In total, 585 patients were screened, data were incomplete in 7patients, leaving 578 patients with

Transcription

1 3.0 RESULTS 3.1 STUDY POPULATION DEMOGRAPHICS In total, 585 patients were screened, data were incomplete in 7patients, leaving 578 patients with complete data, for the purposes of inclusion in this study. The racial representation was as follows: 560 black (97%); ten mixed ethnicity (1.7%); six white (1%); two unknown (0.3%) Number screened females males 50 0 < >60 Age (years) Figure 3.1 Age and gender distribution of screened patients Males comprised 217 (37.5%) and females 361 (62.5%) which reflected the general pattern of gender distribution in the clinic (figure 3.1). The mean age was 37.0 years (range 16-70) and mean CD4 count was 130 cells/mm 3 (range 1-828). On first presentation to the clinic 482/576 patients (84%) could be classified as having AIDS according to CD4 count < 200 cells/mm 3. Baseline HIV RNA viral load quantification was available in 413/585 patients (72%). The relationship between CD4 count and viral load (logarithmic scale) is depicted in figure 3.2. The large proportion of 26

2 patients with high viral load and low CD4 count depicts the advanced stage of HIV disease at the time of first presentation to the clinic Viral load (RNA copies/ml) (log) CD4 count (cells/mm 3 ) Figure 3.2 Viral load and CD4 count at screening (data for 413/585 patients) 3.2 URINARY ABNORMALITIES OTHER THAN PROTEINURIA ON INITIAL SCREENING The study was designed to screen urine for proteinuria as a marker of chronic kidney disease (CKD). It soon became apparent that there were additional abnormalities on urine dipstick that had not been part of the study protocol. These results have important clinical implications for the comprehensive management of HIV patients and for this reason the data although incomplete, has been included LEUCOCYTES / NITRITES All urine dipstick specimens that were positive for leucocytes and/or nitrites were sent to the laboratory for microscopy, culture and sensitivity (MCS). 175 patients screened had leucocytes 27

3 (±nitrites) on dipstick (30.28%). Of those specimens sent to the laboratory, leucocytes (±nitrites) were confirmed in 64.00% of cases (table 3.1). Table 3.1 Abnormalities on screening with Combur 9 urine test strips TEST STRIP PARAMETER NUMBER POSITIVE TEST STRIP RESULTS Leucocytes, no nitrites 161/ Leucocytes and nitrites 14/ Test strip leucocytes / nitrites confirmed on laboratory microscopy *Blood, Haemoglobin, Myoglobin 112/ / Males 55/191 Females (menses) 10/191 Females (no menses) 19/191 Females (menses unknown) 107/191 PERCENTAGE (%) OF TOTAL NUMBER OF TESTS POSITIVE *Not all test strip specimens positive for blood, haemoglobin or myoglobin were sent for confirmation to the laboratory. The primary decision to send urine for MC+S was based on the presence of leucocytes and/or nitrites Table 3.2 depicts MCS results of the urine specimens that were processed by NHLS. Of the specimens sent, 141/175 results for MCS are available. Some specimens sent were not received at the laboratory and others were not processed due to laboratory error (spillage). Table 3.2 Urine microscopy, culture and sensitivity (MCS) results URINE RESULTS CULTURE: POSITIVE CULTURE: NEGATIVE CULTURE: MIXED ORGANISMS OF DOUBTFUL SIGNIFICANCE (MODS) Number of 41/141 (29.1%) 54/141 (38.3%) 46/141 (32.6%) specimens 1 leucocytes 34/41 (82.9%) 40/54 (74.1%) 32/46 (69.6%) 1,2 erythrocytes 9/41 (22.0%) 11/54 (20.4%) 5/46 (10.9%) 1 Normal laboratory reference: <1000 cells/ml urine 2 No comment made by laboratory on whether erythrocytes were dysmorphic 28

4 Initially, it was assumed that most cases with leucocyturia were due to urinary tract infection (UTI) but approximately only one third of the specimens processed isolated an organism. One third each, showed culture negative leucocyturia (CNL) and mixed organisms of doubtful significance (MODS). In the group with confirmed UTI, 70% were caused by E.Coli, with 90% of isolates resistant to cotrimoxazole (table 3.3). Of note, three patients with extended spectrum beta-lactamase (ESBL)- producing organisms were isolated, two of whom had recently been admitted to a hospital which was the most likely source of infection. Table 3.3 Positive urine culture results MICRO-ORGANISM NUMBER RESISTANCE TO CTMX 1 ESBL 2 - PRODUCER E.Coli 29/41(70%) 26/29(90%) 1 3 Klebsiella species 5/41(12%) 4/5 (80%) 1 3 Staphylococcus aureus 2/ Enterobacter species 1/ Enterococcus faecalis 1/ Proteus mirabilis 1/ Streptococcus agalactiae 1/ Streptococcus viridans 1/ CTMX - co-trimoxazole (trimethoprim and sulphamethoxazole) 2 ESBL-PRODUCER extended spectrum beta-lactamase producing organism 3 Two of three patients had recently been admitted to a hospital, the most likely source of the resistant organism As the pattern of MODS and culture negative leucocyturia became more apparent, it was decided to ask patients (where possible) about other common potential causes of leucocyturia, such as treatment/symptoms of tuberculosis (TB) and sexually transmitted infection (STI). A number of those asked, confirmed the presence of symptoms of either one of these conditions. In the group with MODS, 32 had laboratory confirmed leucocyturia. Six had TB-related disease (19%), one had a high grade cervical squamous intra-epithelial lesion (SIL-2) on Papanicolau (PAP) smear and one 29

5 was on chemotherapy for Kaposi s sarcoma. In the group with CNL, 40 had laboratory confirmed leucocyturia. Eight had STI s (20%), including four cases of syphilis and six had TB-related disease (15%) (figure 3.3). None of the urine samples from these two groups were sent off for TB culture, emphasising the diagnosis of TB was outside of the urogenital tract. Of the 12 cases of TB, four were sputum positive (one with multiple drug resistant TB), three had been started on TB treatment prior to referral to the clinic, one each had mycobacterium avium complex on blood culture, tuberculous lymphadenitis, CNS tuberculoma and two were started empirically based on clinical signs and symptoms specimen STI total TB STI total 0 MODS CNL TB Figure 3.3 Concomitant disease with MODS and CNL groups MODS: mixed organisms of doubtful significance CNL: culture negative leucocyturia TB: tuberculosis STI: sexually transmitted infection Total: total number of cases confirmed with laboratory MCS HAEMOGLOBIN / MYOGLOBIN / ERYTHROCYTES Microscopic haematuria on dipstick (32.6%) was another frequent finding which was not included in the study design. The menstrual status was unknown in 79% of women screened. Approximately one third of dipstick positivity for blood was detected in men. Because it was not considered within 30

