End‐stage renal disease and dialysis in HIV‐positive patients: observations from a long‐term cohort study with a follow‐up of 22 years

Abstract

ObjectivesRenal disease is a common and serious complication in HIV-infected patients. MethodsA retrospective cohort analysis for the period 1989-2010 was carried out to determine the prevalence, incidence and risk factors for end-stage renal disease (ESRD). ESRD was defined as initiation of renal replacement therapy. Three time periods were defined: 1989-1996 [pre-highly active antiretroviral therapy (HAART)], 1997 (early HAART) and 2004. ResultsData for 9198 patients [78.2% male; 88.9% Caucasian; cumulative observation time 68 084 patient-years (PY)] were analysed. ESRD was newly diagnosed in 35 patients (0.38%). Risk factors for ESRD were Black ethnicity [relative risk (RR) 5.1; 95% confidence interval (CI) 2.3-10.3; P < 0.0001], injecting drug use (IDU) (RR 2.3; 95% CI 1.1-4.6; P = 0.02) and hepatitis C virus (HCV) coinfection (RR 2.2; 95% CI 1.1-4.2; P = 0.03). The incidence of ESRD decreased in Black patients over the three time periods [from 788.8 to 130.5 and 164.1 per 100 000 PY of follow-up (PYFU), respectively], but increased in Caucasian patients (from 29.9 to 41.0 and 43.4 per 100 000 PYFU, respectively). The prevalence of ESRD increased over time and reached 1.9 per 1000 patients in 2010. Mortality for patients with ESRD decreased nonsignificantly from period 1 to 2 (RR 0.72; P = 0.52), but significantly from period 1 to 3 (RR 0.24; P = 0.006), whereas for patients without ESRD mortality decreased significantly for all comparisons. ESRD was associated with a high overall mortality (RR 9.9; 95% CI 6.3-14.5; P < 0.0001). ConclusionAs a result of longer survival, the prevalence of ESRD is increasing but remains associated with a high mortality. The incidence of ESRD declined in Black but not in Caucasian patients. IDU and HCV were identified as additional risk factors for the development of ESRD.Keywords: chronic kidney disease, haemodialysis, HIV-associated nephropathy, renal failure, renal replacement therapy Accepted 18 July 2012 IntroductionThe prevention and treatment of cardiovascular, liver and kidney diseases have increasingly been the focus of attention in attempts to reduce the morbidity and mortality of HIV-infected individuals [1]. In the USA, HIV-associated ESRD has become epidemic among Black patients [11,12]. Black individuals are more prone to kidney disease than any other ethnic group in the general [13,14] and HIV-infected populations, possibly as a consequence of predisposing genetic polymorphisms [15]. The risk of ESRD in Black HIV-infected individuals has been reported to be three-to six-fold higher than in Caucasian HIV-infected patients [7,16,17], reflecting the susceptibility of Black patients to develop HIVAN. The introduction of highly active antiretroviral therapy (HAART) has reduced the incidence of HIVAN and ESRD among Black patients [18][19][20], but the prevalence of ESRD is projected to further increase [11,12]. Earlier studies, mainly from the USA, concluded that, almost exclusively in Black patients, HIVAN is one of the major causes of ESRD [6,21,22], but histologica...

Prognostic Factors of Human Immunodeficiency Virus-Infected Patients on Chronic Hemodialysis

“…Injected drugs use and HCV co-infection were known risk factors for ESRD in HIV-infected patients [2]. According to our results, these factors are also important determinants of a lower survival in HIV-infected patients on HD.…”

“…Regardless of black patients having more advanced kidney disease at HIV diagnoses, a faster progression to ESRD [12,] and a risk of ESRD 2-6 folds higher than other races [1,2,12], black race is not a survival determinant in this studied population [3,4]. Only one group from the United Kingdom [12] found that black patients had higher survival after renal replacement therapy initiation when compared to other races (5-year survival of 85.2 vs. 43.4%); however, these results were not adjusted to important variables, such as age, gender, infection status, and ESRD etiology.…”

“…With the aging of HIV-infected population, the prevalence of these traditional risk factors for ESRD are increasing among HIV patients [5,6]. At least in one study, diabetes was the most frequent cause of ESRD in HIV-infected patients [2]. …”

“…The development of ESRD in HIV-infected patients is associated with a poorer prognosis [2,3,7]. These patients accumulate the risks for cardiovascular diseases, immunosuppression, anemia, weight loss, and osteodystrophy of both hemodialysis (HD) and HIV infection [4].…”

“…Almost 30% of HIV-infected patients develop chronic kidney disease, which have important prognosis implications [1,][2]. …”