in patients with CD4<200 [Table 3] or age >40 years [Table 4]. Proteinuria was found among 84.3% of patients with CD4 count <200 which was significantly higher than those with CD4≥200 (χ2 = 52.91, < 0.0001).
Table  3: Correlation between proteinuria and CD4 count

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Table  4: Correlation of CD4 count and age with proteinuria

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   Discussion Top


A variety of renal abnormalities have been described among HIV-infected patients including HIVAN, HIV-related immune complex disease, nephropathy secondary to antiretroviral therapy or antibiotics, thrombotic microangiopathy, and diseases related to common comorbidities such as opportunistic infections. The broad spectrum of clinical presentations includes acute renal failure, nephrotic syndrome, progressive chronic renal dysfunction, and electrolyte disturbances.[4] However, few patients will not have such overt presentations, especially in early disease. Little is known about the prevalence of renal diseases that may occur in HIV infection in asymptomatic patients.

In our study, we determined renal dysfunction by preliminary screening investigations in asymptomatic patients. Despite the small sample size, we found proteinuria in 30.7% of patients. These figures are close to those found by Pernasetti et al. and Szczech et al.[5],[6]

Proteinuria causes an increased risk for clinically overt nephropathy.[3],[6],[7] This is emphasized in our study by the significant number of patients with proteinuria showing a relatively low eGFR.

In several studies, low CD4 count and higher age were significantly associated with chronic kidney disease.[3],[8],[9] These findings corroborate with our study.

The study is limited by small sample size. A single urine specimen was used which might introduce misclassification primarily between those without abnormal urinary protein and those with trace proteinuria. The study also does not examine the link between proteinuria or urinary cytological abnormality and subsequent development of clinical disease. There might be a proportion of patients with abnormal findings who might not progress to overt disease.

We found pyuria or hematuria in 7.6% cases. Urinary cytological abnormality was not significantly associated with low eGFR. In contrast, an African study found leukocyturia in 30.3% cases.[10] It seems that African HIV patients have a higher prevalence of leukocyturia (1%–11%) which may be related to more advanced disease seen at screening. However, all our cases were sterile on culture which is comparable to the low culture positivity in the African series.[11],[12] Sterile pyuria may be caused by interstitial nephritis, opportunistic genitourinary pathogens and tuberculosis. Investigations for mycobacterial culture were not recorded for the study. We did not get any case of isolated microscopic hematuria as described in a study on young asymptomatic patients with normal renal function.[13]


   Conclusions Top


The prevalence of proteinuria in the study group was 30.7% and prevalence of abnormal urinary cytology was 8.5%. It is clear that subtle renal changes may start in seropositive patients asymptomatic for renal disease and may be diagnosed early with the help of simple, low-cost screening investigations. The authors, therefore, recommend regular urinary analysis in all HIV +ve patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ross MJ, Klotman PE. Recent progress in HIV-associated nephropathy. J Am Soc Nephrol 2002;13:2997-3004.  Back to cited text no. 1
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2.
Guzmán Martínez-Valls PL, Ferrero Doria R, Morga Egea JP, Navas Pastor J, García Ligero J, Tomás Ros M, et al. AIDS and HIV infections in urologic practice. Actas Urol Esp 1998;22:343-9.  Back to cited text no. 2
    
3.
Gupta SK, Mamlin BW, Johnson CS, Dollins MD, Topf JM, Dubé MP, et al. Prevalence of proteinuria and the development of chronic kidney disease in HIV-infected patients. Clin Nephrol 2004;61:1-6.  Back to cited text no. 3
    
4.
Shah I, Gupta S, Shah DM, Dhabe H, Lala M. Renal manifestations of HIV infected highly active antiretroviral therapy naive children in India. World J Pediatr 2012;8:252-5.  Back to cited text no. 4
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5.
Pernasetti MM, Chiurchiu C, Fuente Jde L, Arteaga Jd, Douthat W, Bardosy C, et al. Renal abnormalities in HIV infected patients. Medicina (B Aires) 2010;70:247-53.  Back to cited text no. 5
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6.
Szczech LA, Menezes P, Byrd Quinlivan E, van der Horst C, Bartlett JA, Svetkey LP, et al. Microalbuminuria predicts overt proteinuria among patients with HIV infection. HIV Med 2010;11:419-26.  Back to cited text no. 6
    
7.
Han TM, Naicker S, Ramdial PK, Assounga AG. A cross-sectional study of HIV-seropositive patients with varying degrees of proteinuria in South Africa. Kidney Int 2006;69:2243-50.  Back to cited text no. 7
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Cheung CY, Wong KM, Lee MP, Liu YL, Kwok H, Chung R, et al. Prevalence of chronic kidney disease in Chinese HIV-infected patients. Nephrol Dial Transplant 2007;22:3186-90.  Back to cited text no. 8
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Szczech LA, Grunfeld C, Scherzer R, Canchola JA, van der Horst C, Sidney S, et al. Microalbuminuria in HIV infection. AIDS 2007;21:1003-9.  Back to cited text no. 9
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10.
Fabian J, Naicker S, Venter WD, Baker L, Naidoo S, Paget G, et al. Urinary screening abnormalities in antiretroviral-naive HIV-infected outpatients and implications for management – A single-center study in South Africa. Ethn Dis 2009;19:S1-80-5.  Back to cited text no. 10
    
11.
Andia I, Pepper LM, Matthieson P. Prevalence of Renal Disease in Outpatients with HIV/AIDS in Mbara Hospital. Presented at the 3rd IAS (International AIDS Society) Conference on HIV Pathogenesis and Treatment. Brazil: Rio de Janeiro; 2005.  Back to cited text no. 11
    
12.
Janabi MY, Chale S, Magao P. Renal Abnormalities Associated with Human Immunodeficiency Virus Infection Among Police Officers in Dar-es-Salaam, Tanzania. Presented at the xiv International AIDS Conference. Spain: Barcelona; 2002.  Back to cited text no. 12
    
13.
Cespedes RD, Peretsman SJ, Blatt SP. The significance of hematuria in patients infected with the human immunodeficiency virus. J Urol 1995;154:1455-6.  Back to cited text no. 13
[PUBMED]    

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Correspondence Address:
Sumana Mukherjee
BH-62, Sector-2, Salt Lake, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_403_17

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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