6 the scope of this study to investigate causes of microscopic haematuria, urine from these specimens was not sent for further investigation. The prevalence of laboratory confirmed erythrocyturia can be seen within the three groups defined in tables 3.1 and 3.2. It would be considered acceptable for microscopic haematuria to be present in confirmed cases of UTI, but it is noteworthy that in the MODS and CNL groups, the prevalence of haematuria was 10.9 and 20.4% respectively. 3.3 PROTEINURIA ON INITIAL SCREENING Laboratory data on proteinuria was available on 578/585 patients screened. 253/578 (43.7%) showed urine dipsticks positive for proteinuria, which included Micral (microalbumin) and Combur /253 (76.3%) of specimens sent were confirmed by the laboratory. After application of the definitions for albuminuria/proteinuria stipulated for this study (although for screening only a single urine sample was sent) 158/193 specimens were included in the data set; 34 specimens were excluded from analysis as their levels of microalbumin were too low for inclusion in the study. The microalbuminuric group was by far the largest, with overt and nephrotic range proteinuria forming progressively smaller proportions: Microalbuminuria: (NHLS definition: mg/mmol) = 107/578 (18.5%) Overt proteinuria (range: g/mmol) = 37/578 (6.4%) Nephrotic range proteinuria (range g/mmol) = 14/578 (2.4%) MICROALBUMINURIA Depending on the definition used, the prevalence of microalbuminuria in the screened population can be seen in figure 3.4. There appears to be little difference between the definitions applied to the data with respect to gender and whether the albumin: creatinine ratio or albumin concentration alone is used. With regard to the high normal ranges of albuminuria that have been more recently recommended, the data showed an additional 32 patients that would have been screened if these criteria were applied. If a pre-screening value of >10mg/L albumin were used, which has been 31

7 recently recommended in those at risk for cardiovascular disease, 142 as opposed to 107/578 patients would have been included in the microalbuminuric data set (de Jong and Curhan, 2006) num ber males females mg/L Definition of microalbuminuria mg/mmol (spot urine) 4 Figure 3.4 Prevalence of microalbuminuria on screening according to definition used mg/L: international guidelines (de Jong and Curhan, 2006) mg/mmol: local laboratory mg/mmol: international guidelines for females (de Jong and Curhan, 2006) mg/mmol: international guidelines for males (de Jong and Curhan, 2006) mg/mmol: high normal range microalbuminuria: international guidelines for females (de Jong and Curhan, 2006) mg/mmol: high normal range microalbuminuria: international guidelines for males (de Jong and Curhan, 2006) Regression analysis was performed to determine whether a correlation existed between creatinine (a marker of muscle mass) and weight in the microalbuminuric group. No correlation was found between microalbumin concentration (mg/l) versus weight and microalbumin creatinine ratio versus weight (figure 3.5) 32

8 microalbumin (mg/l) weight (kg) 60 Microalbumin: creatinine ratio (mg/mmol) weight (kg) Figure 3.5 Regression analysis for microalbuminuria versus weight (above) and microalbumin: creatinine ratio versus weight (below) in screening population 33

9 PATTERNS OF DISEASE ON SCREENING ACCORDING TO SEVERITY OF ALBUMINURIA / PROTEINURIA Table 3.4 is a summary of characteristics of the screened population (158/578; 27.3%) who had albuminuria/proteinuria. Included in the table are reasons for exclusion from the study, as per protocol (chapter 2). Of note, in the microalbuminuric group the prevalence of co-morbid disease was high (predominantly infection) and those with persistent proteinuria requiring renal biopsy was small. In the overtly proteinuric group there was still co-morbid disease and a proportional increase in those requiring renal biopsy. Those with nephrotic proteinuria (as expected) all had chronic kidney disease (CKD) and ideally required renal biopsy. 3.4 PERSISTENT PROTEINURIA AND RENAL BIOPSY The previous sections have dealt with results from the screening component of this study. This section describes those with persistent microalbuminuria, overt and nephrotic proteinuria who underwent renal biopsy, initiation of ART with/out ACE-I, with follow up for at least 12 months PERSISTENT MICROALBUMINURIA Table 3.5 depicts clinical and laboratory data for the microalbuminuric group. Of those screened with microalbuminuria (107/158) 10.3% had persistent proteinuria requiring renal biopsy, of which 8/11 gave consent for biopsy. Follow up in this group has been variable depending upon when they were recruited and has been quantified for each patient. At the stipulated follow up, laboratory tests were repeated (included in parentheses). The patients have been discussed as per allocated numbers in table 3.5. In this group, of the eight patients who underwent renal biopsy, six underwent repeat renal biopsy and two were lost to follow up. One patient who was lost to follow up had developed pneumocystis jiroveci pneumonia (PJP) and deranged liver function after her initial renal biopsy. She was treated with phenytoin for seizures thought to be secondary to multiple calcific granulomata seen on brain CT scan. She had received TB treatment in She attended the outpatient clinic only once after her acute illness and could not be traced thereafter. 34

10 Table 3.4 Characteristics of screening population according to severity of proteinuria ALBUMINURIA/ PROTEINURIA MICRO- ALBUMINURIA ( mg/mmol) CO-MORBID DISEASE IN SCREENED POPULATION INFECTION CARDIOVASCULAR DM 1 MALIGNANCY CKD 2 EXCLUSION CRITERIA TB 3 26 Hypertension 13 Breast cancer 1 Advanced 5 UTI 4 16 Cardiomyopathy 1 Kaposi s disease STI 5 7 Congenital heart 1 Sarcoma 1 Started ART 6 8 Other 3 disease before biopsy Post partum 3 Co-morbid 74 disease OUTCOME Lost to 28 follow up Proteinuria 18 resolved Died 2 RENAL BIOPSY 8 biopsied (3 declined) 107/158 (67.7%) OVERT PROTEINURIA TOTAL: 52 (49%) TB 3 3 UTI 4 3 Hep. B 7 2 Hep.C 8 1 Other 2 TOTAL:15 (14%) Hypertension 3 TOTAL:5 (4.6%) TOTAL:2 (1.8%) Cervical cancer 1 TOTAL:11 (10.3%) Co-morbid 17 disease CKD 2 5 Lost to 8 Follow up Proteinuria 2 resolved 11/107 (10.3%) 7 biopsied (1: declined) (4: biopsied) (2: CKD 2 : excluded) 37/158 (23.4%) NEPHROTIC PROTEINURIA 14/158 (8.9%) 1 DM: Diabetes mellitus TOTAL:11 TOTAL:3 (30%) (10%) nil Hypertension 1 TOTAL:1 (6.6%) TOTAL: 2 (6%) TOTAL:1 (6.6%) TOTAL:1 (3%) Prostate 1 Cancer TOTAL:8 (23%) TOTAL 1 TOTAL:14 (6.6%) (100%) 2 CKD: Chronic kidney disease CKD 2 4 Malignancy 1 Lost to 3 follow up 7/37 (18.9%) 8 biopsied (1: CKD 2 ) (3: lost f/u) (1:cancer) (1:excluded) 8/14 (57%) 3 TB: Tuberculosis 4 UTI: Urinary tract infection 5 STI: Sexually transmitted infection 6 ART: Antiretroviral therapy 7 Hep. B: hepatitis B surface antigen positive 8 Hep.C: hepatitis C antibody positive 35

