The kidney in HIV infection: beyond HIV-associated nephropathy

Abstract

Acute kidney injury (AKI) and chronic kidney disease (CKD) are more common in HIV-infected persons than in the general population. AKI is associated with poor health outcomes, including increased risk of heart failure, cardiovascular events, end-stage renal disease (ESRD), and mortality. The most common causes of AKI in HIV-infected persons are systemic infections and adverse drug effects. The prevalence of CKD is rising in the HIV-infected population and CKD is increasingly likely to be caused by comorbid conditions, such as diabetes and hypertension, that frequently cause CKD in the general population. Guidelines for CKD screening in HIV-infected patients are being revised. It is currently recommended that all patients be screened for creatinine-based estimates of glomerular filtration rate and for urine protein at the time of HIV diagnosis. Annual screening is recommended for high-risk patients. Hemodialysis, peritoneal dialysis, and kidney transplantation are all options for treating ESRD in HIV-infected patients. Hemodialysis and peritoneal dialysis offer similar survival in HIV-infected patients with ESRD. In selected patients with well-controlled HIV infection, kidney transplantation is associated with survival intermediate between that in the overall transplant population and that among transplant recipients older than 65 years. This article summarizes a presentation by Christina M. Wyatt, MD, at the IAS-USA continuing medical education program held in Chicago in May 2012, describing AKI and CKD using case illustrations.

Figure 1.

Outcomes in HIV-infected patients with no acute kidney injury (AKI) or AKI of increasing severity. Adapted from Choi et al.

Figure 2.

Mean difference and 95% confidence interval (CI) in estimated creatinine clearance rate between patients receiving tenofovir and patients not receiving tenofovir in selected randomized controlled trials and cohort studies. Adapted from Cooper et al.

Figure 3.

Hazard ratios and 95% confidence intervals (CI) for chronic kidney disease (defined as glomerular filtration rate [GFR] of less than 60 mL/min or more rapid decline in GFR) according to subgroups of patients receiving tenofovir. P value is for interaction within subgroups. Adapted from Scherzer et al.