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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 28
| Issue : 2 | Page : 119-126 |
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Microalbuminuria among HIV-infected patients from a tertiary health facility in northwest Nigeria
Bawa I Abubakar1, Kabiru Abdulsalam2, Sanni Musa3, Isah A Yahaya2, Sani Adamu4, Daniel O Aina5
1 Department of Chemical Pathology, College of Medical Sciences, Abubakar Tafawa Balewa University, Bauchi, Nigeria
2 Department of Chemical Pathology and Immunology, College of Health Sciences, Bayero University Kano, Kano, Nigeria
3 Department of Chemical Pathology, College of Medicine, Kaduna State University, Kaduna, Nigeria
4 Department of Chemical Pathology, College of Medical Sciences, Gombe State University, Gombe, Nigeria
5 Department of Chemical Pathology, Jos University Teaching Hospital, Jos, Nigeria
| Date of Submission | 03-Jun-2022 |
| Date of Decision | 21-Sep-2022 |
| Date of Acceptance | 22-Nov-2022 |
| Date of Web Publication | 21-Mar-2023 |
Correspondence Address:
Bawa I Abubakar
Department of Chemical Pathology, College of Medical Sciences, Abubakar Tafawa Balewa University, Bauchi
Nigeria
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijmh.IJMH_46_22
Background: Microalbuminuria and gradual reduction of glomerular filtration rate (GFR) are some of the early manifestations of renal involvement in HIV/AIDS. Therefore, early detection of microalbuminuria provides an opportunity to identify individuals at risk of developing chronic kidney disease, creating a platform for the institution of preventive measures and optimization of comorbid conditions. Objective: The main objective of this study was to determine the prevalence of microalbuminuria in HIV/AIDS-infected adults in a tertiary heath institution in Nigeria. Materials and Methods: A descriptive cross-sectional study was carried out among 750 participants including 250 highly active antiretroviral therapy (HAART)-treated and 250 HAART-naive HIV/AIDS participants and 250 age-matched controls. An interviewer-administered structured questionnaire was used to collect relevant demographic and clinical information. Blood and urine samples were collected for serum creatinine and urinary albumin and creatinine measurements, respectively, and the results were collated and analyzed. Data were analyzed with SPSS version 20.0 with level of significance set at P < 0.05. Results: The prevalence of microalbuminuria among HIV/AIDS-infected participants was 20.6% when compared with 4.0% for the control group with statistically significant difference (P = 0.001). HAART-treated and HAART-naive groups have prevalence of 18.4% and 22.8%, respectively, with no statistically significant difference (P = 0.22). Low CD4 count and estimated GFR <90/mL/min/1.73 m2 were associated with the development of microalbuminuria. Conclusion: This study has shown that microalbuminuria is common among both HAART-treated and HAART-naive HIV/AIDS patients. Screening for microalbuminuria is recommended in all HIV/AIDS patients to allow for early detection of renal damage. Keywords: Highly active antiretroviral therapy, HIV/AIDS, microalbuminuria
How to cite this article:
Abubakar BI, Abdulsalam K, Musa S, Yahaya IA, Adamu S, Aina DO. Microalbuminuria among HIV-infected patients from a tertiary health facility in northwest Nigeria. Int J Med Health Dev 2023;28:119-26 |
How to cite this URL:
Abubakar BI, Abdulsalam K, Musa S, Yahaya IA, Adamu S, Aina DO. Microalbuminuria among HIV-infected patients from a tertiary health facility in northwest Nigeria. Int J Med Health Dev [serial online] 2023 [cited 2023 May 28];28:119-26. Available from: https://www.ijmhdev.com/text.asp?2023/28/2/119/372149 |
| Introduction | |  |
About 38 million people were living with HIV/AIDS globally as at 2018. Out of these, only 23.3 million had access to antiretroviral therapy (ART).[1],[2] Africa accounts for more than two-thirds of the people living with HIV/AIDS globally, among which 20.6 million reside in East and Southern Africa.[1],[2] In Nigeria, an estimated 1.9 million are living with HIV/AIDS as at 2018, which represents a prevalence rate of 1.5%.[2] However, the prevalence rate of HIV/AIDS in North West Nigeria is 0.6%, whereas that of Kano is 0.5%, with an estimated 55,950 people living with the disease.[2]