11 Table 3.5 Clinical and laboratory data for those with microalbuminuria undergoing renal biopsy (values in parentheses are at follow up) Patient 1 (MN) 2 (XN) 3 (EM) 4 (TM) 5 (KR) 6 (NM) 7 (SS) 18 8 (TN) 18 Gender M F M F F F M F age (years) follow up (months) BMI (20.6) 24.3 (23.7) 23.1 (21.1) 18.6 (23.3) 22.6 (23.34) 24.0 (24.4) na 24.3 CD4 count (cells/mm 3 ) 93 (405) 297 (320) 83 (140) 355 (462) 31 (186) 132 (416) 96 (432) 23 HIV-1 viral load > (RNA copies/ml) (<40) (130) (<40) (18000) (<40) (<40) (390) Microalbumin Concentration 2 (4.8) (19) (9.3) (62.4) (3) (16.4) Microalbumin: Creatinine ratio 3 (0.4) (1.7) (0.7) (3.4) (0.5) (4.1) Cockroft/Gault 4 Modified MDRD 5 93 (109) 129 (144) 84 (79.8) 90.1 (85.8) 95.7 (101.1) (125.8) (108.4) 95.9 (123.2) (106.7) (113.7) (124.2) (126.3) ml/min Positive serology 6 nil ANA+ (1:160) 9 Nil nil nil nil nil nil Other disease nil Hypertension 10 Hypertension 10 UTI 16 x 2 Kaposi s Hypertension 10 nil pyrexia TB 11 VZV 13 LRTI 14 Colostomy Sarcoma Additional medication nil ACE-I 12 ACE-I 12 ACE-I 12 nil ACE-I 12 nil phenytoin ART regimen 7 d4t(azt) 8 3TC/EFV d4t/3tc/efv d4t (AZT) 15 3TC/EFV d4t/3tc EFV d4t/3tc EFV (NVP) 17 d4t (AZT) 8 3TC/EFV d4t 3TC/EFV Never started 1 BMI: Body Mass Index (kg/m 2 ) Microalbumin concentration (mg/l) Microalbumin: creatinine ratio (mg/mmol): average of 2 readings. The follow up value (parentheses) is a single reading 4 Cockcroft and Gault formula: estimated glomerular filtration rate (egfr) ml/min/1.73m 2. In patient 7 the body surface area was not recorded. In this case egfr with this formula was used without adjustment for body surface area (ml/min) 5 Modified MDRD: modified equation from Modification of Diet in Renal Disease study: estimated glomerular filtration rate (egfr) ml/min/1.73m 2 6 Serology tested: Syphilis, Hepatitis B surface antigen, Hepatitis C antibody, Anti-nuclear antibody (ANA), Rheumatoid Factor (RF) 7 ART (antiretroviral therapy) regimen: d4t = stavudine; 3TC = lamivudine; EFV = efavirenz; AZT = zidovudine; NVP = nevirapine 8 d4t changed to AZT for drug-induced sensory peripheral neuropathy 9 History and clinical examination: nil to suggest auto-immune disease 10 Hypertension developed after initiation of ART 11 TB = tuberculosis (systemic): mycobacterium tuberculosis complex - diagnosed from blood culture 12 ACE-I: angiotensin converting enzyme-inhibitor: enalapril maleate 13 VZV: varicella zoster virus infection (shingles) 14 LRTI: lower respiratory tract infection: confirmed as streptococcal after initiation of ART 15 Patient developed lactic acidosis syndrome: switched from d4t to AZT after 11 months on ART 16 UTI: urinary tract infection 17 Intends to fall pregnant, switched to nevirapine (NVP) to reduce teratogenenic risk 18 Lost to follow up 36

12 The second patient lost to follow up was a prisoner at the time of his initial biopsy and used a pseudonym for his hospital records. After release from prison he reverted to his birth name and was re-issued with a new hospital identification number and file. He was lost to follow-up and after 18 months was found in the clinic but had intermittently interrupted treatment. At time of this report he was being traced to return for follow up. His data are incomplete and his follow-up renal biopsy has not been done. Patient two (XN) was referred for recurrent suppurative otitis media and persistent cervical lymphadenopathy. Lymph node biopsy revealed non-specific reactive changes on histology. At her initial visit she had an E.Coli UTI and extensive corporeal scabies which were treated. She had a history of hypertension but was not on treatment. Her blood pressure at initial and subsequent visits was 172/100; 130/75; 140/80mmHg and anti-hypertensives were not initiated. After renal biopsy and initiation of ART, she interrupted treatment for one month. Upon return she was pyrexial, had culture negative leucocyturia (CNL) and had lost four kilograms. She was started on empiric TB treatment, blood culture confirmed mycobacterium tuberculosis infection and the CNL resolved. Moderate hypertension prompted commencement of ACE-I three months after renal biopsy. Patient three (EM) developed streptococcal pneumonia two months after commencing ART, followed by herpes zoster at six months and lactic acidosis syndrome at 11 months. At this point, he had lost 5kg in weight and serum lactate was 8.8mmol/L (normal<2mmol/l). He was switched to zidovudine (AZT) as an outpatient with excellent clinical response in spite of his high lactate level. His microalbuminuria resolved within two months of ART. He had no prior history of hypertension. On initial screening and follow up at different visits his blood pressure recordings were 140/80; 132/102; 144/80mmHg. He was started on ACE-I with low dose hydrochlorothiazide for persistent mild hypertension 11 months after commencing ART. Patient 4 (TM) was referred for ART after a hemicolectomy for ruptured appendicitis. She had CNL on three separate occasions prior to renal biopsy and two episodes of confirmed UTI during follow 37

