POS-238 The evolving spectrum of renal histology in HIV positive patients in South Africa in the antiretroviral and tuberculosis era

Abstract

The spectrum of HIV related kidney diseases is evolving, however there are likely to be regional influences. South Africa [SA] is still challenged by the highest burden of HIV worldwide and the highest roll out of antiretroviral therapy [ART]. SA is also dealing with a combined epidemic of tuberculosis [TB] and increasing numbers of people living longer on ART, predisposing to non-communicable diseases. The aim of this study was to retrospectively review and classify all HIV positive renal biopsies at Groote Schuur Hospital[GSH] Cape Town from 2005-2018 according to the KDIGO schemata and review trends. Biopsies were subdivided into 4 main groups 1. HIVAN, 2. Immune complex GNs, 3. Tubulointerstitial diseases and 4. Other. Follow up data on creatinine, eGFR and UPCR were collected over 24 months. Mortality was recorded from electronic clinical records: and HIV clinics. This retrospective study included all HIV-positive patients undergoing a renal biopsy at [GSH] between January 2005 and December 2018. Ethical approval was obtained from the University of Cape Town. All biopsies were reviewed in accordance with the HIV KDIGO classification schemata. Baseline demographic data [ age, gender, sex and ethnicity] were collected. Laboratory data were collected at baseline [HIV viral load, CD4 count, creatinine, eGFR, UPCR, haemoglobin, albumin, hepatitis B and C, anti-nuclear antibody, anti-double-stranded DNA, VDRL, anti-streptolysin titre, anti-DNase B titre, and complement). Clinical features included need for dialysis, kidney sizes on ultrasound, oedema and blood pressure. History of tenofovir, rifampicin and co-trimoxazole use were documented, as well as dates of ART and TB treatment. Creatinine, eGFR and UPCR were collected up to 24 months. Mortality was recorded from electronic clinical records and HIV clinics. Of the 538 biopsies reviewed, the majority were black African (87%), the median age was 36.8 years. Eighteen percent of patients were on ART in 2006 which peaked at 97% in 2016 and has subsequently declined to 70%. 7.8% of patients had hypertension, 3.7% diabetes and 17% were coinfected with Hepatitis B. There was a reduction in the proportion with HIVAN [80% of biopsies in 2005 declined to 20% however has been rising since 2017].The proportion of patients having an ICGNs was stable over the study period. The most common ICGN was membranoproliferative GN. There was a notable rise in tubulointerstitial disease [119 patients]; 64 had granulomatous intersitital nephritis [GIN], 20 had acute interstitial nephritis [AIN]. There has been a specific increase in the proportion of GIN from 2005 which peaked at 70% in the 2014 with a gradual decline to 25%. ART improved survival in all subgroups. Improvement in renal function was not association with ART in the ICGN group. The survival of patients with GIN was poor without ART. ART therapy has shifted the landscape of HIV-associated kidney disease however there is a disturbing increase in HIVAN over the last couple of years which may be attributed to nonadherence. Tuberculosis is also impacting significantly on renal disease in SA. The spectrum of kidney disease in HIV is clearly influenced by regional factors.