Among the early laboratory findings of renal involvement in HIV-infected patients is the presence of microalbuminuria.[3],[4],[5],[6] It is defined as a urinary albumin excretion (UAE) of 30–300 mg/day or 20–200 µg/min.[5],[6] Microalbuminuria is also defined as albumin creatinine ratio (ACR) ≥ 2.5 mg/mmol in males and ≥ 3.5 mg/mmol in females or, with both albumin and creatinine measured by mass, as an ACR between 30 and 300 mg/g creatinine, using spot urine sample.[5],[6],[7] Measurement of UAE in a 24-h urine collection is the gold standard method to determine the presence of microalbuminuria biochemically. However, on the basis of the prospective cohort study conducted on 241 participants, with each of the participants providing three different urine samples, i.e., 24-h, early morning urine, and spot urine samples, it was observed that the ACR in the early morning urine sample best aligned with the 24 h UAE in the determination of microalbuminuria when compared with spot urine samples.[8]
HIV/AIDS is found to affect almost all the major organs of the body. These include the kidneys, liver, adrenals, CNS, among others. These affectations will result in disease conditions such as chronic kidney disease, liver failure, adrenal insufficiency, HIV dementia complex, and so on.[9]
Incidence of microalbuminuria in ambulatory patients with HIV/AIDS was reported in Newark, NJ, USA. A total of 72 HIV/AIDS HAART-naive patients were studied with 19.4% of the patients having microalbuminuria, whereas 50% had proteinuria similar to what is seen in patients with diabetic nephrotic syndrome.[10]
Another study by Baekken et al.[11] showed that the prevalence of microalbuminuria was found to be 8.7% in the HIV/AIDS subjects, three to five times higher.
A cohort study conducted in Ilorin to determine the prevalence of microalbuminuria among ambulatory HIV/AIDS HAART-naive participants showed a prevalence of 35.6% against 13.3% in HIV-negative individuals (control).[12]
In a study conducted in Jos, Nigeria, to determine the prevalence of microalbuminuria in HIV/AIDS patients before commencement of HAART, increased UAE was present in 39 (19.5%) subjects and 5 (5.0%) controls.[13]
In another study conducted on HIV/AIDS HAART-naive patients in Kano, Nigeria, to determine the prevalence of microalbuminuria, 17.5% of the participants had microalbuminuria with a significant number of these patients (16%) having low estimated glomerular filtration rate (eGFR). However, this study did not evaluate patients on HAART.[14]
Microalbuminuria has been consistently shown to be associated with decreasing eGFR and low CD4 counts in HIV/AIDS.[10],[11],[12],[13],[14]
Although the prevalence of HIV/AIDS in Nigeria is on the decline, patients are still at risk of HIV-associated nephropathy and ultimately end stage renal disease, not only as a result of viral infection but also as a result of long-term use of HAART.[1],[2] Furthermore, a previous study of microalbuminuria in the same study area did not consider its prevalence among HIV/AIDS patients on HAART.[14] Therefore, the aim of the study was to determine the prevalence of microalbuminuria in HIV/AIDS adult patients on HAART in Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria when compared with HAART-naive HIV/AIDS patients and controls.
| Materials and Methods | | |
The study was conducted at Professor S.S. Wali Treatment Centre of AKTH, Kano, Nigeria, between February 2020 and December 2020 among HIV-positive patients attending the facility and HIV-negative controls.
Ethical considerations
Ethical approval for the study was obtained from the Health Research Ethics Committee/Ethical Research Committee of AKTH, Kano, Nigeria and issued on April 12, 2019. Ethical clearance number is AKTH/MAC/SUB/12A/P-3/VI/2580
All the participants consented to the study by means of a written informed consent form.
Study type and population
This was a descriptive cross-sectional study which includes consenting HIV/AIDS patients on HAART between 18 and 45 years of age and age-matched HIV/AIDS HAART-naive patients attending Professor S.S. Wali HIV Clinic of Aminu Kano Hospital. The sample size was determined using Fisher’s formula using the prevalence rate of 17.5% from the previous study conducted in Kano, Nigeria.[14],[15] Consequently, 250 HIV/AIDS participants on HAART served as group I and 250 HIV/AIDS HAART-naive participants served as group II. Also 250 HIV-negative apparently healthy volunteers served as controls (group III). Therefore, a total of 750 participants were enrolled for the study.