13 up. Her clinical course has been complicated as has been her response of proteinuria to treatment (figure 3.6). On admission for renal biopsy, her proteinuria had increased (protein: creatinine ratio 0.18g/mmol). ART was commenced and one month later she was admitted for sepsis. Empiric TB treatment was started on this admission and she completed 6 months of TB therapy. TB was never confirmed on repeated blood cultures. At her next visit, ART had been stopped for 3 weeks and proteinuria had resolved. ART was restarted for one month, but interrupted for the next two months due to poor social circumstances. At this point ART was restarted again - for two months - with commencement of ACE-I after one month. She was then admitted for acute gastroenteritis complicated by dehydration and acute renal failure (serum creatinine 1177µmol/L from baseline of 73µmol/L). Her renal failure reversed with intravenous fluids and cessation of ACE-I. At this point, her ART had been interrupted for another month. She was restarted on ART and has not interrupted her treatment for 14 months. After three months on ART her proteinuria worsened and an ACE-I was commenced with reversion to microalbuminuria within two months. At time of follow up, her viral load was incompletely suppressed and she was referred for HIV resistance testing Albuminuria (mg/l) Figure 3.6 Albuminuria on ART for patient 4 (TM) 0 screening for study 1 renal biopsy 2 after one month of ART, no ACE-I 3 after interruption of ART for one month 4 admission for ARF 5 ART for three months, no ACE-I 6 ACE-I for two months with ART 7 four months ART and ACE-I 8 one year ART and ACE-I 38

14 Patient 5 (KR) had been on ART but stopped two years previously. She had persistent CNL in spite of syndromic management for STI. She underwent vulval biopsy for persistent vulval plaques which showed squamous hyperplasia. CNL and the vulval lesions resolved spontaneously after 6 months of ART. After 17 months on ART she became pregnant and developed facial cutaneous Kaposi s sarcoma (confirmed on biopsy). She was advised, after consultation with the antenatal HIV clinic to terminate the pregnancy, complete chemotherapy and then consider a planned pregnancy. Her ART regimen was changed from efavirenz to nevirapine to reduce teratogenic risk. Patient 6 (NM) had a sensory peripheral neuropathy unresponsive to amitryptiline. She was switched from d4t to AZT with good clinical response. At screening, there was a history of hypertension but she was not on treatment. She initially had a single blood pressure reading of 158/112mmHg which subsequently normalised (124/86mmHg) with no evidence of hypertension on follow up visits. Her microalbuminuria resolved after four months of ART. After 20 months on ART she developed moderate hypertension and an ACE-I was prescribed. The distinguishing feature in this patient has been persistent, unexplained CNL. STI was excluded and after her CD4 count recovered (>200 cells/mm 3 for 6 months) co-trimoxazole was stopped. She is on no medication that may be a drug-related cause of interstitial nephritis. It was assumed the most likely cause of persistent CNL was interstitial nephritis, but histology (table 3.6; figure 3.8) showed no evidence of interstitial disease. As a group, follow up ranged from months. Six of eight patients had AIDS at start of the study (CD4 count of <200 cells/mm 3 ). Three patients (2, 4, and 7) with incomplete viral suppression had interrupted their ART regimens. Two of three patients had a prior history of hypertension, which did not initially require treatment. After commencement of ART, three were initiated of ACE-I therapy for hypertension, rather than microalbuminuria. Patient 4 was the only patient for which an ACE-I was prescribed for persistent albuminuria. A summary of histology forf the initial and follow up renal biopsies can be seen in table 3.6. A more detailed description of the histological findings 39

15 can be seen in appendix C. Histology for patient 3 (EM) has been discussed separately (summary in table 3.7, detailed description in appendix D; figures 3.9 and 3.10). Table 3.6 Renal biopsy results for persistent microalbuminuria group Patient 1 Initial biopsy Follow up biopsy (after 22 months of ART) Minimal change disease No change Patient 2 Initial biopsy Follow up biopsy (after 16 months of ART) Benign nephrosclerosis and active CIN 1 No change Patient 4 Initial biopsy Follow up biopsy (after 20 months of ART) Active CIN 1 Mesangial hyperplasia Glomerular enlargement FSH 2 (secondary) with active CIN 1 worsening in severity Resolution of mesangial hyperplasia Resolution of glomerular enlargement Patient 5 Initial biopsy Follow up biopsy (after 19 months of ART) Diagnosis Mild glomerular enlargement Active CIN 1 GBM 3 holes Resolution of glomerular enlargement Less intense CIN 1 GBM 3 holes unchanged Patient 6 Initial biopsy Follow up biopsy (after 19 months of ART) Diagnosis Minimal change with mesangial hyperplasia: forme frustre of HIVAN 4 Resolution of mesangiopathic changes. Hyaline arteriolosclerosis in keeping with hypertension Patient 7 Diagnosis Initial biopsy, no follow up biopsy HIV-ICD 5 with mesangial and GBM 3 components Patient 8 Initial biopsy, no follow up biopsy Diagnosis active CIN 4 1 CIN: chronic interstitial nephritis 2 FSH: Focal Segmental Hyalinosis 3 GBM: glomerular basement membrane 4 HIVAN: HIV-associated nephropathy 5 HIV-ICD: HIV-associated immune complex disease 40

16 Figure 3.7 Renal biopsy of patient 4 (TM) Mesangial hyperplasia (red arrow), patchy to diffuse active chronic interstitial nephritis (yellow arrow); silver methenamine stain; magnification x200 Figure 3.8 Renal biopsy of patient 6 (NM) Increased mesangial matrix and increased mesangial cellularity (yellow arrows); haematoxylin and eosin stain; magnification x400 41

