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Impaired Renal Function of Patients Initiating HAART in 2 Developing Countries
David Olson*1, E Thomas2, M Allheimen3, S Balkan4, E Szumilin4, and P Humblet5
1Doctors without Borders, New York, NY, US; 2MSF-France, Arua, Uganda; 3MSF-France, Guatemala City, Guatemala; 4MSF-France, Paris; and 5MSF-Belgium, Brussels
Background: HIV-related
nephropathy is well-known in developed countries but few data are available
from developing countries. Certain ART drugs have renal toxicity or need dose
adjustment in those with significant declines in renal function. Creatinine measurement
is usually not available. Surrogate markers of renal insufficiency, such as the
measurement of proteinuria by urine dipstick, would
prove useful in a resource-poor setting.
Methods: In Arua (Uganda),
165 ART-naïve adult patients with a CD4 count <200 cells/mL
prospectively underwent serum creatinine (Cr) testing
and urine protein determination by dipstick. In Guatemala City, baseline serum creatinine levels done prior to the start of ART (start
criteria: CD4 <200 cells/mL, World Health Organization Stage 4 disease) for the most
recent 200 adults enrolled in the program were retrospectively collected.
Patient age, weight, and gender were noted in both groups. Cr was measured by
automated colorimetry. Creatinine
clearance (CrCl) was estimated using the Cockcroft-Gault equation. Level of proteinuria
was visually determined by dipstick color change and reported as 0, 1+, 2+, or
3+.
Results: Historically,
mean CD4 count at the initiation of ART is 88 (IQR:39
to 142) and 87 (IQR:35 to 162) cells/mL in Arua (n = 1499)
and Guatemala City
(n = 688), respectively. A CrCl <50 mg/dL was found in
46% (78 of 165) of the patients in Arua and in 19% (37 of 200) of the patients
in Guatemala City.
In Arua, among the 135 patients with a negative urine dipstick, 58 (43%) had a CrCl <50; in 35 patients with any proteinuria
(1+ to 3+), 20 (57%) had a CrCl <50 (p = 0.17).
Conclusions:
Results indicate that impaired renal function can be highly prevalent in
resource-limited settings. Proteinuria, as measured
by urine dipstick, did not appear useful for predicting renal insufficiency.
Treatment simplification strategies for scaling-up in developing countries
could be affected by the need to adapt ART regimens and dosing based on renal
function, as would the need for laboratory follow-up when using first-line
agents with possible renal toxicity.
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