Patients with hematuria or overt proteinuria, or a history of hypertension, diabetes mellitus, renal disease, and previous diagnosis of microalbuminuria were excluded from the study. Pregnant and lactating mothers, patients with signs and symptoms of urinary tract infection (UTI) or who are on treatment for UTI, as well as individuals above 45 years were also excluded from the study.
Sampling and data collection methods
Study participants were selected using the systematic sampling technique. The sample frame of eligible participants was generated from the list of patients on each clinic day visit. The patients were numbered serially and the total number constitutes the sampling frame. The sample interval was computed on the basis of the required sample size for the three groups and the total number of patients (that are on that regimen) booked for appointment. The selected study participants were then identified and recruited for the study on their clinic day. In addition, consenting age-matched HIV/AIDS-negative healthy volunteers were consecutively recruited in the study from blood donors and clients at the voluntary counselling and testing units. An interviewer-administered structured questionnaire was used to collect relevant demographic and clinical information.
Laboratory methods
Visual inspection and dipstick examination of the urine samples were carried out. The levels of urinary creatinine and serum creatinine concentrations for all subjects were measured using an Architect c4000 Automated Clinical Chemistry Analyzer (Abbott Diagnostics®; serial number: C461238; IL, USA), which is based on the Jaffe reaction.[16],[17]
Urine albumin determination
Urine albumin was measured using HemoCue Albumin analyzer (HemoCue America, USA) that utilizes the principle of turbidimetric immunoassay.
The urine ACR was calculated mathematically. Results were interpreted using the American Diabetes Association (ADA)-recommended reference values for urinary ACR as follows[18]:
Normal <30 mg/g creatinine
Microalbuminuria 30–300 mg/g creatinine
Macroalbuminuria >300 mg/g creatinine.
The eGFR was calculated using the Cockcroft and Gault formula.[17] Results were interpreted using the Kidney Disease Improving Global Outcome (KDIGO) criteria.[19]
Data analysis
All data generated from both laboratory analysis and questionnaire were entered into an Excel spreadsheet and subsequently exported into Statistical Package for Social Sciences (SPSS) version 20.0 for processing and analysis. Frequencies and percentages were used to describe categorical variables. Comparison of categorical variables for associations was conducted in most cases using the χ2 test with P < 0.05 being statistically significant.[20] In situations in which the tables contained empty cell numbers, Fisher’s exact test was used for the comparison.[20] The prevalence of microalbuminuria was presented as percentages.
| Results | | |
The mean age for groups I, II, and III were 33.46 ± 7.2, 31.70 ± 6.74, and 32.20 ± 7.03 years, respectively, with no statistically significant difference (P = 0.4224) observed [Table 1].
This study shows a slight female preponderance in groups I and II and a slight male preponderance in group III with a male-to-female ratio of 1:2.3, 1:1.4, and 1.3:1 for groups I, II, and III, respectively [Table 2].
The prevalence of microalbuminuria among all the study participants irrespective of the HIV status was 15.1%. However, the prevalence of microalbuminuria among HIV-infected subjects was 20.6%. The microalbuminuria prevalence among the different study groups was 18.4%, 22.8%, and 4.0% in groups I, II, and III, respectively [Table 3]. There was a statistically significant difference in the prevalence of microalbuminuria between groups I and III (P = 0.001) as well as between groups II and III (P = 0.001) but no significant difference was observed between groups I and II (P = 0.22) [Table 3].
Majority of the participants in all the three groups had normal body mass index (BMI). However, participants in group I had the highest proportion of those with class I (25.2%), class II (11.2%), and class III obesity (1.2%). In contrast, participants in group II had the highest proportion of underweight (17.2%). The difference in BMI among the three groups was statistically significant (P < 0.001) [Table 4].
