HIV infection is a public health problem facing the world. The global prevalence of HIV has increased from 31 million in 2002 to an estimated 40.0 million as at end of 2023, almost 3 million are children aged less than 15 years [1]. Each day, approximately 685 children became infected with HIV and approximately 250 children died from AIDS related causes [1]. HIV is now a manageable chronic disease due to available and effective antiretroviral therapy (ART) [2]. Treatment focus is now on management of HIV-related morbidities of which renal dysfunction is key amongst them.

Renal disease is a common non-infectious complication of HIV [3]. The mechanisms of renal affectation by HIV are multiple. They range from active replication of the virus itself within renal cells causing HIV-associated nephropathy (HIVAN), drug related side effects from prolonged exposure to ARTs like tenofovir, immune-complex kidney disease, chronic diseases that co-exist including hypertension and diabetes [4]. HIV related kidney disease is more common in the Black population. Among persons with HIV infection who receive dialysis, 91% were black according to the US Renal Data system [5]. This warrants earlier detection and management amongst disadvantaged populations especially when at risk of double burden of communicable and non-communicable diseases [6].

Proteinuria is the first sign of renal injury and is preceded by microalbuminuria (MA) which is an amount of urinary albumin that is greater than the normal value but also lower than what is detected by a conventional dipstick [7]. Therefore, it serves as an early screening sign for renal dysfunction. The burden of MA in normal and overweight adolescents [8,9], those with heart diseases [10] and their associated factors have been studied in Sokoto, however, there is no report from the study area in North western-Nigeria on the prevalence and associated factors of MA amongst children with HIV infection, a group at prime risk for renal morbidity, hence, this study. Screening for MA, a more sensitive marker of renal dysfunction, is encouraged to detect early kidney diseases in asymptomatic patients and improve renal outcomes.

The study was conducted at the Paediatric ART Clinic of Usmanu Danfodiyo University Teaching Hospital, Sokoto. The hospital is a major referral center for paediatric cases in the North-Western region of Nigeria and the neighbouring Niger and Benin. The study was a descriptive cross-sectional study. It was conducted between 1st July 2015 and 30^th November 2015. Subjects consisted of HIV-infected children aged 3 months to 15 years presenting to Paediatric ART clinic.

Sample Size Calculation

A previous study in Kano reported a prevalence of 6.7% [11], and was used as follows.

Where n = minimum sample size, z = 1.96, p = Prevalence, q = 1 - p = 1 – 0.067 = 0.933

                 d = degree of accuracy desired = 0.05

Allowing for 10% attrition rate, the minimum sample size to be selected (n_s) was: 96 + 9.6 = 105.2~ 106. However, at the time of the study less than 100 HIV infected were registered in the clinic and only 53 consented and fulfilled the inclusion criteria.

Inclusion and Exclusion Criteria

All HIV-infected aged 3 month to 15 years presenting to Paediatric ART clinic whose caregivers gave informed written consent were included. While, those who had: febrile illnesses within 2 weeks prior to and at the time of the study, symptoms of urinary tract infection, used antibiotics and non-steroidal analgesics (NSAIDS) 2 weeks prior to the study, menstruating females, any other comorbidity known to affect renal function eg sickle cell disease, taken drugs known to affect protein excretion such as radio-opaque dye and nitrofurantoin within the previous 4 weeks were excluded.

Subject Recruitment

HIV infected children were recruited consecutively. Their demographic data, anthropometry, blood pressure, ART treatment details, and CD4+ T-lymphocyte counts were recorded.

Measurement procedure for MA

The subjects were educated on how to collect urine samples and given labelled sterile universal sample bottles a day prior . The urine sample collected was the early morning urine on getting up from bed to reduce incidence of orthostatic proteinuria. The urine sample was brought to the clinic by the subject. The urine was divided equally and dipstick urinalysis was performed on one of the urine samples to test for protein, leucocytes, blood, nitrite, glucose and specific gravity. Urine samples that tested positive for above were not tested for MA.

The strips for the MA test which are semi-quantitative Micral test strips were used in the second bottle of urine according to manufacturer’s instructions. Depending on the albumin concentration, the detection field ranges in color from white to red. The color scale consists of four colour tones corresponding to albumin concentrations of 0, 20, 50, and 100 mg/l. Level of 20 mg/l is considered positive for MA and corresponds to an albumin excretion rate greater than 30 mg/24 hours [12-14].

Ethical Approval

Ethical approval was obtained from the Ethics and Research committee, UDUTH, Sokoto. Consent and assent where applicable were obtained from the care giver and subject respectively.

Data Analysis

Data was analyzed using Statistical Package for Social Science (SPSS) statistical software (version 20.0). Variables analyzed were gender, age, use & duration of ART, CD4 count,  blood pressure, body mass index, which were independent variables whilst presence of urine dipstick anomalies, MA, and level of MA (based on the dipstick value) were dependent variables. Univariate analysis (mean, median, standard deviation) was done for the continuous variables such as age while frequency tables, charts and proportions were used for the categorical variables such as gender, diagnosis and year of diagnosis. Bivariate analysis (chi square or Fisher’s Exact test) was used to assess relationship of gender, age category, CD4 category, BP, BMI category to the degree of MA. The level of statistical significance was set at p- value <0.05.

Sociodemographic Characteristics

Fifty-three HIV infected children were sampled. Their mean (±SD) age was 9.9±3.2 years (range 3 -15 years). There were 29 males and 24 females with M: F ratio 1.2:1. Table 1 shows that about a third (34.0%) had abnormal urinalysis and were excluded from the Micral test. Sixteen (45.7%) of those with normal urinalysis had positive Micral urine test. This accounted for 30.2% of the total.