17 Table 3.7 Renal biopsy results for patient 3: Initial biopsy; 7 months; 25 months of ART 1 Patient 3 Initial bx Biopsy at 7 months Biopsy at 25 months LM (Light Microscopy) Diagnosis Glomerular enlargement Mesangial hyperplasia: deposits in mesangial +paramesangial areas Frequent GBM 2 holes Mild arteriolar hyalinosis, mild, CIN 3 HIV-ICD 4 with mesangial and GBM 2 components Glomerular enlargement Majority of mesangial regions within normal limits, 40% of glomeruli show mesangial hyperplasia Unchanged Unchanged HIV-ICD 4 (with less prominent mesangial alterations) No glomerular enlargement No mesangial alterations Unchanged Unchanged Low-titre HIV-ICD 4 (with residual GBM 2 component) 1 It was initially decided to perform follow up biopsies at six twelve months after initiation of treatment. Patient 3 (EM) was the first to undergo follow up renal biopsy at six months. After reviewing the histology, it appeared that there was some resolution of his immune complex disease, but the data was inconclusive. At this point, it was decided to defer repeat biopsy until at least 12 months in the remaining study group. This patient was asked whether he would consider repeat biopsy at 24 months, as an exception, to which he agreed 2 GBM: glomerular basement membrane 3 CIN: chronic interstitial nephritis 4 HIV-ICD: HIV associated immune-complex disease None of the patients demonstrated the typical features of HIVAN; HIV-ICD occurred in two patients; active CIN in six patients and four patients demonstrated mesangial hyperplasia. After treatment in the follow up biopsies, those with SEM features of podocyte foot process effacement showed no change; of the six patients that exhibited an active CIN of variable intensity, one worsened and one improved; both glomerular enlargement and mesangial disease resolved (patients 3, 4, 6). The near complete resolution of immune-complex deposition in patient 3 appeared to be time-course dependant and did not correlate with rapid resolution of microalbuminuria. Similarly, the resolution of microalbuminuria seen in all patients appears to be relatively rapid (3-6months) but does not correlate with the features on histology, which in three cases were unchanged. 42

18 Figure 3.9 Renal biopsy of patient 3 (EM) Depicting sub epithelial eosinophilic glomerular basement membrane (GBM) deposits with a variable GBM reaction pattern (yellow arrow); in some areas demonstrating the ball in cup reaction pattern (red arrows); silver methenamine stain; magnification x1000 Figure 3.10 Follow up renal biopsy of patient 3 (EM) after 25 months of ART Depicting residual glomerular basement membrane holes (yellow arrows) suggestive of prior immune complex deposition; silver methenamine stain; magnification x

19 Figure 3.11 Response of microalbuminuria to treatment Numbers 1 6: patients undergoing renal biopsy for persistent microalbuminuria (as per patient designation in table 3.5). Patient 4 has been depicted separately in figure OVERT PROTEINURIA Four patients with overt proteinuria underwent renal biopsy. Clinical and laboratory data are depicted in table 3.8 and a summary of the histopathology results in table 3.9; a detailed description of histopathology findings can be found in appendix E. One patient developed pulmonary Kaposi s sarcoma after renal biopsy and was lost to follow up, another patient relocated to a different province and a third patient was followed up for one year and then lost to follow up before repeat biopsy. The only patient for which there is a follow up biopsy in this group also had a period in which he interrupted treatment. Patient 9 (SK) was referred with erythrodermic seborrhoeic dermatitis. On screening, he had sterile leucocyturia, microscopic haematuria and was hepatitis B surface antigen positive. His biopsy showed mesangioproliferative glomerulonephritis which could be ascribed to HIV-ICD or hepatitis B. He was started on ART without ACE-I and proteinuria resolved completely within three months. After four months of treatment he relocated to Kwa-Zulu Natal (KZN) and was lost to follow up. 44

20 Patient 10 (GS) was in his fourth month of TB treatment at screening and completed six months during follow up. He was on 25mg hydrochlorothiazide from a clinic for hypertension which was controlled at different visits and on admission for renal biopsy. After one month on ART his blood pressure was 156/110mmHg and an ACE-I was started (he was still proteinuric). After 3 months on ART and 2 months on ACE-I, he had complete resolution of proteinuria. Although clinically asymptomatic, he developed hyperkalaemia (K+ 5.8mmol/L), metabolic acidosis (serum bicarbonate 13mmol/L) and his creatinine increased to 166µmol/L (from 139). The ACE-I was stopped and he was changed to a calcium channel blocker. The features were consistent with renal tubular acidosis (RTA), possibly induced by the non-nucleoside reverse transcriptase inhibitors (NNRTI). He was lost to follow up for 3 months. Upon his return, he was seen by a different doctor who recommenced NNRTI therapy. A month later, arrangement was made for admission for repeat renal biopsy and review of his medication, but he did not return. His blood results at this time were still consistent with an RTA: K+ 5.9mmol/L, serum bicarbonate 10mmol/L, creatinine 90µmol/L. There was also a small rise in albuminuria (microalbumin: creatinine increased from mg/mmol). Histology showed mesangial changes with active CIN. The histopathologist advised that diabetes needed to be excluded based on some of the biopsy features (table 3.9). He had no symptoms of diabetes and on repeated blood testing his serum glucose was normal. Patient 11 (KM) was referred after treatment for sepsis with acute renal failure. At this point she was proteinuric with CNL. Upon admission for renal biopsy she had an asymptomatic E.Coli UTI which was treated. She underwent renal biopsy and a skin biopsy which confirmed cutaneous Kaposi s sarcoma. She returned to KZN for December and while in KZN she developed a cough. In January she had features of a lower respiratory tract infection and genital ulcer disease which were treated. Two weeks later the cough worsened and there was a miliary pattern on CXR. Empiric TB treatment with oral corticosteroids was started for two weeks. After this two week period her proteinuria had regressed to microalbuminuria. She continued to deteriorate and after review a decision was made to commence chemotherapy for possible pulmonary Kaposi s sarcoma in addition to TB and PJP treatment. Her sputa and blood cultures for TB were negative. She 45

