CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 4, July/August 2014
156
AFRICA
It is important to note that renal biopsies are not routinely
performed in patients with microalbuminuria and normal renal
function.
In a large biopsy series from Cape Town, HIVAN
presented with nephrotic range proteinuria and impaired renal
function.
7
Patients not receiving ART had a poor prognosis.
27,28
Microalbuminuria is non-specific and is amarker of inflammation
and cardiovascular risk independent of renal function.
29
In our small study, no patient had a clinically relevant
reduction in eGFR (
<
60 ml/min/1.73 m
2
), and only one patient
had overt macroalbuminuria, which resolved on treatment
with ART. This suggests that the approximate prevalence of
CKD in an otherwise-healthy HIV population is about 1.6%,
considerably lower than previously reported.
23,30
Importantly, a
high CD
4
count and normal creatinine level does not exclude
renal disease in HIV.
6,7,26
Patients demonstrating proteinuria, who would not normally
be eligible for ART due to an elevated CD
4
count, benefit from
timely initiation of ART, which can greatly improve survival
rates, with stabilisation of eGFR.
7,30
Therefore screening of
patients enrolling into an ART programme, with urine dipsticks
or spot urine sampling for proteinuria should be standard
practice and could have an impact on the prevalence of HIVAN.
This is particularly important in South Africa where, due to the
problem of limited access to renal replacement, there is a need
for early identification and management of renal disease.
In this study, no cases of hypertension were identified, and
there was a small but significant increase in office SBP after
six months on ART. However in a subset of patients, ABP
monitoring did not confirm these findings. ABP monitoring is
the most reliable method of assessing BP and suggests that the
effect of ART on BP may be minimal.
In the ABP substudy there was no difference in mean daytime
SBP and DBP between patients and controls. However the mean
night-time SBP was significantly higher in the HIV group, as
was the proportion of non-dippers compared to the control
group with similar demographics (BMI, age, gender, socio-
economic status). A non-dipping pattern is an established entity,
with important clinical implications, and is associated with a
higher cardiovascular morbidity and mortality rate.
31
The high
prevalence of non-dippers in the HIV-infected group in this
study supports data from Italy and Norway.
9,12
The potential mechanisms underlying the non-dipping
phenomenon in HIV-positive patients are uncertain. It does
suggest an underlying dysregulation of the cardiovascular
system. Chronic infection and arterial inflammation contribute
to endothelial dysfunction, which may be further exacerbated
by ART.
2,3
In addition, HIV-related endocrinopathies (i.e.
hyperaldosteronism and hypercortisolism) and autonomic
dysfunctionmay play a role.
32,33
However, the lack of improvement
in dipping status after six months of ART with suppressed viral
loads suggests that other mechanisms may also be involved.
Our study has several limitations. Firstly, the sample size
for the ABP substudy was small and the nocturnal dipping
status between HIV-positive and HIV-negative controls was
marginal. Secondly, the short length of follow up (six months)
may have been a limitation as the effects of ART on BP and
nocturnal dipping may take longer to manifest. Thirdly, a
single spot sample was used for establishing microalbuminuria.
Also, ABP measurements were conducted during a presumed
typical weekday and we could not objectively observe daytime
activity and duration of night-time bed rest, which has been
shown to affect diurnal BP patterns. Lastly, the HIV-negative
ABP-monitoring control group was recruited from another study.
The focus of HIV care in our country remains viral suppression
and management of opportunistic infections. Our findings
correlate with established evidence linking HIV to increased
cardiovascular risk. Young black females are traditionally at low
risk for cardiovascular disease. However a non-dipping status in
the context of HIV infection could confer a greater risk in this
group.
If there are approximately 5.6 million HIV-positive people
in South Africa, potentially 4.48 million (80%) are non-dippers.
Therefore, as HIV-infected patients are living longer, investigating
and addressing the cardiac and metabolic complications related
to HIV is becoming more important.
The authors acknowledge all the patients in this study and the staff at the
Groote Schuur Hospital hypertension clinic for their participation. The
Faculty of Health Sciences, University of Cape Town research fund provided
the funding.
References
1.
UNAIDS 2012
.
World AIDS Day report.
2.
Fourie CMT, van Rooyen JM, Schutte AE. HIV infection and cardio-
vascular risk in black South Africans [Editorial].
Cardiovasc J Afr
2011;
22
(3): 117–118.
3.
Grinspoon SK. Metabolic syndrome and cardiovascular disease in
patients with human immunodeficiency virus.
Am J Med
2005;
118
(2):
23S–28S.
4.
Durand M, Sheehy O, Baril JG,
et al
. Association between HIV infec-
tion, antiretroviral therapy, and risk of acute myocardial infarction:
a cohort and nested case-control study using Quebec’s public health
insurance database.
J Acquir Immune Defic Syndr
2011;
57
(3): 245–253.
5.
Dave JA, Lambert EV, Badri M,
et al
. Effect of nonnucleoside reverse
transcriptase inhibitor-based antiretroviral therapy on dysglycemia
and insulin sensitivity in South African HIV-infected patients.
J Acquir
Immune Defic Syndr
2011;
57
(4): 284–289.
6.
Arendse C, Okpechi I, Swanepoel C. Acute dialysis in HIV-positive
patients in Cape Town, South Africa.
Nephrology
2011;
16
: 39–44.
7.
Wearne N, Swanepoel C, Boulle A,
et al
. The spectrum of renal histolo-
gies seen in HIV with outcomes, prognostic indicators and clinical corre-
lations.
Nephrol Dial Transplant
2012;
27
(11): 4109–4118.
8.
Gazzaruso C, Bruno R, Garzaniti A,
et al
. Hypertension among HIV
patients: prevalence and relationship to insulin resistance and metabolic
syndrome.
J Hypertension
2003;
21
(7): 1377–1382.
9.
Vittorio G, De Socio L. Negative influence of HIV infection on day–
night blood pressure variability.
J Acquir Immune Defic Syndr
2010;
55
:
356–360.
10. Jerico C, Knobel H, Montero M,
et al
. Hypertension in HIV-infected
patients: prevalence and related factors.
Am J Hypertens
2005;
18
:
1396–1401.
11. Dolan E, Stanton A, Thijs L,
et al
. Superiority of ambulatory over
clinic blood pressure measurement in predicting mortality. The Dublin
outcome study.
Hypertension
2005;
46
: 156–161.
12. Baekken M, Os I, Stenehjem A,
et al
. Association between HIV infec-
tion and attenuated diurnal blood pressure rhythm in untreated hyper-
tensive individuals.
HIV Med
2009;
10
: 44–52.
13. Morar N, Seedat YK, Naidoo DP, Desai DK. Ambulatory blood pres-