Table 1: Socio-demographic and clinical characteristics (n=53).

Mean Clinical Parameters of Subjects In Relation To MA

Table 2 shows the mean age, duration of ART, CD4 cell count, anthropometry and blood pressure of all the subjects. It also depicts the mean difference between these parameters between those with and without MA. Those with MA were older, had higher mean weight, height and systolic BP. They were also on ART for longer duration and had higher CD4 counts. However, they had lower diastolic BP and BMI. All differences were not statistically significant as shown.

Table 2: Mean of clinical parameters and differences in relation to MA.

Association of Categorical Parameters with MA

Table 3 shows the categorical variables of age, duration of ART, CD4 cell count, anthropometry and blood pressure of all the subjects. Microalbuminuria occurred with higher proportion among the older age, females, and those more than 5 years on treatment. The differences were however not statistically significant.

Table 3: Relation of categorical variables with MA (n=53).

RVD = Retroviral disease; OW = overweight; OB = obese; FE = Fisher’s Exact test

Level of Microalbuminuria among the Subjects

Out of the 16 who had MA, 11 (68.8%) had levels of 20mg/ml while 5 (31.3%) had levels of 50mg/ml. These levels were not statistically significantly related to age, gender, duration of ART, level of CD4 count, BMI nor blood pressure.

Blood Pressure Pattern of the Subjects

Figure 1 below shows the pattern of blood pressure distribution among the subjects. Majority (80%) had normal blood pressure.

Figure 1: Blood pressure distribution of subjects.

Clinical Stage of the Study Subjects

Figure 2 shows that majority of the subjects (53%) were in clinical stage 1 of the disease and least had Stage 3.

Figure 2: Shows the proportion with different stages of the disease.

Pattern of Urinary Abnormalities by Dipstick

Out of the 53 HIV infected children, 18(34%) had abnormal dipstick test. The pattern showed majority had bilirubinuria sampled (13.2%).

This study was on a small sample of HIV-infected children to evaluate the prevalence of MA and factors associated with its presence. It has been recommended as a standard routine of care in HIV-infected children as well as in other at risk of cardiovascular and renal dysfunction [7], but this is not the case especially in many settings in Africa.

Microalbuminuria was present in 30.2% of the subjects recruited. This was higher than 6.7% reported by Mudi from Kano [11]. That study used a quantitative test and also tested for persistent MA by repeat testing after 2 weeks. It has been shown in studies by the authors among normal and obese adolescents in Sokoto [8,9] and others elsewhere [15] that repeat testing reduces the prevalence of MA and may reveal those with persistent MA and this is related to their risk profile. This was not done in this present study and may also contribute to the high figure.

Other studies in south Nigeria that used the Micral test with no repeat testing also revealed lower figures than this study. Areprekumor [16] for instance reported a figure of 18.7% with a larger sample size and compared with HIV-uninfected who had 2.7%. Bertilla Uzoma [17] in Enugu, South-east Nigeria found a 0% prevalence which could be due to the shorter duration of infection in their study subjects compared to ours where they were much older. Other studies reported lower prevalences include Ihekaike in Jos of 22.2%, Okechukwu in Abuja of 13.7%, Eke in Port Harcourt with 12%, Iduoriyekemwen in Benin of 11.1% while Nsa in Calabar had higher prevalence of 32.9% [18-22]. Studies in other countries even outside the continent were also lower than this study with not so wide variations in their figures such as El Hammoud in the United States 23%, Mosten 28.8% and Frederick 20.4% in Tanzania, Melaine in Cote d’Ivoire 29%, Ekulu in Congo 18% and Sharma in India 20% [23-28]. This shows that MA is common in children with HIV infection and worths monitoring for their renal status or dysfunction.

There was no significant relationship between MA and age, sex, duration of infection, and the use of ART similar to some of the studies [11,22]. It was reported by Nsa [22] that there was no significant association between renal disease and severe HIV disease and that renal disease is common in HIV-infected children with or without medication. S.harma [28] found similar prevalence in those on ART and those not on it of 20% and 21%.

However, in many other studies [26] it was related to the clinical stage especially with older children [23] that have high viral load [19], advanced disease [18,20,21,24] lower CD4 counts [19,20,23,24,28,29] short duration of treatment [24,26], and poor adherence which was not assessed in this study.

These differences may require the need for a stricter control of confounders in the methodology in order to improve on the specificity of the results according to Eke [20].

Mean systolic and diastolic blood pressures at 99+/-9.9mmHg and 63.9+/-9.3 mmHg were slightly higher than reported by Meston [24] in Tanzania (92±9 and 59±8 mmHg) respectively probably because subjects were older in this study. None of the patients in index study was underweight due to the fact probably that most were on ARTs limiting risk for opportunistic infections and recurrent ill health. More than three quarters of children had normal nutritional status in same study [24]. Mean BMI was lower in this study compared to Meston study 14+/-2.3 kg/m² vs 16.3±2.5 kg/m² probably reflecting the general lower nutritional status due to other external influences apart from HIV infection.

In conclusion, MA was high among the population but not significantly associated with disease severity, length of infection, BMI or . Periodic screening for MA using albumin specific dipstick should be considered for children with HIV infection.

Nil

Acknowledgement

Authors acknowledge all patients and caregivers that enabled this study to be done and all those infected or affected by HIV.

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