ORIGINAL

Niger J Paed 2013; 40 (1):65 - 69

Urinary findings in HIV positive

children by dipstick screening test in

Enugu

Ezeonwu BU

Oguonu T

Ikefuna AN

Okafor HU

DOI:http://dx.doi.org/10.4314/njp.v40i1.12

Accepted: 7th July 2012

Abstract Background: Human im-

munodeficiency virus (HIV) affects

the kidney. Urine screening for ab-

normalities can detect early renal

parenchymal diseases.

Objectives: To determine the preva-

lence of abnormal urinary findings

in HIV positive children in Univer-

sity of Nigeria Teaching Hospital,

(UNTH), Enugu.

Method: Urinary screening was car-

ried out in 159 HIV positive chil-

dren in UNTH over a period of4-

months, to detect presence of abnor-

malities such as glycosuria, protein-

uria, haematuria, as well as the pres-

ence of nitrite and leucocyte es-

terase, abnormal urine pH and spe-

cific gravity (SG).

leucocyte esterase. Subjects with

proteinuria were older (5-14 years),

had longer duration of HIV diagno-

sis, longer duration of treatment

with HAART, and a lower CD4 cell

count (p=0.01). Sixty percent of

those with proteinuria had severe

immunosuppression, with 4 out of

the 5 of them with urine SG more

than 1.015. The children with urine

SG more than 1.015 were among

the older age group (5-14 years), on

HAART, had non-advanced HIV

disease as well as low CD4 cell

count (p= <0.0001).

Conclusion: Urinary abnormalities

occur among HIV infected children.

Longer duration of HIV diagnosis,

older age and low CD4 cell count,

are probable factors associated with

proteinuria.We recommend routine

urinary examination for HIV posi-

tive children.

(

)

Ezeonwu BU

Department of Paediatrics, Federal

Medical Center Asaba , Nigeria.

Email: uzovin@yahoo.com.

Tel: +2348033257313

Oguonu T, Ikefuna AN, Okafor HU

Department of Paediatrics,

University of Nigeria Teaching

Hospital, Ituku Ozalla Enugu,

Nigeria.

Results: Eighty males and 79 fe-

males were screened. Five (5), 4,

and a child had proteinuria, SG of >

1

.015 and alkaline urine, giving a

prevalence rate of 3.1%, 2.5% and

.6% respectively. Neither of the

0

Key words: Urinary abnormalities,

proteinuria, advanced HIV disease,

immunosuppression

subjects had glycosuria, haematuria

nor tested positive to nitrite and

3

, 4

Introduction

population. The prevalence of haematuria in HIV in-

fected adults was 3.3%, inability to concentrate urine

3

Human immunodeficiency virus (HIV) pandemic is a

major global health emergency. It affects multiple or-

gans and the kidney is a common target. A variety of

acute and chronic renal syndromes may occur during the

course of HIV infection such as acute tubular dysfunc-

tion caused by infections and nephrotoxic drugs, HIV

glomerulopathies related to immunological abnormali-

ties, HIV associated thrombotic microangiopathies and

HIV associated nephropathy (HIVAN) caused by direct

was found in 16% of the subjects. Afhami and col-

leagues found no glycosuria among their subjects. The

1

4

2

prevalence rates of the various urinary abnormalities in

HIV inf₅e_,₆cted children have been document₅ed by several

studies.

Steel-Duncan and colleagues found 3%

prevalence for proteinuria while Esezobor and cowork-

ers documented 20.5%. Steel-Duncan and colleagues

6

5

documented haematuria in 3 of the 7 children who were

commenced on Indinavir and found the prevalence of

UTI to be 16.8%. However, the prevalence of other uri-

nary abnormalities (glycosuria, urine concentration ab-

normality) has not been documented in children.

2

HIV infection of renal epithelial cells. These renal syn-

dromes can present with varied abnormal urinary find-

ings including haematuria, proteinuria, glycosuria, poor

urine concentration ability and urinary tract infection

(

UTI).

With increasing prevalence of HIV/AIDs in the country

and among the paediatric age group, the determination

of the renal consequence of the disease in this popula-

tion cannot be further ignored. This study is timely as

Some studies have shown varied prevalence rates of

various urinary abnormalities in HIV infected adult

6

there has been no published study on other urinary ab-

normalities in HIV positive children in Nigeria, other

than proteinuria.

dipstick reading from trace (100mg/dL) to 4+ (2000mg/

4 14

dL). High specific gravity (SG) was value >1.015

while normal specific gravity (SG) was between 1.005

1

4

and 1.015. Urinary tract infection was suspected by the

positive leucocyte esterase (LE) and nitrite in urinary

1

5

dipstick. Urine sa₁m₄ ple with pH value above 7 was re-

garded as alkaline.

