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-naïve, 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/µl (IQR 89-492 cells/µl). 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-naïve 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.

Risk factors for death in HIV-infected adult African patients receiving anti-retroviral therapy.

OBJECTIVE: To determine risk factors for death in HIV-infected African patients on anti-retroviral therapy (ART). DESIGN: Retrospective Case-control study. SETTING: The MOH-USAID-AMPATH Partnership ambulatory HIV-care clinics in western Kenya. RESULTS: Between November 2001 and December 2005 demographic, clinical and laboratory data from 527 deceased and 1054 living patients receiving ART were compared to determine independent risk factors for death. Median age at ART initiation was 38 versus 36 years for the deceased and living patients respectively (p<0.0148). Median time from enrollment at AMPATH to initiation of ART was two weeks for both groups while median time on ART was eight weeks for the deceased and fourty two weeks for the living (p<0.0001). Patients with CD4 cell counts <100/mm3 were more likely to die than those with counts >100/mm3 (HR=1.553. 95% CI (1.156, 2.087), p<0.003). Patients attending rural clinics had threefold higher risk of dying compared to patients attending clinic at a tertiary referral hospital (p<0.0001). Two years after initiating treatment fifty percent of non-adherent patients were alive compared to 75% of adherent patients. Male gender, WHO Stage and haemoglobin level <10 grams% were associated with time to death while age, marital status, educational level, employment status and weight were not. CONCLUSION: Profoundly immunosuppressed patients were more likely to die early in the course of treatment. Also, patients receiving care in rural clinics were at greater risk of dying than those receiving care in the tertiary referral hospital.

Causes of delay in diagnosis of pulmonary tuberculosis in patients attending a referral hospital in Western Kenya.

OBJECTIVE: To determine the length of delays from onset of symptoms to initiation of treatment of pulmonary tuberculosis (PTB). DESIGN: Cross-sectional study. SETTING: Chest/TB clinic, Moi Teaching and Referral Hospital (MTRH), Eldoret, Kenya. SUBJECTS: Newly diagnosed smear positive pulmonary tuberculosis (PTB) patients. RESULTS: Two hundred and thirty patients aged between 12 and 80 (median; 28.5) years were included in the study. They comprised 148 (64.3%, median 30 years) males and 82 (35.7%, median 28 years) females. One hundred and two (44%) came from urban and 128 (56%) came from rural setting covering a median distance of 10 (range 0-100) kilometres and paying Kshs 20 (range 0-200) to facility. Cough was the commonest symptom reported by 228 (99.1%) of the patients followed by chest pain in 214 (80%). The mean patient delay was 11 +/- 17 weeks (range: 1-78 weeks) with no significant difference between males and females, the mean system delay was 3 +/- 5 weeks (range: 0-39 weeks). The median patient, health systems and total delays were 42, 2, and 44 days respectively for all the patients. Marital status, being knowledgeable about TB, distance to clinic and where help is sought first had significant effect on patient delay. CONCLUSION: Patient delay is the major contributor to delay in diagnosis and initiation of treatment of PTB among our patients. Therefore TB control programmes in this region must emphasise patient education regarding symptoms of tuberculosis and timely health seeking behaviour.