21 continued TB treatment and chemotherapy and was seen two months later in the clinic for initiation of ART. At this point, without ART or ACE-I, her urine dipstick for microalbumin was negative. Table 3.8 Clinical and laboratory data for those with overt proteinuria undergoing renal biopsy (values in parentheses are at follow up) Patient 9 (SK) 10 (GS) 11 (KM) 12 (PK) Gender M M F M age (years) follow up (months) BMI (kg/m 2 ) (20.5) Not done 19.8 (19.5) CD4 count (cells/mm 3 ) (133) (165) HIV-1 viral load (RNA copies/ml) > Not done (22 000) Protein 1.8 (16.2mg) (78.6mg) (66.8mg) 0.88 Concentration (g/l) Protein Creatinine ratio (g/mmol) Cockroft/Gault Modified MDRD Positive serology 4 Other disease Additional medication 0.12 (0.2mg/mmol) Hepatitis B surface antigen+ Erythrodermic seborrhoeic dermatitis (4.1mg/mmol) (9.7mg/mmol) (28.25mg) 0.04 (1.4mg/mmol ) 44.4 (67.6) 51.1 (88.1) 70ml/min Not done 95.4 (92.8) (122.8) RF=27IU/ml 11 Negative Syphilis titre: 1:2 10 TB treatment at time of screening Hypertension Topical corticosteroids ACE-I 5, HCTZ 6, CCB 7 Kaposi s Sarcoma Chemotherapy, TB treatment, Prednisone x2/52 ART regimen 8 d4t, 3TC, EFV d4t, 3TC, EFV Nil d4t, 3TC, EFV 1 Average of 2 readings 2 Cockcroft and Gault formula: estimated glomerular filtration rate (egfr) ml/min/1.73m 2 3 Modified MDRD: modified equation from Modification of Diet in Renal Disease study: estimated glomerular filtration rate (egfr) ml/min/1.73m 2 4 Serology tested: Syphilis, Hepatitis B surface antigen, Hepatitis C antibody, Anti-nuclear antibody (ANA), Rheumatoid factor (RF) 5 ACE-I: angiotensin converting enzyme-inhibitor: enalapril maleate 6 HCTZ: hydrochlorothiazide 7 CCB: calcium channel blocker 8 ART (antiretroviral therapy) regimen: d4t = stavudine; 3TC = lamivudine; EFV = efavirenz; AZT = zidovudine 9 Data in parentheses are after treatment interruption for 14 months 10 Was treated with intramuscular benzathine penicillin. Repeat testing 3 months later showed negative serology 11 Rheumatoid Factor was positive but there were no features on history or clinical examination to suggest rheumatoid arthritis or other auto-immune disease nil nil 46

22 Patient 12 (PK) had weakly positive serology for syphilis (RPR titre of 1:2) which was treated with long-acting intramuscular penicillin. After three months of ART his viral load was suppressed (49 RNA copies/ml from an initial ), CD4 count increased (363 cells/mm 3 from 201), proteinuria decreased (Pr: Cr 0.03 g/mmol to 10.2mg/mmol). Repeat syphilis serology was negative. The initial renal biopsy was in keeping with HIV-ICD but could also be attributed to syphilis. He was lost to follow up for 14 months after relocating to another province. Upon his return, it was confirmed that he had not been on any treatment during this period. Repeat testing showed his CD4 count had dropped, viral load increased but renal function had not deteriorated and there was no proteinuria. It was decided to repeat his renal biopsy, as the membranous nephropathy may have resolved if it was due to syphilis. Repeat biopsy revealed the immune-complex disease was more prominent and was most likely due to HIV infection. He was recommenced on ART and is being followed up. All patients in this group were classified with AIDS, three on the basis of CD4 count and one with an AIDS-defining illness (Kaposi s sarcoma). Histology showed prominent mesangial hyperplasia with an active CIN in two patients, both of whom had decreased GFR and one of whom developed RTA on NNRTI treatment. Immune-complex disease was present in the remaining patients and in both, co-morbid disease (active hepatitis B and syphilis) in addition to HIV could explain the histology. The resolution of proteinuria in this group was rapid: three months for patient 9 with no ACE-I; three months of ART and two months of ACE-I for patient 10. The resolution of proteinuria without ART or ACE-I, but on corticosteroids, TB treatment and chemotherapy in patient 11 was noteworthy. The persistent membranous glomerulopathies in patient 12 is also interesting, with initial response of proteinuria after three months on ART, followed by the absence of proteinuria after interruption of ART for 14 months, despite histological evidence of worsening immune-complex deposition. 47

23 Table 3.9 Renal biopsy results for overt proteinuria group Patient 9 Diagnosis Patient 10 Initial biopsy Mesangioproliferative Glomerulonephritis: part of HIV-ICD 2 or hepatitis B Initial biopsy Diagnosis Mesangial hyperplasia, active CIN 1 Glomerular and vascular changes of benign nephrosclerosis (suggestion: exclude evolving diabetic glomerulopathy clinically) 5 Patient 11 Initial biopsy Diagnosis Mesangial hyperplasia, active CIN 1 Patient 12 Initial biopsy Follow up biopsy (ART 3 months, then interrupted ART 14 months) Diagnosis HIV-ICD 2 or membranous nephropathy HIV-ICD 2 due to syphilis and active CIN 1 Active CIN 1 1 CIN: chronic interstitial nephritis 2 HIV-ICD: HIV-associated immune complex disease 3 GBM: glomerular basement membrane 4 TBM: tubular basement membrane 5 No history of diabetes, random glucose= 4.6mmol/L 6 EDD: electron dense deposits NEPHROTIC RANGE PROTEINURIA Eight patients were biopsied from this group, two demised, one relocated after three months of ART and one was lost to follow up. The four remaining patients underwent repeat renal biopsy. The clinical and laboratory data from the four patients (13, 14, 15 and 16) that did not undergo repeat biopsy are included in table 3.10 and a summary of their histology results are in table 3.12; a detailed description of histology in appendix F. The clinical and laboratory data for the four patients (17, 18, 19, 20) who did undergo repeat renal biopsy are in table 3.11 with a summary of their corresponding histology results in table 3.14; a detailed description of histology in appendix G. Patient 13 (EM) was referred with nephrotic syndrome and renal biopsy was performed. He was started on ACE-I with ART and did not return for follow-up. Patient 14 (SM) originated from Mozambique, also referred with nephrotic syndrome. Her initial renal dysfunction (creatinine 261µmol/L) improved by the time of renal biopsy (113µmol/L) but proteinuria persisted. She was reluctant to commence ART and expressed the desire to have a child. She was counselled, ART was started and the ACE-I was stopped to accommodate a pregnancy. She was lost to follow up 48

