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Renal Impairment – Signs and Symptoms

Signs and Symptoms

Chronic kidney disease (CKD) is generally asymptomatic in early stages:1,2 

  • Patients do not normally present with symptoms, so regular monitoring of renal function is essential for those at risk
    • monitoring should be frequent if CKD risk factors are present and/or prior to starting treatment with nephrotoxic drugs
    • people living with HIV (PLWHIV) both on and not on antiretroviral (ARV) therapy should undergo risk assessment annually
    • estimation of glomerular filtration rate (eGFR) should be performed at diagnosis, prior to starting cART and then every 3–12 months, with more frequent monitoring if CKD risk factors are present
and/or prior to starting and on treatment with nephrotoxic drugs.3
    • urine dipstick analysis should be performed at diagnosis, prior to starting cART and then every 6 months if eGFR <60mL/min; if proteinuria ≥1+ and/or eGFR <60mL/min then urine protein/creatinine ratio, or urine albumin/creatinine ratio should be measured3
       
  • Patients with CKD may not notice any symptoms until they reach end stage kidney/renal disease (ESRD), requiring dialysis or transplant (eGFR <15mL/min/1.73m2).
     
  • Symptoms of ESRD include:1
    • nocturia
    • malaise
    • anorexia/nausea/vomiting
    • pruritus
    • restless legs
    • dyspnoea
       

Patients with acute renal failure from glomerulonephritis caused by viral infection and immune reaction can present with proteinuria and “nephritic sediment”. Clinical symptoms are determined by the extent of proteinuria with loss of protein and loss of renal function and include:4

  • edema
  • tiredness
  • reduced performance
  • susceptibility to infections
  • hyperlipidemia
  • anemia
  • metabolic acidosis
  • problems with calcium-phosphate metabolism
     

Emergency signs and symptoms of kidney disease in PLWHIV include:

  • severe respiratory distress due to pulmonary oedema, particularly in cases of kidney failure; bilateral crepitations (crackles and rattles in both lungs) heard with a stethoscope; hypoxia
  • hyperventilation (particularly in people with metabolic acidosis), which may present with very rapid, deep and laboured breathing
  • shock – quick recognition and treatment is essential to preserve and/or restore kidney function, and to prevent death; symptoms of shock include pallor, cold/clammy skin, weak but fast pulse, capillary refill longer than two or three seconds, dizziness and fatigue.
     

Some patients, particularly those on ARVs known to cause renal impairment can present with Fanconi syndrome with symptoms including:2,6

  • renal failure
  • hypokalemia
  • hypophosphatemia
  • metabolic acidosis
  • albuminuria/proteinuria
  • hyperaminoaciduria
  • glucosuria
  • calciuria
  • hypouricemia
  • phosphate and potassium wasting.

Table 1: Levels of hypophosphataemia have been graded.7  

Classification Level
Grade 1 (mild) 2.5 mg/dL–< LLN*
  0.81 mmol/L–< LLN
Grade 2 (moderate) 2.0–2.4 mg/dL
  0.65–0.80 mmol/L
Grade 3 (severe) 1.0–1.9 mg/dL
  0.32–0.64 mmol/L
Grade 4 (potentially life-threatening) <1.00 mg/dL
  <0.32 mmol/L

*LLN = lower limit of normal. 


Find out more about diagnostic tools
 


References

  1. Kidney Health Australia. Chronic kidney disease management in General Practice. Accessed 1 March 2011.
  2. Winston J, Deray G, Hawkins T, et al. Kidney disease in patients with HIV infection and AIDS. Clin Infect Dis. 2008;47:1449–1457.
  3. European AIDS Clinical Society (EACS). Guidelines. Version 6.0. Accessed 4 July 2012. 
  4. Rieke A. Clinical manifestation/diagnosis of nephropathy: HIV and Renal Function. Accessed 1 March 2011.
  5. Aidsmap. Key kidney disease investigations. Accessed 28 February 2011.
  6. Gupta SK, Eustace JA, Winston JA, et al. Guidelines for the Management of Chronic Kidney Disease in HIV-Infected Patients: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2005;40:1559–1585.
  7. Division of AIDS table for grading the severity of adult and pediatric adverse events, version 1.0, December 2004; Clarification August 2009. Accessed 22 March 2011.