Risk of End-Stage Renal Disease in HIV-Positive Potential Live Kidney Donors

Abstract

New federal regulations allow HIV-positive individuals to be live kidney donors; however, potential candidacy for donation is poorly understood given the increased risk of end-stage renal disease (ESRD) associated with HIV infection. To better understand this risk, we compared the incidence of ESRD among 41 968 HIV-positive participants of North America AIDS Cohort Collaboration on Research and Design followed for a median of 5 years with the incidence of ESRD among comparable HIV-negative participants of National Health and Nutrition Examination III followed for a median of 14 years. We used risk associations from multivariable Cox proportional hazards regression to derive cumulative incidence estimates for selected HIV-positive scenarios (no history of diabetes, hypertension, AIDS, or hepatitis C virus coinfection) and compared these estimates with those from similarly selected HIV-negative scenarios. For 40-year-old HIV-positive individuals with health characteristics that were similar to those of age-matched kidney donors, viral load <400 copies/mL, and CD4⁺ count ≥500 cells/μL, the 9-year cumulative incidence of ESRD was higher than that of their HIV-negative peers, yet still low: 2.5 versus 1.1 per 10 000 among white women, 3.0 versus 1.3 per 10 000 among white men, 13.2 versus 3.6 per 10 000 among black women, and 15.8 versus 4.4 per 10 000 among black men. HIV-positive individuals with no comorbidities and well-controlled disease may be considered low-risk kidney donor candidates.

Keywords: clinical research/practice; donors and donation: living; infection and infectious agents; infectious disease; kidney transplantation/nephrology; viral: human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS).

Figure 1

Estimated 9-year cumulative incidence of ESRD among HIV-positive participants of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) according to HIV viral load and CD4+ cell count for the hypothetical profile of a 40-year-old male with no diabetes, no hypertension, no HCV co-infection, and expected eGFR by age and race/ethnicity (95, 95, and 105 ml/min/1.73m² for white, Hispanic, and black individuals). Scenarios including suppressed viral load and CD4+ count >500 cells/μL meet the Department of Human and Health Services criteria for well-controlled HIV infection in a HIV-positive potential live kidney donor (5)

Figure 2

Estimated 9-year cumulative incidence of ESRD in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) and the Third National Health and Nutrition Examination Survey (NHANES-III) for the hypothetical profile of a 40-year-old with no diabetes, no hypertension, and HCV seronegative* *Characteristics specific to HIV-positive scenarios from NA-ACCORD: using ART for 1 year (including the TDF formulation of tenofovir), suppressed viral load (<400 copies/mL), CD4+ count 500 cells/μL, and no AIDS. Characteristics specific to HIV-negative scenarios from NHANES-III: urinary albumin-to-creatinine ratio 4 mg/g, systolic blood pressure 120