24 after one month. A member of the family informed us she had returned to Mozambique and demised a year after the last treatment in our clinic. Patient 15 (SG) was referred for investigation of nephritic-nephrotic syndrome. Serology revealed hepatitis B surface antigen positivity. Renal biopsy showed a crescentic glomerulonephritis. He was started on prednisone, furosemide, ACE-I and an ART regimen that included lamivudine for anti-hepatitis B activity. Response to treatment was dramatic with a marked reduction in proteinuria, improvement of renal function and resolution of nephritic-nephrotic syndrome by the third month of treatment. At this stage he elected to return to KZN and was lost to follow up. Patient 16 (TS) was referred with nephrotic syndrome. He had been a type 1 diabetic for 11 years, serological testing confirmed hepatitis C antibody and hepatitis B surface antigen positivity. The hepatitis C RNA viral load was not measured. The patient underwent renal biopsy which revealed membranous glomerulonephritis, either due to hepatitis B, C or HIV. There were no features of diabetic nephropathy. After extensive counselling he chose not to start ART, nor did he wish to continue non-art medication (ACE-I, furosemide, statin). He was phoned on numerous occasions to return for follow up and subsequently demised. Patient 17 (SN) had a creatinine of 354µmol/L, CNL, and proteinuria at initial screening. At second screening, the creatinine decreased to 168µmol/L, CNL resolved and proteinuria persisted. Serology was negative, there was no co-morbid disease and she was not clinically nephrotic. This patient (SN) deserves special consideration for many reasons. Her response to treatment was rapid, from an immunological and renal perspective. Within one month of ART the CD4 count increased (12 to 162 cells/mm 3 ); protein: creatinine ratio decreased (0.33 to 0.19g/mmol without ACE-I); viral load decreased ( to 400 RNA copies/ml) and GFR normalized (33 to 92ml/min). After two months on ART, ACE-I was started with a gradual upward titration in dose. She has not suffered any side-effects of ART and has been the only patient in this study that showed reversal of histological lesions on repeat renal biopsy (18 months of treatment). 49

25 Table 3.10 Clinical and laboratory data for those with nephrotic proteinuria undergoing initial renal biopsy only (values in parentheses are at follow up) Patient 13 (EM) 14 (SM) 15 (SG) 16 (TS) Gender M F M M age (years) follow up (months) BMI (kg/m 2 ) 1.73 Not done Not done 1.89 CD4 count (cells/mm 3 ) (884) 167 HIV-1 viral load Not done > (RNA copies/ml) (190) Protein:Creatinine ratio (0.55) 0.91 (0.20) 0.39 (g/mmol) Protein concentration (3.0) 8.06 (3.74) 2.92 (g/l) Cockroft/Gault 1 Modified MDRD ml/min 33.5ml/min (72.5ml/min) Positive serology 3 Negative Negative ( ANA and RF not done) Hepatitis B surface antigen positive Hepatitis B surface antigen positive Hepatitis C antibody positive Additional clinical information Nephrotic syndrome Nephrotic syndrome Nephritic Nephrotic syndrome Nephrotic syndrome, IDDM for 11 years Cholesterol (mmol/l) Triglycerides (mmol/l) Additional medication ACE-I 5 ACE-I Prednisone (1mg/kg/day) Furosemide, ACE-I Calcium channel blocker, insulin Furosemide ART regimen 4 d4t, 3TC, EFV d4t, 3TC, EFV (NVP) 7 d4t, 3TC, EFV Never commenced Outcome Lost to follow up No follow up, demised Relocated after Declined ART and demised after 11 months 3 months 1 Cockcroft and Gault formula: estimated glomerular filtration rate (egfr) ml/min/1.73m 2. In patients 14 and 15 the body surface area was not recorded. In these cases egfr was used without adjustment for body surface area (ml/min) 2 Modified MDRD: modified equation from Modification of Diet in Renal Disease study: estimated glomerular filtration rate (egfr) ml/min/1.73m 2 3 Serology tested: Syphilis, Hepatitis B surface antigen, Hepatitis C antibody, Anti-nuclear antibody (ANA), Rheumatoid Factor (RF) 4 ART (antiretroviral therapy) regimen: d4t = stavudine; 3TC = lamivudine; EFV = efavirenz; AZT = zidovudine; NVP = nevirapine 5 ACE-I: angiotensin-converting enzyme inhibitor: enalapril maleate 6 ACE-I was stopped after one month: patient intended to fall pregnant 7 Atfer one month of ART, patient changed to NVP for intention to fall pregnant 8 After three months he relocated to another province and was lost to follow up 50

26 Table 3.11 Clinical and laboratory data for those with nephrotic proteinuria undergoing initial and follow up renal biopsy (values in parentheses are at follow up) Patient 17 (SN) 18 (DM) 19 (VN) 20(SN) Gender F F M M age (years) follow up (months) BMI (kg/m 2 ) (20.94) 21.7 (42.2) 20.7 (20.2) 22.6 (24.6) CD4 count (cells/mm 3 ) 12 (362) 98 (458) 117 (297) 487 (424) HIV-1 viral load (<40) Initial: unknown (110) (523) <40) (RNA copies/ml) Protein:Creatinine ratio 0.33 (malb:cr: 0.4) (malb:cr: 0.9) (malb:cr 16.9) (0.36) (g/mmol) Protein concentration 1.65 (4mg/L) 1.23 (7.5mg/L) (82.6mg/L) 5.98 (1.91) (g/l) Cockroft/Gault(ml/min) Modified MDRD (GFRml/min/1.73m 2 ) 33.0 (92) 35.1 (103.3) 23.2 (154.0) 20.0 (119.7) Positive serology 1 Negative Hepatitis C antibody positive, confirmed hepatitis C PCR positive 44.9 (53.8) 55.3 (65.5) Hepatitis C antibody positive, confirmed hepatitis C PCR positive 68.9 (77) 66.1 (66.5) Negative Other disease Nil Hypertension 5 Asthma Cutaneous Kaposi s Sarcoma ACE-I 4 Additional medication ACE-I 4 ACE-I 4 ; CCB 6 ; MD 7, HCTZ 8 Salbutamol inhaler, furosemide ACE-I 4 ART regimen 2 d4t, 3TC, EFV d4t, 3TC, EFV switched: d4t, 3TC, EFV switched: d4t, 3TC, NVP 10 3TC, EFV, LPN/RTV LPN/RTV, 3TC, EFV 9 1 Serology tested: Syphilis, Hepatitis B surface antigen, Hepatitis C antibody, Anti-nuclear antibody (ANA), Rheumatoid Factor (RF) 2 ART (antiretroviral therapy) regimen: d4t = stavudine; 3TC = lamivudine; EFV = efavirenz; AZT = zidovudine; NVP = nevirapine; LPN/RTV =lopinavir/ritonavir 3 Proteinuria resolved: follow up: measured as microalbumin: creatinine ratio (mg/mmol) 4 ACE-I: angiotensin converting enzyme-inhibitor: enalapril maleate 5 Hypertension developed after initiation of ART when the patient fell pregnant 6 CCB: calcium channel blocker 7 MD: alpha-methyl dopa 8 HCTZ: hydrochlorothiazide 9 Patient developed macrocytic anaemia, renal tubular acidosis, thought to be related to d4t. She was switched to LPN/RTV, 3TC, EFV and both conditions resolved, the patient then fell pregnant and EFV was stopped 10 Severe neurological side-effects from EFV: switched to NVP 51