Majority of participants in all the groups have eGFR greater than 90 mL/min/1.73 m2, with the control group having the highest percentage of participants with eGFR >90 mL/min/1.73 m2 [Table 5]. About 82.6% of the participants with microalbuminuria in group I and 78.9% of the particiants with microalbuminuria in group II had eGFR ≥ 60 mL/min/1.73 m2; this difference was statistically significant [Table 6].  | Table 6: Relationship between eGFR and microalbuminuria in the study subjects
Click here to view |
The CD4 count of HIV-infected study subjects shows a statistically significant differences in CD4 count between groups I and II [Table 7]. In addition, microalbuminuria was found among participants with CD4 count of less than 500 cells/mm3 in both groups I and II. There was a statistically significant association between CD4 count and the development of microalbuminuria in both the groups [Table 8].  | Table 8: Relationship between CD4 count and microalbuminuria (MA) in the study subjects
Click here to view |
| Discussion | | |
This study demonstrated that in both the HAART-treated and HAART-naive groups, majority of the participants were between 23 and 37 years of age. This suggests that HIV/AIDS affects individuals at their prime, as obtained in most developing nations, with consequent loss of productivity and resultant socio-economic effects. Possible explanation to this finding is the fact that participants in this age group are likely to be more sexually active with increased tendency of unprotected sexual intercourse, drug abuse, and other negative acts associated with increase sexual drive. This observation is in agreement with the United Nation Progress report on Nigeria, 2019, which stated that drug abuse and unprotected sexual intercourse are among the leading causes of HIV in this age group.[1]
A slight female preponderance was found in this study, and this corroborates the findings by Laah and Ayiwulu in Nasarawa (North-Central Nigeria) and that reported by Nwozor and Nwankwo in Awka (South-East Nigeria) with a female preponderance of 51.5% and 68.9%, respectively.[21],[22] These findings may just be a reflection of better health-seeking behavior in females. A similar female preponderance was reported in other studies conducted outside Nigeria by Owusu[23] in the eastern region of Ghana as well as Pettifor et al.[24] in South Africa. This finding may be related to the increased risks of acquiring HIV infection among females when compared with their male counterparts as a result of cultural and religious values that permit polygamy, low socioeconomic status of females when compared with males and favouritism of male education within our communities.
However, Iliyasu et al.[25] reported a male preponderance of 54.6% in Kano (North-West Nigeria). Furthermore, in contrast to HAART-treated and HAART-naive groups, sex distribution among the control group revealed a male preponderance, and this may be attributed to the fact that most of the participants in this group were recruited from the blood donor clinic, in which most of the donors were males.
The prevalence of microalbuminuria (18.4%) among HAART-treated HIV/AIDS subjects reported in this study is similar to the 20.8% reported by Yusuf et al. in Zaria (North-West Nigeria), 18.6% by Wantakisha et al. in Zambia, 19.4% by Luke et al. in New Jersey, and 18.1% by Guiller et al. in France.[10],[26],[27],[28] However, the prevalence is much lower than that reported by Adedeji et al.[29] and Katia et al.,[30] who reported higher prevalence rates of 51.9% and 49.7%, respectively. The higher prevalence rates observed in their studies may be attributed to their larger sample sizes, the prospective nature of those studies, and the inclusion of study participants with ages above 45 years.[29],[30] In addition, hypertension and diabetes mellitus were not exclusion criteria in some of those studies.[29],[30] In contrast, our finding is higher than that reported by Hadigan et al.[31] (14.0%), and this variation could be ascribed in part to a smaller sample size and the fact that their study population was predominantly Caucasian, who are less likely predisposed to HIV-associated nephropathy and other renal diseases, compared with individuals of African descent.
