Determinants of Survival among HIV-Infected Chronic Dialysis Patients

Abstract

ABSTRACT. Over 100 HIV-infected patients have initiated chronic dialysis at San Francisco General Hospital (SFGH) since 1985. This study employed retrospective analysis to identify determinants of and trends in survival among HIV-infected patients who have initiated chronic dialysis at SFGH from January 1, 1985 to November 1, 2002 (n = 115). Cohort patient survival was compared with survival after an AIDS-opportunistic illness in all HIV-infected patients in San Francisco during the study period. Higher CD4 count (hazard ratio [HR], 0.86 per 50 cells/mm3 increase; 95% confidence interval [CI], 0.80 to 0.93) and serum albumin (HR, 0.53 per 1 g/dl increase; CI, 0.36 to 0.78) at initiation of dialysis were strongly associated with lower mortality. Survival for those initiating dialysis during the era of highly active antiretroviral therapy (HAART) was 16.1 mo versus 9.4 mo for those initiating dialysis before this time, but this difference was not statistically significant. In adjusted analysis, only a non-statistically significant trend toward improved survival during the HAART era was noted (HR, 0.59; CI, 0.34 to 1.04). By comparison, survival for all HIV-infected patients after an AIDS-opportunistic illness in San Francisco increased from 16 mo in 1994 to 81 mo in 1996. The dramatic improvement in survival that has occurred since the mid-1990s for patients with HIV appears to be greatly attenuated in the sub-group undergoing dialysis. Although this may partly reflect confounding by race, injection drug use and HCV co-infection, future attempts to improve survival among HIV-infected dialysis patients should focus on barriers to the effective use of HAART in this group. E-mail: Rudy@itsa.ucsf.edu

Morbidity and mortality of black HIV-positive patients with end-stage kidney disease receiving chronic haemodialysis in South Africa

“…In the international literature, survival of HIV-positive patients receiving chronic haemodialysis in various cohorts in the USA ranged from 74% at 1 year to 30% at 2 years. [2,4] In Europe, 1-and 2-year survival rates were 93.8% and 89.4%, respectively, with the strongest predictors of survival being CD4 counts >200 cells/µl and serum albumin >30 g/L, [2,5] which are comparable to the CD4 counts and serum albumin levels in the patients in our study. Our HIV-positive patients did have in creased rates of infection.…”

“…[1] In the USA before 1995, when ART was not freely available, median survival of HIV-positive patients on chronic haemodialysis ranged from 1.4 to 12 months. [2] After 1995, as access to effective ART improved, studies began to show progressive improvements in survival in HIV-positive patients receiving chronic haemodialysis, but survival was still significantly lower than in their HIV-negative counterparts. [3,4] In 2006, French researchers showed that the 2-year survival of HIVpositive patients on haemodialysis with access to ART was comparable (89%) to a cohort of HIV-negative patients.…”

Update on kidney transplantation in human immunodeficiency virus infected recipients

“…Furthermore, HIV positive individuals have higher waitlist mortality rates than their HIV negative counterparts. This along with an understanding of the role of immune activation in HIV disease pathogenesis and how immunosuppressant drugs exert antiviral effects contributed to a renewed interest in studying the outcomes of transplantation in these patients [8] .…”

“…Furthermore, most HIV sero-positive patients are co-infected with hepatitis C virus which can also cause CKD [7] . Progression to ESRD in CKD patients who are also HIV infected is more rapid than those without HIV infection [8] . Kidney diseases associated with HIV infection are summarized in Table 1.…”

“…Outcomes of HIV infected dialysis patients have improved dramatically [8,9] . Actual number of HIV positive patients who received kidney transplants or who are on the waiting list is unknown.…”