27 Table 3.12 Renal biopsy results for nephrotic proteinuria group (patients 13, 14, 15, 16) Patient 13 Initial biopsy Diagnosis Differential: HIV-ICD 3, or Incompletely expressed 4 membranous glomerulopathy (with areas of endocapillary hypercellularity), or Immunotactoid glomerulopathy 4, or Incompletely expressed post-infectious glomerulopathy 4 Patient 14 Initial biopsy Diagnosis HIVAN, FSH subtype 6, active CIN 1 Patient 15 Initial biopsy Diagnosis Focal, segmental glomerulonephritis with active and sclerosing lesions, crescentic glomerulonephritis (possibly due to HIV or hepatitis B), ATN 7 Patient 16 Initial biopsy Diagnosis Membranous Glomerulonephritis with mesangial alterations: secondary to HIV or Hepatitis B/C 1 CIN: chronic interstitial nephritis 2 GBM: glomerular basement membrane 3 HIV-ICD: HIV-associated immune complex disease 4 Incompletely expressed: due to immunosuppression secondary to HIV infection 5 FSSG: focal segmental sclerosing glomerular lesions 6 HIVAN, FSH subtype: HIV-associated nephropathy, subtype: Focal and Segmental Glomerulosclerosis with Hyalinosis 7 ATN: acute tubular necrosis Figure 3.12 Histology for patient 17 (SN) prior to ART and ACE-I treatment Scattered tubular microcysts (yellow arrow); active CIN (red arrow); mesangial hyperplasia (green arrow); silver methenamine stain; magnification x200 52

28 Figure 3.13 Histology for patient 17 (SN) prior to ART and ACE-I treatment Mesangial expansion (green arrow); mesangial and paramesangial eosinophilic deposits (yellow arrows); plump parietal epithelial cell reaction (red arrow); silver methenamine stain; magnification x1000 Figure 3.14 Histology for patient 17 (SN) after 18 months of ART and 16 months of ACE-I treatment Resolution of glomerular and interstitial changes; silver methenamine stain; magnification x400 53

29 Figures 3.12 and 3.13 depict the histology prior to ART and ACE-I treatment; figure 3.14 depicts histology after treatment. The lesions on histology were compatible with a combination of an HIV- ICD, with predominant mesangiopathic changes and HIVAN (microcystically dilated tubular profiles); these changes showed impressive resolution on repeat biopsy. Patient 18 (DM) was initially admitted to the medical wards with acute renal failure. Her only feature on history was onset of diarrhoea prior to admission. On clinical examination she was acidotic, profoundly weak with a sensory peripheral neuropathy. There was no ingestion of herbal toxins, nor was she on ART. Blood results showed a raised anion gap metabolic acidosis (serum bicarbonate 11mmol/L), hypokalaemia (1.9mmol/L), normal serum magnesium, phosphate, calcium, lactate and glucose. Serum creatinine was 241µmol/L and creatine kinase >10000U/lL. She had nephrotic range proteinuria and urine analysis showed a culture negative leucocyturia. After resuscitation and antibiotic treatment, her metabolic acidosis worsened (ph 7.1, serum bicarbonate 3.5mmol/L, base excess -25.7mmol/L) and creatinine increased (330µmol/L). The renal unit was asked to review her condition at which point a presumptive diagnosis of AKI with RTA possibly secondary to HIV was made. Based on the deterioration in renal function and worsening acidosis, she was commenced on acute haemodialysis to which she responded. Dialysis was stopped after three months and she was discharged. Two weeks later she was re-admitted with a creatinine of 604µmol/L, K+ 2.4mmol/L, serum bicarbonate 11mmol/L. Haemodialysis was not recommenced, as per the policy in the unit at the time. After consultation with the patient, it was decided to commence ART (dose adjusted for renal failure) and assess her response to treatment. At this point she was not on ACE-I, nor any oral potassium or bicarbonate replacement. Her response to ART was rapid but after three months on ART she developed hyperkalaemia, worsening acidosis and macrocytosis (table 3.13). The d4t was replaced with high dose lopinavir/ritonavir and both the RTA and the macrocytosis resolved. After her third month of ART, a renal biopsy was performed and serological screening revealed she was Hepatitis C antibody positive, which was confirmed with hepatitis C PCR. 54

30 Table 3.13 Patient 18 (DM) time course response to ART Time on ART (months) serum potassium (mmol/l) Serum bicarbonate (mmol/l) serum creatinine (µmol/l) protein: creatinine ratio (g/mmol) not done 0.06 not done 0.02 CD4 count (cells/mm 3 ) 98 not done not done 406 not done 504 ART regimen D4T: stavudine 3TC: lamivudine EFV: efavirenz LPN/RTV: lopinavir/ritonavir d4t 3TC EFV d4t 3TC EFV d4t 3TC EFV LPN/RTV 3TC EFV LPN/RTV 3TC EFV LPN/RTV 3TC Renal biopsy showed mesangioproliferative glomerulonephritis (possibly HIV-ICD or related to hepatitis C infection), resolving acute tubular necrosis and active CIN (figure 3.15). After nine months on ART she was started on ACE-I and HCTZ for hypertension. At this point, she has doubled her body mass index from 21.7 to 42.2kg/m 2. After 14 months on treatment she spontaneously miscarried, after which time she was switched from ACE-I to a calcium channel blocker, EFV was stopped and she was maintained on LPN/RIT and 3TC. She underwent repeat renal biopsy after 15 months on ART (figure 3.16). In spite of her impressive clinical response, her repeat renal biopsy showed only partial resolution of both mesangioproliferative glomerulonephritis and activity of the CIN. This may in part be due to her hepatitis C positivity for which she had not received specific treatment. She became pregnant after 17 months of ART. Methyl-dopa was added for blood pressure control with an uncomplicated pregnancy at time of writing. 55

31 Figure 3.15 Histology for patient 18 (DM) after 3 months of ART Mesangioproliferative glomerulonephritis (yellow arrow); active CIN (green arrow); haematoxylin and eosin stain; magnification x200 Figure 3.16 Histology for patient 18 (DM) after 15 months of ART Partial resolution of mesangioproliferative glomerulonephritis (yellow arrow) and less activity of CIN (green arrow); haematoxylin and eosin stain; magnification x200 56