Chronic Kidney Disease in People with HIV

As people with HIV live longer due to effective antiretroviral therapy, they have more time to develop progressive chronic illnesses, including liver and kidney disease. Researchers from Mount Sinai School of Medicine presented data from a study of chronic kidney disease (CKD) among HIV patients in the October 1, 2007 issue of AIDS.

"Kidney disease is an important complication of HIV, particularly in minority populations," the authors wrote. They noted that between 1999 and 2003, more than 4000 new cases of end-stage renal disease (ESRD) were attributed to HIV disease in the U.S., with more than 90% of these cases occurring in black individuals [1].

They added that although antiretroviral therapy improves the course of HIV-associated nephropathy (kidney damage), it may increase the risk of co-morbid CKD or drug-related nephrotoxicity (kidney toxicity).

Earlier this year, the EuroSIDA Study Group observed a low prevalence of chronic kidney disease in a cohort of predominantly white patients treated with antiretroviral therapy [2]. However, rates of kidney disease are known to be higher among black patients.

The authors of the present study sought to describe the prevalence of CKD among patients at the Mount Sinai AIDS Center, serving East Harlem, New York, a large clinic population with a high proportion of minority patients.

The researchers collected cross-sectional data for all active adult patients, including demographic information, serum creatinine, urinalysis, hepatitis C virus (HCV) antibody and hepatitis B virus (HBV) surface antigen status, CD4 cell count, and HIV viral load. Additional data were collected for patients with CKD, including history of diabetes or hypertension, antiretroviral therapy regimen, and use of anti-hypertensive agents (drugs to lower blood pressure).

Nearly 90% of the 1239 included patients were black and one-third were older than 50 years. One-quarter had a CD4 cell count below 200 cells/mm3 and approximately one-half had a detectable viral load.

CKD was defined as proteinuria (protein in the urine) or decreased kidney function as indicated by a glomerular filtration rate (GFR) less than 60 ml/min per 1.73 m2.

Results

• Overall, 192 patients (15.5%) had chronic or end-stage kidney disease.

• 51 patients (4.1%) had ESRD, including 7 kidney transplant recipients.

• About 10.5% of the 934 patients with available urinalysis results had urine protein of 1+ or greater, including 68 subjects who had a GFR of 60 ml/min per 1.73 m2 or greater (stage 1-2).

• 30 patients with proteinuria and 43 without proteinuria had a GFR less than 60 ml/min per 1.73 m2 (stage 3-5).

• Factors that independently predicted CKD were:

- older age;
- black race;
- HCV coinfection;
- lower CD4 cell count.

• Undetectable HIV viral load was more common among patients with CKD, in conflict with previous studies.

• Among 129 patients with pre-end stage CKD for whom clinical data were available:

- 77 (55%) had hypertension;
- 26 (20%) had diabetes;
- Only 26% were taking an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker.
- More than 84% were on HAART.
- 41 were taking trimethoprim (which may interfere with tubular creatinine secretion), most of whom had proteinuria or low GFR.
- No patients with CKD were prescribed other nephrotoxic antimicrobial agents.

Conclusion

In conclusion, the study authors wrote, "These data suggest that chronic kidney disease remains a common complication of HIV infection in the era of antiretroviral therapy."

They added that the findings "highlight the need for increased awareness of CKD, particularly in minority populations…Early recognition facilitates the diagnosis and treatment of reversible causes, the anticipation of complications, and preparation for dialysis or transplantation in patients with progressive disease."

10/02/07

Source

CM Wyatt, JA Winston, CD Malvestutto, and others. Chronic kidney disease in HIV infection: an urban epidemic. AIDS 21(15): 2101-2103. October 1, 2007.

References

1. US Renal Data System (USRDS). USRDS 2005 Annual Data Report: Atlas of end-stage renal disease in the United States. Bethesda, MD, USA: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2005.

2. Mocroft A, Kirk O, Gatell J, and others (EuroSIDA Study Group). Chronic renal failure among HIV-1-infected patients. AIDS 2007; 21:1119-1127.