Subjects and methods

Demographic and laboratory data were analyzed using

the Software Package for Social Science (SPSS) version

15.0 for Windows®. Continuous variables such as age,

duration of HIV diagnosis and CD4 cell count, were

analyzed and expressed as mean and standard devia-

tions. For tests of significance: Chi squared test was

used and ANOVA for comparison of means of continu-

ous variables while for categorical variables, Chi

squared test was used. Significant levels were set with p-

value of < 0.05 and 95% confidence interval.

This study was carried out at the University of Nigeria

Teaching Hospital, (UNTH), Enugu, in the Paediatric

Infectious Disease Clinic of the hospital. The clinic was

established in the year 2005 with a total of 236 patients

registered at the time of the study. Ethical approval was

obtained from the UNTH Health Research and Ethics

Committee before subject recruitment. The minimum

sample size of 146 was determined using the sampling

method for estimation of proportions of study popula-

7

tion less than 10, 000. This was a cross sectional de-

scriptive study in which consecutive HIV infected chil-

dren who were aged 18 months to 14 years, were en-

rolled from October 2009 to January 2010. The study

participants were recruited from the patients attending

the clinic. On presentation to the clinic, a written con-

sent was obtained, while data on gender, age, HAART

use and duration, duration of HIV diagnosis, CD4 cell

count and percent were collected from the clinic records.

The physical examination was done on all subjects to

elicit vital clinical features for categorizing them accord-

ing to WHO clinical staging system for infants and chil-

Results

One hundred and fifty nine subjects were enrolled and

comprised of 80 (50.3%) males and 79 (49.7%) females.

The means (in months) for the respective ages, duration

of HIV diagnosis and HAART use of the study popula-

tion were;79.4±39.7 (95% CI, 73.1 to 85.6, p=<0.0001),

21.1±15.8 (95% CI, 18.6 to 3.6, p=<0.0001) and

16.4±16.0 (95% CI, 13.9 to 18.9, p=<0.0001) respec-

tively. The mean CD4 cell count was 696.0±446.5 cell/

8

dren. Each child was given a universal bottle for urine

collection to fill up to about two thirds of the bottle

3

(

about 15mls). The urine testing was done with

mm (95% CI, 626.0 to 765.9, p=<0.0001) while that of

Multistix (Combi 11 strip series, urine reagent strip,

Korea, LOT 90219) according to manufacturer’s specifi-

cation. The urine dipstick was used for the study due to

CD4% was 23.1±12.6% (95% CI, 21.1 to 5.1,

p=<0.0001). The proportion of the subjects who were on

HAART was 77.4%, 92.5% had vertical transmission,

those with advanced HIV disease was 4.4%, those who

had severe immunosuppression was 23.3% (Table 1).

9

proven sensitivity and specificity in detecting urinary

‘contents’.

For standard assessment of the subjects the HIV- posi-

tive children, were stratified into three different age

groups; 18 months - 35 months, 36 month - 59 months

and five years - 14 years according to the WHO age

stratification for age –related CD4 values. Using the

WHO classification of HIV disease the children were

categorized on the basis of their clinical attributes.

Table 1: General characteristics of the HIV positive

children

Parameter

Frequency

%

1

0

Medication

On HAART

123

36

77.4

Not on HAART

Mode of transmission

22.6

Advanced HIV disease was defined with WHO clinical

stage three and four while stages one and two defined

1

Vertical

Blood transfusion

Disease severity

147

12

92.5

7.5

non-advanced disease. Severe immunosuppression was

3

defined as CD4 cell count of less than 200cells/mm in

those subjects equal to or more than five years old,

CD4% of less than 15% for those between 36 and 59

months, CD4%₁₀ of less than 20% for those between 18

and 35months.

Advanced HIV disease

7

4.4

Non advanced HIV disease

152

95.6

Immunosuppression

For the assessment of the outcome different parameters

were defined accordingly. Haematuria was indicated by

urinary dipstick reading of greater than 50 RBC/µL of

Severe immunosuppression

37

23.3

76.7

Non severe immunosuppression

122

6

urine (50x10 cells/L) which corresponds to urinary ex-

cretion of greater than five red blood cells (RBC)/high

power field (hpf).

protein ≥1+ on urinary dipstick. Glycosuria was urinary

The most important urinary abnormalities observed were

proteinuria and high SG, with the prevalence rate of

3.1%, and 2.5% respectively (Table 2). None of the sub-

1

2,13

Proteinuria was defined as urine

6

7

jects had haematuria, glycosuria or findings suggestive

of UTI. There was no significant gender difference in

the distribution of the urinary abnormalities, for protein-

uria and high SG (Table 3).

