The Impact of Hepatitis C Virus Coinfection on HIV-related Kidney Disease
 Despite
the advent of HAART, kidney disease
continues to be a concern in people with HIV.
Researchers at the Mount Sinai School of Medicine reported results of a study
of the impact of hepatitis C virus
(HCV) infection in HIV patients with kidney disease in the September 12, 2008
issue of AIDS. (Two related
reports looked at kidney disease in HCV monoinfected individuals.)
Between
1999 and 2003, there were more than 4000 new cases
of end-stage renal (kidney) disease attributed to HIV in the U.S., primarily
among African Americans, the study authors wrote as background [1]. With improvements
in the survival of HIV positive kidney dialysis patients and the increasing prevalence
of HIV infection among African Americans, the prevalence of HIV-related end-stage
renal disease (ESRD) continues to rise.
The
increased recognition of kidney problems as an important complication in people
with HIV is evident in the recent publication of consensus guidelines for the
detection and management of chronic kidney disease in HIV patients [2].
In
this review and meta-analysis, investigators identified English-language citations
in MEDLINE and Web of Science from 1989 through July 2007. References cited in
the selected articles were reviewed. Observational studies and clinical trials
of HIV-related kidney disease and antiretroviral nephrotoxicity were eligible
if they included at least 50 participants and reported hepatitis C status. Data
on study characteristics, populations, and kidney disease outcomes were abstracted
by 2 independent reviewers.
After screening 2516 articles, 27 studies
were eligible -- including a total of more than 18,000 patents -- and 24 authors
confirmed or provided data. Separate meta-analyses were performed for chronic
kidney disease outcomes (n = 10), proteinuria (n = 4), acute renal failure (n
= 2), and indinavir (Crixivan) kidney
toxicity (n = 5).
Results
•
The pooled incidence of chronic kidney disease was higher in patients with HIV-HCV
coinfection compared to those without hepatitis C (6.2% vs 4.0%; relative risk
1.49).
•
In a meta-regression, the percentage of black patients in a study and the proportion
of patients with hepatitis C were independently associated with risk of chronic
kidney disease.
•
The relative risk associated with hepatitis C coinfection was significantly increased
for proteinuria (1.15) and acute renal failure (1.64).
•
The relative risk of indinavir toxicity was 1.59 with hepatitis C coinfection.
These
findings led the researchers to conclude that hpatitis C coinfection is associated
with a significant increase in the risk of HIV-related kidney disease.
Discussion
The
results of the current meta-analysis suggest that HIV-HCV coinfection is associated
with an increased risk of kidney disease compared with HIV infection alone. In
pooled analyses of data from more than 18,000 HIV-infected patients, HCV coinfection
increased the risk of chronic kidney disease by nearly 50%, proteinuria by 15%,
and acute renal failure by 64%, as well as increasing the risk of urological and
nephrotoxic complications related to the protease inhibitor indinavir.
According
to the study authors, "These findings have important implications for clinical
care and for global public health, and they may provide a new impetus for pathogenic
studies of kidney disease in patients with HIV and HCV."
Few of the
studies included in the current meta-analysis provided adjusted estimates of the
risk for kidney disease associated with HCV coinfection. "The observed association
between HCV coinfection and increased risk for kidney disease could reflect confounding
by other factors, such as older age, black race, history of injection drug use,
or exposure to nephrotoxic medications," the authors wrote.
They
also noted, "Data on potential mediators such as diabetes, cryoglobulinemia,
and end-stage liver disease were also not reported in most studies."
The
authors encouraged healthcare providers to be aware that HCV coinfection in HIV
positive patients is associated with an increased risk of kidney disease, and
further recommended that "[f]uture studies should investigate the mechanism
of the observed association to allow for targeted interventions in susceptible
patients."
"In the interim," the investigators cautioned,
"patients with HIV-HCV coinfection should be regarded as being at increased
risk for acute and chronic kidney disease, regardless of the presence of traditional
kidney disease risk factors."
9/23/08
Reference
CM
Wyatt, C Malvestutto, SG Coca, and others. The impact of hepatitis C virus coinfection
on HIV-related kidney disease: a systematic review and meta-analysis. AIDS 22(14):
1799-1807. September 12, 2008. (Abstract). Other
Citations 1.
U.S. Renal Data System. USRDS 2007 Annual Data Report: Atlas of chronic kidney
disease and end-stage renal disease in the United States. 2007. 2.
SK Gupta, JA Eustace, JA Winston, and others. 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. Clinical Infectious
Diseases 40: 1559-1585. 2005. |
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