End-stage renal disease among HIV-infected adults in North America

Abstract

Background: Human immunodeficiency virus (HIV)-infected adults, particularly those of black race, are at high-risk for end-stage renal disease (ESRD), but contributing factors are evolving. We hypothesized that improvements in HIV treatment have led to declines in risk of ESRD, particularly among HIV-infected blacks.

Methods: Using data from the North American AIDS Cohort Collaboration for Research and Design from January 2000 to December 2009, we validated 286 incident ESRD cases using abstracted medical evidence of dialysis (lasting >6 months) or renal transplant. A total of 38 354 HIV-infected adults aged 18-80 years contributed 159 825 person-years (PYs). Age- and sex-standardized incidence ratios (SIRs) were estimated by race. Poisson regression was used to identify predictors of ESRD.

Results: HIV-infected ESRD cases were more likely to be of black race, have diabetes mellitus or hypertension, inject drugs, and/or have a prior AIDS-defining illness. The overall SIR was 3.2 (95% confidence interval [CI], 2.8-3.6) but was significantly higher among black patients (4.5 [95% CI, 3.9-5.2]). ESRD incidence declined from 532 to 303 per 100 000 PYs and 138 to 34 per 100 000 PYs over the time period for blacks and nonblacks, respectively, coincident with notable increases in both the prevalence of viral suppression and the prevalence of ESRD risk factors including diabetes mellitus, hypertension, and hepatitis C virus coinfection.

Conclusions: The risk of ESRD remains high among HIV-infected individuals in care but is declining with improvements in virologic suppression. HIV-infected black persons continue to comprise the majority of cases, as a result of higher viral loads, comorbidities, and genetic susceptibility.

Keywords: HIV infection/AIDS; HIV/AIDS; chronic kidney disease (CKD); end-stage renal disease (ESRD); glomerular filtration rate (GFR).

Figure 1.

Age- and sex-standardized incidence of end-stage renal disease among human immunodeficiency virus (HIV)-infected adults stratified by race and compared with age- and sex-standardized rates in the general population (US Renal Database System). Incidence rates are 3-year rolling averages. Abbreviation: PY, person-years.

Figure 2.

Unadjusted and adjusted incidence rate ratios for end-stage renal disease (ESRD) risk factors. Adjusted estimates are from multivariate Poisson models adjusting for all factors presented. All factors were assessed at baseline except for age, CD4⁺ count, human immunodeficiency virus (HIV) RNA, and antiretroviral drugs (ARV) use, which were a time-varying factors. Age is shown in years. Abbreviations: CI, confidence interval; DM, diabetes mellitus; eGFR, estimated glomerular filtration rate (mL/min) [26]; HCV, hepatitis C virus; HTN, hypertension; IDU, injection drug use; VL, viral load (copies/mL).