Table 5: The clinical characteristics of HIV disease and occur-

rence of proteinuria

Parameter

Frequency

Proteinuria

Fisher’s

exact (p

value)

No proteinuria

On HAART

4

1

5

0

119

35

Table 2: Prevalence of urinary abnormalities among

HIV positive children by age

0.70 (0.02)

1.00 (0.42)

Not on HAART

Vertical transmission

Blood transfusion

142

12

Age range

Proteinuria

Specific gravity

Alkaline urine

Positive

Negative

≤1.015

>1.015

Positive

Negative

Advanced HIV disease

Non advanced HIV disease

Severe immunosuppression

1

4

3

6

148

34

1

8-35

months

6-59

months

-14 years

0

1

22

44

22

0

1

0

22

45

0.20 (2.98)

0.08 (3.90)

3

44

Non severe immunosuppres-

sion

2

120

5

4

88

89

3

4

1

91

Total

5

154

155

2.5

1

158

Prevalence

3.1

0.6

Table 6: Specific gravity and general characteristics of the

(

χ (p value)

%)

study population

2

1.28 (0.50)

0.79 (0.70)

0.73 (0.70)

Mean of parameters

Normal SG

High SG

t

p value

Age in months±SD

Duration of HIV diagnosis

in months±SD

79.2±39.7

21.0±15.8

86.2±49.2

24.7±15.0

0.90

0.32

0.70

0.60

Table 3: Urinary abnormalities among HIV positive children

by gender

Gender

Proteinuria

Positive

Specific gravity

Alkaline urine

Duration of HAART use in

months ±SD

16.2±16.0

23.0±17.2

0.61

0.20

0.40

0.03

Negative

≤1.015

>1.015

Positive

Negative

CD4 cell count in cells/

708.1±444.1

226.7±268.

9

3

Male

Female

Total

Fisher’s

exact (p

value)

3

2

5

0.19 (0.50)

77

154

78

77

155

2

4

0

80

mm ±SD

1

78

1

158

Table 7: HIV disease characteristics and specific gravity

0.00 (1.00)

1.02 (0.50)

Parameter

Frequency

Normal SG

Fisher’s

exact (p

value)

High SG

On HAART

120

35

3

1

The subjects with proteinuria had longer duration of

HIV diagnosis, longer duration of HAART use and low

CD4 cell counts, as shown in Table 4. Among the group

with proteinuria, 3 subjects (60%) were immunosup-

pressed while 4 (80%) were on HAART, (Table 5) .All

the subjects with proteinuria had vertical transmission,

and the time of duration from diagnosis of HIV infection

to the commencement of HAART treatment was shorter

0.01 (1.00)

4.14 (0.20)

Not on HAART

Advanced HIV disease

Non advanced HIV disease

Severe immunosuppression 35

6

149

1

3

2

1

.64 (0.20)

Non severe immunosup-

pression

120

2

(

1.6±2.1 months) compared to those without proteinuria

5.1±9.8 months), p= 0.40.

Discussion

The four children whose urine SG was more than 1.015

were predominantly among the older age group

The important urinary abnormalities found in this study

among HIV infected children were proteinuria and high

specific gravity. The prevalence of proteinuria in the

index study was 3.1%, which is comparably low as Ese-

(

Table 2). All the 4 children had proteinuria (Fisher’s

exact = 126.38, p value = <0.0001) while their CD4 cell

counts were comparatively lower than those with normal

SG (Table 6). In addition, three out of these four were

on HAART while 1 had advanced HIV disease (Table

6

zobor and c₆oworkers found 20.5% while Chaparro and

1

colleagues noted 33%. We found low risk factors for

the development of proteinuria in our study population:

they were younger, had non-advanced disease, on

7

).

Table 4: Proteinuria and general characteristics of HIV

positive children

HAART treatment and had high₂_,C₆_,₁D₇ 4 cell count.

2

Younger age, non-advanced disease,

ment

HAART treat-

3

,6,16,18

2,5,16,18

are docu-

and high CD4 cell count

Mean of parameters

Positive pro-

teinuria

Negative

proteinuria

t

p value

mented low risk factors for proteinuria in HIV infected

children.

