Research Article: Serum albumin and mortality in patients with HIV and end-stage renal failure on peritoneal dialysis

Date Published: June 10, 2019

Publisher: Public Library of Science

Author(s): Kwazi Celani Zwakele Ndlovu, Perpetual Chikobvu, Thabiso Mofokeng, Verena Gounden, Alain Assounga, Antonio Carlos Seguro.


Peritoneal dialysis (PD) is an easily implementable dialysis modality in end-stage renal disease (ESRD). PD may improve access to renal replacement therapy in low- and middle-income countries; however, these countries have a higher prevalence of protein-energy wasting in patients and poorer socioeconomic conditions. We evaluated the effects of HIV infection on serum albumin levels in ESRD patients starting continuous ambulatory PD (CAPD) and mortality outcomes.

We conducted a single-center prospective cohort study of consecutive incident CAPD patients recruited from two hospitals in Durban, South Africa, from September 2012 to February 2015. Seventy HIV-negative and 70 HIV-positive ESRD patients were followed monthly for serum albumin levels and mortality events during the first 18 months of CAPD therapy.

The HIV-positive cohort recorded 28 deaths (40%) among patients with a functional CAPD catheter at 18 months and 13 deaths (18.6%) in the HIV-negative cohort (p = 0.005). The mean serum albumin levels were lower in the HIV-positive cohort than in the HIV-negative cohort during the 18-month follow-up. The mean difference in serum albumin levels between the two cohorts was 4.24 g/L (95% confidence interval [CI] 2.02–6.46, p<0.001) at baseline and 3.99 g/L (95% CI 1.19–6.79, p = 0.006) at 18 months. HIV-positive status (adjusted regression coefficient -2.84, CI -5.00–-0.67, p = 0.011), diabetes (adjusted coefficient -2.85; CI, -5.58–-0.12; p = 0.041), and serum C-reactive protein and blood hemoglobin levels were independent predictors of serum albumin levels on multivariable linear regression. Baseline serum albumin <25 g/L (subdistribution-hazard ratio [SHR] 13.06, 95% CI 3.09–55.14, p<0.001) and CD4+ cell count <200 cells/μL (SHR 3.2, CI 1.38–7.45, p = 0.007) were independent predictors of mortality in our competing risk model. HIV infection can adversely affect serum albumin levels in ESRD patients managed with CAPD, while low baseline serum albumin levels and impaired immunity reliably predict mortality.

Partial Text

Peritoneal dialysis (PD) is an easily implementable renal replacement therapy (RRT) option for patients with end-stage renal disease (ESRD) owing to fewer resource requirements compared to hemodialysis and has been suggested to be a cost-effective approach when favorable country policies underpin its application [1–5]. In low- and middle-income countries that typically have reduced access to RRT due to poor health care funding and infrastructure, PD can potentially allow for easier upscaling of RRT access when local manufacturing and policy conditions favor lower costs of PD fluids [1, 6, 7].

This prospective cohort study evaluated the effect of HIV infection on serial serum albumin levels and associated mortality in ESRD patients managed with CAPD over an 18-month follow-up period. HIV was associated with significantly lower serum albumin levels at baseline and follow-up and negatively predicted monthly serum albumin levels over 18 months. Moreover, initiation of CAPD was associated with momentary drops in serum albumin levels in both HIV-infected and non-infected ESRD patients. Furthermore, HIV was associated with increased mortality rates, with baseline CD4+ cell counts <200 cells/μL and serum albumin <25 g/L independently predicting all-cause mortality. However, technique failure rates did not significantly differ according to HIV status.   Source: