Interventions for HIV-associated nephropathy: Cochrane systematic review
Assessed as up to date: 2012/01/12
Human immunodeficiency virus-associated nephropathy (HIVAN) is the most common cause of end stage kidney disease (ESKD) in human immunodeficiency virus-1 (HIV-1) serotype patients and it mostly affects patients of African descent. It rapidly progresses to ESKD if untreated. The goal of treatment is directed toward reducing HIV-1 replication and/or slowing the progression of chronic kidney disease. The following pharmacological agents have been used for the treatment of HIVAN: antiretroviral therapy, angiotensin-converting enzyme inhibitors (ACEi), steroids and recently cyclosporin. Despite this, the effect of each intervention is yet to be evaluated.Objectives
To evaluate the benefits and harms of adjunctive therapies in the management of HIVAN and its effects on symptom severity and all-cause mortality.Search methods
In January 2012 we searched the Cochrane Renal Group's Specialised Register, AIDS Education Global Information System (AEGIS database), ClinicalTrial.gov, the WHO International Clinical Trials Registry Portal, and reference lists of retrieved articles without language restrictions. In our original review we searched CENTRAL, MEDLINE, EMBASE, and AIDSearch, in addition to contacting individual researchers, research organisations and pharmaceutical companies.Selection criteria
Randomised controlled trials (RCTs) and quasi-RCTs of any therapy used in the treatment of HIVAN.Data collection and analysis
We independently screened the search outputs for relevant studies and to retrieve full articles when necessary. For dichotomous outcomes results were to be expressed as risk ratios with 95% confidence intervals, and for continuous scales of measurement the mean difference was to be used.Main results
We identified four relevant ongoing studies: one is still ongoing; two have completed recruitment but are yet to be published; and the fourth study was suspended for unspecified reasons. No completed RCTs or quasi-RCTs were identified. We summarised and tabulated the data from the observational studies, however no formal analyses were performed.Authors' conclusions
There is currently no RCT-based evidence upon which to base guidelines for the treatment of HIVAN, however three ongoing studies have been identified. Data from observational studies suggest steroids and angiotensin-converting enzyme inhibitors appear to improve kidney function in patients with HIVAN, however no formal analyses were performed in this review. This review highlights the need for good quality RCTs to address the effects of interventions for treating this group.
Yahaya Ismail, Uthman Olalekan A, Uthman Muhammed Mubashir B
Interventions for treating HIV-associated nephropathy
HIV-associated nephropathy (HIVAN) is a kidney disease common among HIV positive patients, especially patients of African origin. The condition rapidly deteriorates if left untreated. Various treatment options exist, but the benefit of each is unknown. These include: antiretroviral therapy, steroids, angiotensin-converting enzyme inhibitors (ACEi) and cyclosporin. The aim of this review was to determine the benefits and harms of each treatment option. No completed randomised control trials (RCT) of any interventions for HIVAN were found and so the effects of the treatment options could not be evaluated. However, the results of observational studies identified showed that steroids and ACEI were beneficial in improving the kidney functions of patients. We await the results of three ongoing studies, however more RCTs are needed.
Implications for practice
It is likely that clinicians will continue with their current practice, using clinical judgement and prescribing patterns to dictate treatment because there is no RCT-based evidence to help guide their choice of drug. It is difficult to know whether current practice is justified outside of a well designed, conducted and reported RCT.
Currently policy makers have no RCT-based evidence upon which to base guidelines for HIVAN. They are likely to continue to rely on opinion and habit when making their recommendations. Funders of studies may wish to make this important subgroup of people a priority for future research.
Implications for research
At present there is no convincing evidence to support the use of any intervention for HIVAN. Given the magnitude of problem associated with HIVAN, clinically meaningful RCTs are needed to help guide clinicians in their management of people with HIVAN. While ideally, RCTs evaluating the effect of interventions for treating HIVAN could be carried out, the detrimental effect of untreated HIV in the presence of effective medication (HAART) makes it unethical to conduct such a study. Thus, studies may compare different types of therapies combined with HAART as long as the intervention and control group both received HAART and the only difference between groups is a non-antiretroviral intervention. Outcomes to be included in such studies should be relevant to allow for the evaluation of the benefits and risks of the intervention.Get full text at The Cochrane Library
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