Age in months±SD

95% CI)

102.6±56.1

(32.9 to 172.3)

78.6±39.1

(72.9 to 84.8)

0.10

0.14

0.20

0.50

(

18

Duration of HIV

diagnosis in

25.8±13.2

(9.4 to 42.2)

21.0±15.9

(18.4 to 23.5)

Leroy and co-workers found no proteinuria among

HIV infected children with mean age of 44 months and

prevalence rate for proteinuria was zero percent. Steel-

months±SD (95%

CI)

Duration of HAART

use in months±SD

95% CI)

24.2±15.2

(5.4 to 43.0)

16.1±16.0

(13.6 to 18.7)

0.33

0.08

0.30

0.01

5

Duncan and colleagues found a prevalence of 3% in

(

HIV infected children w₁₆ith mean age of 60 months,

Chaparro and coworkers documented 33% and mean

age of their subjects was 132 months. Though our study

had a relatively lower prevalence of proteinuria, it

seemed to show proteinuria to occur more in the older

CD4 cell count in

219.4±233.4

(-70.4 to

509.2)

711.4±443.6

(640.8 to 782.1)

3

cells/mm ±SD (95%

CI)

6

8

children. The reason for this predilection could be be-

cause older children have supposedly longer duration of

exposure to HIV. The natural course of HIV infection is

such that with increasing duration of exposure, there is

disease progression which is characterized by increase

viral load and depletion of CD4 cells which are pr₁o₉ven

high risk factors for the development of proteinuria.

results from pres₁e₃nce of molecules in urine such as pro-

tein and glucose.

The presence of alkaline urine in one subject may be an

aberrant finding, for there was no explicable factor that

could be responsible for it. The subject lacked any of the

features such as UTI, use of amphotericin B and sodium

bicarbonate which could account for the presence of

1

7

The use of HAART suppresses viral load and the direct

effect of the HIV on the renal cells, re₁₆stores normal re-

nal function and reduces proteinuria. Leroy and oth-

alkaline urine. None of the subjects had haematuria or

glycosuria which is similar to the findings by Afhami

4

and colleagues. The absence of glycosuria could be at-

1

8

ers found zero percent as all the children were₃_,₆o_,₁n₆

HAART, whereas the subjects in the other studies,

with varying prevalence rates of proteinuria were

HAART naïve. Although the increased proportion of

those on HAART treatment in our study may explain the

low prevalence of proteinuria in this population of chil-

dren, majority of those with proteinuria were already on

HAART treatment and for a longer duration too. Ordi-

narily the assumption that the use of HAART may sup-

press the virus that affects the renal cells may be rational

but this finding seems to counter the argument but rein-

forces the possibility of multi-factorial influence to₁₉its

occurrence such as the viral load and CD4 cell count.

tributed partly to the preservation of renal tubular func-

tion which is commonly deranged in HIV positive sub-

jects on protease inhibitors, notably tenofovir and Indi-

5

navir. Subjects in the study by Afhami and in the index

study were not on protease inhibitor. The absence of

Indinavir use in the subjects could also explain the ab-

sence of evidence of UTI and absence of haematuria.

The risk of UTI and haematuria in HIV positive subjects

is increased by use of Indinavir because of the nephro-

5

lithiasis associated with its use.

Conclusion

Subjects with high CD4 cell count are less likely to de-

velop HIVAN and hence proteinuria, because of the low

Urinary abnormalities occur in HIV positive children.

Older age and low CD4 cell count are risk factors asso-

ciated with proteinuria. Dipstick urine testing for urinary

abnormalities is good screening tool in HIV positive

children and should be done routinely in the clinic.

1

9

viral load associated with high CD4 cell count. On the

other hand, low CD4 cell count is a risk factor for the

2

, 6,

development of proteinuria in HIV positive children.

16

We found that subjects with proteinuria had compara-

bly lower CD4 cell count and CD4% and majority were

severely immunosuppressed.

Author’s contribution: Ezeonwu BU conceived the

study,

All authors reviewed the study and analysed the data

Conflict of interest: None.

The normal SG in the study subjects indicates optimal

renal concentrating ability. Contrary to this finding,

Estremadoyro and colleagues, found several evidence

3

of renal tubular dysfunction among their subjects, in-

cluding poor urine concentrating ability and renal tubu-

lar acidosis. This finding could be attributed to the use

Funding : None

3

of amphotericin B for the treatment of fungal infection

among their subjects, as this drug causes renal tubular

damage. The high specific gravity noted in some sub-

jects in the index study could be attributed to the pres-

ence of protein in their urine. High specific gravity

Acknowledgement

1

3

We are grateful to all the children who participated, with

their parents/caregivers.

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