Date Published: April 17, 2019
Publisher: Public Library of Science
Author(s): Rosbel M. Brito, Duc T. Nguyen, Justine R. Johnson, Eric J. Lai, Rochelle E. Castro, Angelina M. Albert, Ann. S. Barnes, Edward A. Graviss, Wadi N. Suki, Karen Cohen.
HIV-infected patients are at risk for developing chronic kidney disease (CKD), defined by estimated glomerular filtration rate (eGFR) <60 ml/min/1.73m2. Our purpose was to understand the genesis of CKD in HIV patients from a large urban clinic in Houston, Texas, USA, and to characterize progression of CKD in the cohort. A retrospective cohort study (2012–2016) was conducted in all HIV-infected patients seen in a federally qualified community health center in Houston, Texas. CKD prevalence and its association with HIV viral load and CD4 count were determined. The association of the change in eGFR over time and comorbidities was assessed using linear mixed models. Of 3714 HIV-infected patients analyzed, 153 (4.1%) had CKD. The prevalence of CKD in the different racial groups was 5.4% White, 4.0% African American, 2.8% Hispanic/Latino and 3.2% Asian. There was no difference in the rate of decline in kidney function in White vs. African American HIV infected patients with CKD. Compared with non-CKD patients, CKD patients were older, had lived longer with HIV infection, had lower CD4 cell counts, higher proportions of hypertension, hyperlipidemia, and cerebrovascular disease, and had significantly higher rates of eGFR deterioration represented by a median decrease of 26.5% from first to last follow-up eGFR (versus 0% change). Linear mixed modeling identified older age, male gender, White race, longer time with HIV infection, hypertension, history of kidney stones, cerebrovascular disease, autoimmune disease, increased potassium and total cholesterol levels, and being treated with combination ART as associated with a worsening eGFR over time. This study demonstrates a prevalence of CKD in HIV-infected patients of 4.1% and points to an important role for HIV medications and other common comorbidities in the genesis and progression of kidney disease. Importantly, CKD was not more prevalent in African Americans than in Whites, perhaps due to a low prevalence of IV drug abuse as inferred from the lower prevalence of HCV infection in this cohort.
Renal disease was first reported in HIV-seropositive individuals in 1984 by Rao and colleagues, in a group of ten patients with advanced acquired immune deficiency syndrome (AIDS), and the syndrome was initially designated AIDS nephropathy . The term was later changed to HIV-associated nephropathy (HIVAN). This entity classically presents with heavy proteinuria and rapidly progressive renal failure, and frequently, (although higher CD4 levels in these patients have been reported ), an association with low CD4 cell counts and high viral loads . The treatment for HIV infection involves the use of Highly Active Antiretroviral Therapy (HAART) which has been widely accepted since 1996. Typically HAART consists of a combination of two reverse transcriptase inhibitors (RTIs) and a protease inhibitor (PI) or the combination of three RTIs. Reverse transcriptase inhibitors are composed of three classes of inhibitors: Nucleoside RT inhibitors (NRTIs), nucleotide RT inhibitors (NtRTIs), and non-nucleoside RT inhibitors (NNRTIs) .
Of 3719 HIV-infected patients seen at the study center from January 1, 2012 to October 15, 2016, five patients were excluded due to unavailable race/ethnicity. Among the remaining 3,714 patients included in the analysis, 153 (4.1%) had an eGFR<60 ml/min/1.73m2 (CKD) and 3,561 (95.9%) had an eGFR ≥60 ml/min/1.73m2 (non-CKD) (Fig 1). The patients’ demographics, comorbidities and laboratory parameters are presented in Table 1. Compared with non-CKD patients, patients with CKD were significantly older reflecting their longer time living with HIV infection (Table 1). Smoking, hypertension, hyperlipidemia, and HSV infection were the most frequent comorbidities documented (47.5%, 28.5%, 23.8% and 16.0%, respectively). Other comorbidities (such as peripheral vascular disease, chronic hepatitis C, and tuberculosis) were found in less than 10% of the patients. Hypertension was the most common comorbidity found in the CKD sub-group, which was present in nearly two-third of the patients. Diabetes, while it occurred in only 8.4% of the total cohort, was significantly more prevalent in the CKD vs non-CKD cohort (15% vs. 8.1%; p = 0.003). No significant difference was found in the proportion of smokers between non-CKD and CKD sub-groups (Table 1). CKD patients were more likely to have lower levels of hemoglobin, platelets and albumin and higher levels of total cholesterol and triglycerides than non-CKD patients (Table 1). This retrospective cohort study in HIV-infected patients seen in a large, urban U.S. community clinic, evaluated patient characteristics: demographics, comorbidities, laboratory parameters and HARRT medications usage. We found that CKD was associated with older age, male gender, longer time of HIV infection, hypertension, history of kidney stone, cerebrovascular disease, autoimmune disease, higher potassium level, higher total cholesterol level, and being treated with combination ART. Of interest and contrary to expectation, the prevalence of CKD in African Americans in this cohort was not greater than that in White members of the cohort. Furthermore, the rate of decline of eGFR in African Americans with CKD was not greater than that in White patients with CKD. Prior studies have reported that African Americans are at increased risk for incident CKD compared with white subjects and that CKD progression to ESRD is more rapid than in the White HIV-infected population [19, 20]. The lower incidence of CKD in AA than in Whites in the present cohort may be related to the manner by which HIV had been contracted (that is by sexual contact vs. IV drug abuse [IVDA]) (see discussion below regarding HCV prevalence in the present cohort). Of note, in the study by Wong et al, the incidence of IV drug abuse as the cause of HIV infection was greater in the patients with CKD than in those without CKD . Source: http://doi.org/10.1371/journal.pone.0215575