title: Acute Kidney Injury, Risk Factors, and Prognosis in Hospitalized HIV-Infected Adults in South Africa, Compared by Tenofovir Exposure.
abstract: There are limited data describing acute kidney injury (AKI) in HIV-infected adult patients in resource-limited settings where tenofovir disoproxil fumarate (TDF), which is potentially nephrotoxic, is increasingly prescribed. We describe risk factors for and prognosis of AKI in HIV-infected individuals, stratified by those receiving and those naive to TDF. A prospective case cohort study of hospitalized HIV-infected adults with AKI stratified by TDF exposure. Adults (≥18 years) were recruited: clinical and biochemical data were collected at admission; their renal recovery, discharge, or mortality was ascertained as an in-patient and, subsequently, to a scheduled 3-month follow-up. Among this predominantly female (61%), almost exclusively black African cohort of 175 patients with AKI, 93 (53%) were TDF exposed; median age was 41 years (interquartile range 35-50). Median CD4 count and viral load and creatinine at baseline were 116 cells/mm3and 110,159 copies/ml, respectively. A greater proportion of the TDF group had severe AKI on admission (61% vs. 43%, p = .014); however, both groups had similar rates of newly diagnosed tuberculosis (TB; 52%) and nonsteroidal anti-inflammatory drug (NSAID; 32%) use. Intravenous fluid was the therapeutic mainstay; only seven were dialyzed. Discharge median serum creatinine (SCr) was higher in the TDF group (p = .032) and fewer in the TDF group recovered renal function after 3 months (p = .043). Three-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. 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 coinfection in HIV-infected patients with AKI warrants more intensive monitoring. In all those with poor renal recovery, our data suggest that a lower threshold for dialysis is needed.
authors.affiliation: 1 Department of Internal Medicine, Faculty of Health Sciences, University of Witwatersrand , Johannesburg, South Africa .
authors.forename: Faheem
authors.initials: F
authors.lastname: Seedat
authors.affiliation: 2 Perinatal HIV Research Unit (PHRU), MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand , Johannesburg, South Africa .|3 Johns Hopkins University Centre for TB Research , Baltimore, Maryland.
authors.forename: Neil
authors.initials: N
authors.lastname: Martinson
authors.affiliation: 2 Perinatal HIV Research Unit (PHRU), MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand , Johannesburg, South Africa .
authors.forename: Katlego
authors.initials: K
authors.lastname: Motlhaoleng
authors.affiliation: 2 Perinatal HIV Research Unit (PHRU), MRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand , Johannesburg, South Africa .
authors.forename: Pattamukkil
authors.initials: P
authors.lastname: Abraham
authors.affiliation: 4 Council for Scientific and Industrial Research , Pretoria, South Africa .
authors.forename: Dalu
authors.initials: D
authors.lastname: Mancama
authors.affiliation: 1 Department of Internal Medicine, Faculty of Health Sciences, University of Witwatersrand , Johannesburg, South Africa .
authors.forename: Saraladevi
authors.initials: S
authors.lastname: Naicker
authors.affiliation: 1 Department of Internal Medicine, Faculty of Health Sciences, University of Witwatersrand , Johannesburg, South Africa .
authors.forename: Ebrahim
authors.initials: E
authors.lastname: Variava
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced* / Q000453:epidemiology* / Q000473:pathology; D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000009:adverse effects* / Q000627:therapeutic use; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy*; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D000068698:Tenofovir / Q000009:adverse effects* / Q000627:therapeutic use; D014376:Tuberculosis / Q000453:epidemiology / Q000401:mortality; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents; D000068698:Tenofovir
keywords: HIV; South Africa; acute kidney injury; mortality; renal insufficiency; tenofovir