The prevalence of microalbuminuria among HIV/AIDS HAART-naive subjects in this study is similar to the report of Dalili and colleagues in Jos (North-central Nigeria), Struik et al. (Malawi), Han and colleagues (South Africa), and Luke et al. (New Jersey), in which they found 19.5%, 23.3%, 24.0%, and 19.4%, respectively.[10],[13],[32],[33] The ethno-geographical status of the study subjects in this study closely resembles that of Dalili and colleagues,[13] Struik et al.[32] and Han’s[33] study population, and this may be partly responsible for the closeness of the findings.[13],[32],[33] In contrast, the prevalence of microalbuminuria among the HAART-naive group was higher than the 17.5% reported by Sakajiki et al.[14] in Kano (North-west Nigeria). Likewise, Yanagisawa et al.[34] from Japan, Baekken et al.[11] in Oslo, Norway, and Szczech et al. (USA) reported lower prevalences of 13.2%, 8.7%, and 11.0%, respectively.[35] These findings could be attributed to the fact some of the studies used spot urine samples which has lower sensitivity compared with the early morning urine sample used in this study.[8] The latter studies (Japan, USA, Norway), in which healthcare accessibility, availability, affordability, as well as good healthcare-seeking behavior by individuals with HIV/AIDS and are more likely to present early before complications set in, may partly explain the lower prevalence rates observed.[11],[34],[35] Nonetheless, the prevalence of 22.8% for HAART-naive participants reported in this study is lower than what was observed by Kwaifa and Bason in Zaria (Northwest Nigeria), Komolafe et al. (Ilorin, North-central Nigeria) and Abene and colleagues who observed 33.1%, 35.6%, and 29.8%, respectively.[12],[36],[37] It is well established that glomerular changes occur with advancement in age[38]; thus, the older participants recruited in the latter mentioned studies may account for the higher prevalence rates.[12],[36],[37] This is also true in our study in which the proportion of participants with microalbuminuria was significantly higher among patients aged 28 years and above, thereby constituting an independent predictor of microalbuminuria. Also, the higher sample size in the above studies and the different criteria used in the definition of microalbuminuria in those studies may be contributory.
Again, a much lower prevalence was found in the control groups compared with the HAART-naive and HAART-treated groups. This is not unexpected because the study group consisted of mainly young apparently healthy people who do not have HIV/AIDS infection and are not on HAART, so are less likely to develop glomerular disease leading to microalbuminuria. This finding is similar to reports from earlier studies.[12],[13],[14],[26]
Although majority of the study participants had normal BMI, the proportion of those with high BMI (overweight, class I, class II, and class III obesity) and those who are underweight may affect the true value of eGFR, considering the effect of body mass and nutritional status on creatinine.[39]
The control (HIV-negative) group had the highest percentage of participants with normal eGFR. This is unsurprising as HIV-negative adults have been found to generally have higher eGFR levels compared with those who are HIV-positive.[40]
The statistically significant association of low CD4 count with the development of microalbuminuria in both groups of HIV-infected participants is consistent with findings from previous studies.[12],[28],[41] This observation may be due to the fact that lower CD4 counts indicate the degree of immunosuppression and HIV acivity and by extension, an increased likelihood of HIV-associated renal damage.
Limitations of the study
Single measurement of serum creatinine and urine albumin-creatinine ratio used in this study is not as sensitive in detecting microalbuminuria as sequential measurement of UACR, ideally done on at least three occasions in a period of 3–6 months.[42] Therefore, the prevalence found in this study may not be adequately representative of the prevalence of microalbuminuria among the study participants. Viral load, which is a more direct indicator of HIV activity and viral burden than CD4 count, was not measured in this study.
In addition, our study was single-centered and hospital-based; hence, the prevalence of microalbuminuria among HIV/AIDS patients found in this study may not be adequately representative of the general population.
| Conclusion | | |
This study has shown that microalbuminuria is common among both HIV/AIDS HAART-treated and HAART-naive patients. This may suggest that these groups of patients be routinely monitored for the development of microalbuminuria for early detection of renal glomerular dysfunction, so that early institution of therapy may retard the progression of the disease.
Recommendations
We recommend that physicians managing HIV/AIDS patients should routinely screen these patients for microalbuminuria to help in the identification and risk stratification of those susceptible to renal disease, so that appropriate measures can be instituted. Laboratories may consider adopting more sensitive methods of determination of microalbuminuria such as sequential measurement of UACR (at least three occasions in a period of 3–6 months) to improve the detection rates for microalbuminuria.[39] Multi-centered and community-based studies with a larger sample size should be carried out to determine the prevalence of microalbuminuria that would be more representative of the general population and of patients with HIV/AIDS.
Acknowledgement
The authors wish to appreciate the efforts of Prof. Azinge Elaine Chinyelu (Chemical pathology, LUTH, Lagos) and Dr. Dauda E. Suleiman (Histopathology, ATBUTH, Bauchi) for their valuable advice and contributions to the manuscript.
Financial support and sponsorship
Nil.
Conflicts of ineterst
The authors declare no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
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