Screening for Decreased Glomerular Filtration Rate and Associated Risk Factors in a Cohort of HIV-Infected Patients in a Middle-Income Country

Abstract

With the introduction of combined active antiretroviral therapy and the improved survival of HIV-infected patients, degenerative diseases and drug toxicity have emerged as long-term concerns. We studied the prevalence of decreased glomerular filtration rate (GFR) and associated risk factors in a cohort of HIV-infected patients from a middle-income country. Our cross-sectional study included all adult patients who attended an urban outpatient clinic in 2008. GFR was estimated using the CKD-EPI equation. The prevalence ratio (PR) of decreased GFR (defined as <60 mL/min/1.73 m2) was estimated using generalizing linear models assuming a Poisson distribution. We analyzed data from 1,970 patients, of which 82.9% had been exposed to ART. A total of 249 patients (12.6%) had a GFR between 60 and 89 mL/min/1.73 m2, 3.1% had a GFR between 30 and 59, 0.3% had a GFR between 15 and 29, and 0.4% had a GFR <15. Decreased GFR was found in only 74 patients (3.8%). In the multivariate regression model, the factors that were independently associated with a GFR below 60 mL/min/1.73 m2 were as follows: age ≥50 years (PR = 3.4; 95% CI: 1.7–6.8), diabetes (PR = 2.0; 95% CI: 1.2–3.4), hypertension (PR = 2.0; 95% CI: 1.3–3.2), current CD4+ cell count <350 cells/mm3 (PR = 2.1; 95% CI: 1.3–3.3), past exposure to tenofovir (PR = 4.7; 95% CI: 2.3–9.4) and past exposure to indinavir (PR = 1.7; 95% CI: 1.0–2.8). As in high-income countries, CKD was the predominant form of kidney involvement among HIV-infected individuals in our setting. The risk factors associated with decreased glomerular filtration were broad and included virus-related factors as well as degenerative and nephrotoxic factors. Despite the potential for nephrotoxicity associated with some antiretroviral drugs, in the short-term, advanced chronic renal disease remains very rare.

Evaluation of the Side Effects of Antiretroviral Treatment

“…Patient characteristics: Of the 95 patients included in our study, 84 (88%) were male and 11 (12%) were female, with ages ranging between 20 and 68. The median (IQR) age was 37 (30-47) years and median (IQR) BMI was 24 (22)(23)(24)(25)(26).…”

HIV and Noncommunicable Diseases (NCDs) in Latin America

“…Risk factors associated with decreased glomerular filtration included HIVrelated factors (a current CD4 + cell count ,350 cells/mm 3 ), past exposure to tenofovir and indinavir, and degenerative and nephrotoxic factors (older age, diabetes, hypertension). 37 The widespread use of indinavir in the early years of ART scale up, and more recently the preference of tenofovir-containing regimens for therapy, as well as the traditional risk factors for renal dysfunction in PLHIV (such as older age and low CD4 counts at presentation) highlight the importance of studying the occurrence of kidney disease among PLHIV in LACs.…”

HIV and kidney diseases: 35 years of history and consequences

“…Studies in Brazil have reported CKD prevalence rates from 3.8 to 8.4% [48, 49]. In a prospective Portuguese study, the prevalence of CKD was 5.9% in a cohort of 1281 patients using the creatinine (SCr)-based Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation to estimate GFR [50].…”

“…Risk factors for CKD in HIV-persons are therefore a combination of traditional and HIV-related factors including low CD4 counts, high viral load, intravenous drug use, HCV co-infection and also cART, mainly tenofovir, indinavir, lopinavir/ritonavir, atazanavir/ritonavir and abacavir [44, 47, 48, 58–60]. In this regard, a quarter of HIV-infected patients are co-infected by HCV and co-infection with HCV may cause specific immune complex-mediated kidney disease [61–63].…”