Chronic Kidney Disease in HIV Infection: An Urban Epidemic

1
Chronic Kidney Disease in HIV Infection An Urban
Epidemic Wyatt CM, Winston JA, Malvestutto CD,
Fishbein DA, Barash I, Cohen AJ, Klotman
ME, and Klotman PE. Department of Medicine,
Division of Nephrology, and Division of
Infectious Diseases, Mount Sinai School of
Medicine, NY NY
BACKGROUND
FACTORS ASSOCIATED WITH CKD OR ESRD
PATIENT CHARACTERISTICS STRATIFIED BY ESRD
CKD/ ESRD (n192) No CKD (n1047) p-value
Age (years) 49.2 /- 10.1 45.1 /- 10.6 lt0.0001
Male 110 (57.3) 594 (56.7) 0.9
Race Black White Hispanic Other/ unknown 115 (59.9) 9 (4.7) 58 (30.2) 10 (5.2) 410 (39.2) 70 (6.7) 527 (50.3) 40 (3.8) lt0.0001 0.3 lt0.0001 0.4
CD4 (cells/mm3) 396.7 /- 316.2 447.5 /- 329.4 0.05
Viral load gt 50 copies/ml 95 (49.5) 611 (58.4) 0.02
Hepatitis C 86/182 (47.3) 335/965 (34.7) 0.001
Hepatitis B 11/168 (6.6) 54/906 (6.0) 0.8
Univariate OR (95 CI) Adjusted OR (95 CI)
Age (years) 1.04 (1.02-1.06) 1.03 (1.01-1.05)
Black race 2.32 (1.70-3.18) 2.37 (1.70-3.30)
CD4/100cells/mm3 0.95 (0.90-1.0) 0.93 (0.87-0.98)
Viral load gt 50 copies/ml 0.70 (0.51-0.95) 0.61 (0.43-0.87)
Hepatitis C 1.69 (1.22-2.32) 1.48 (1.04-2.10)
Kidney disease is as an important complication of
HIV infection and antiretroviral therapy (ART).
Between 1999-2003, more than 4,000 new cases of
ESRD were attributed to HIV in the US. Over 90
of those cases occurred in blacks (1). With
improvements in survival of HIV-infected dialysis
patients and a continued rise in the prevalence
of HIV in susceptible minority populations, the
prevalence of HIV-related ESRD is increasing (2).
Prior studies of earlier chronic kidney disease
were performed prior to combination ART (3-4).
ART has a positive impact on HIV-associated
nephropathy (2, 5), but may increase the risk of
kidney disease due to diabetes, hypertension, or
nephrotoxicity (6).
CONCLUSIONS

• 15.5 of our urban HIV population met criteria
  for CKD or ESRD
• Factors associated with kidney disease in our
  population included older age, black race, HCV,
  and lower CD4.
• Virologic suppression was more likely among
  patients with kidney disease. Reduced GFR may
  result in higher blood levels of renally
  eliminated antiretrovirals, or improved survival
  with virologic suppression may allow development
  of late complications.
• Our data likely underestimate the true burden of
  disease in our population Black race in GFR
  calculations would overestimate GFR in
  non-blacks, and lower levels of proteinuria were
  excluded to improve specificity. Inclusion of
  these patients would increase the prevalence of
  chronic kidney disease to gt 35.
• Future studies should consider factors, such as
  race or hepatitis co-infection, that may also be
  associated with progression.
• There is a high prevalence of chronic kidney
  disease among HIV-infected patients, suggesting
  that chronic kidney disease will remain an
  important complication in the ART era.

PURPOSE
To describe the prevalence of chronic kidney
disease (CKD) in HIV infected patients in the ART
era, including early disease that may be amenable
to intervention.
CHRONIC KIDNEY DISEASE STAGES
STAGE OF CKD
PREVALENCE 1 GFR 90 ml/min/1.73m2 with
proteinuria 40 (3.2) 2 GFR 60-89
ml/min/1.73m2 with proteinuria 28
(2.3) 3 GFR 30-59 ml/min/1.73m2
56 (4.5) 4 GFR 15-29 ml/min/1.73m2
10 (0.8) 5 GFR lt15 ml/min/1.73
m2 7 (0.6) ESRD 51 (4.1)
METHODS

• Cross-sectional data were abstracted for all
  active patients age, gender, self-reported
  race, serum creatinine, urinalysis, hepatitis C
  virus antibody, hepatitis B virus surface
  antigen, CD4 cell count, and HIV viral load
• Additional data were abstracted for patients with
  CKD diabetes, hypertension, ART regimen, and
  antihypertensives
• Any creatinine deviating ? 0.3 mg/dL from prior
  values was excluded, and the last stable value
  was used
• Urinalyses with possible infection (leukocyte
  esterase ?1 and/ or culture) or hematuria ?2
  were also excluded
• GFR was calculated using the 4-variable MDRD
  equation, assuming black race
• Proteinuria was defined as urine protein ? 100
  mg/dL.
• CKD was defined by proteinuria or GFR lt
  60ml/min/1.73m2
• Inter-group comparisons were performed using
  chi-square, or ANOVA and unpaired t-tests as
  appropriate. Multivariate logistic regression was
  used to identify independent predictors of kidney
  disease

CHARACTERISTICS OF 129 PATIENTS WITH CKD
CHARACTERISTICS
Hypertension 75 (54.6)
Diabetes 26 (20.2) Taking ACEI or
ARB 34 (26.4) On ART
Protease Inhibitors 106
(82.2) Nucleoside/ nucleotides
69 (53.5) Non-nucleosides 36
(27.9) Fusion Inhibitor 2 (1.6)
Taking TMP-SMX 41(31.8)
BIBLIOGRAPHY
1. US Renal Data System (USRDS) USRDS 2005
Annual Data Report.The National Institutes of
Health, Bethesda, 2005. 2. Schwartz EJ et al, J
Am Soc Nephrol 2005 16 2412-2420. 3. Szczech
LA et al, Kidney Int 2002 61195-202. 4.
Krawczyk CS et al, AIDS 2004 182171-2178. 5.
Szczech LA et al, Kidney Int 2004
661145-1152. 6. Wyatt CM et al, Expert Opin Drug
Saf 2006 5275-287.