Absence of HIV-Associated Nephropathy Among Antiretroviral Naive Adults With Persistent Albuminuria in Western Kenya

Introduction: HIV-associated nephropathy (HIVAN) has been strongly linked to African ancestry. However, studies have demonstrated wide variability in the prevalence of HIVAN in different sub-Saharan African populations. Accurate assessment of the disease burden is important because antiretroviral therapy (ART) is increasingly available and may prevent progression to end-stage renal disease. Methods: We prospectively screened ART-naive, afebrile, nonhypertensive, and nondiabetic adults attending a large HIV care program in Western Kenya for the presence of albuminuria (dipstick albumin >= trace or urine albumin to creatinine ratio [UACR] >= 30 mg/g). Those with albuminuria confirmed on 2 occasions, subject to consent, underwent kidney biopsy. Results: Among 523 subjects screened, 85 (16.3%) had albuminuria on the initial screen, and persistent albuminuria was confirmed in 32 of the 53 (60%) who returned for confirmatory testing. A total of 27 subjects with persistent albuminuria underwent biopsy. The median age was 34 years (interquartile range [IQR] 30 - 42 years), and 63% were female. The median CD4 count was 369 cells/ml (IQR 89-492 cells/ml). Renal function was normal in 92%. Median UACR was 257.5 mg/g (IQR 93.5 - 543 mg/g), and 92% had UACR < 1 g/g. No subject had histologic features consistent with HIVAN; 41% had acute interstitial nephritis (AIN); 33% had nonspecific findings, and 2 patients had arteriosclerosis. Focal segmental glomerulosclerosis, acute postinfectious glomerulonephritis, chronic interstitial nephritis, pyelitis, and papillary sickling were seen in 1 patient each. Discussion: Among ART-naive adults with persistent albuminuria at a referral center in Western Kenya, we observed no cases of HIVAN. AIN was the most common cause of persistent proteinuria in this setting.