How to manage HIV-infected patients with chronic kidney disease in the HAART era

Resting state network connectivity alterations in HIV: Parallels with aging

The increasing incidence of age-related comorbidities in people with HIV (PWH) has led to accelerated aging theories. Functional neuroimaging research, including functional connectivity (FC) using resting-state functional magnetic resonance imaging (rs-fMRI), has identified neural aberrations related to HIV infection. Yet little is known about the relationship between aging and resting-state FC in PWH. This study included 86 virally suppressed PWH and 99 demographically matched controls spanning 22-72 years old who underwent rs-fMRI. The independent and interactive effects of HIV and aging on FC were investigated both within- and between-network using a 7-network atlas. The relationship between HIV-related cognitive deficits and FC was also examined. We also conducted network-based statistical analyses using a brain anatomical atlas (n = 512 regions) to ensure similar results across independent approaches. We found independent effects of age and HIV in between-network FC. The age-related increases in FC were widespread, while PWH displayed further increases above and beyond aging, particularly between-network FC of the default-mode and executive control networks. The results were overall similar using the regional approach. Since both HIV infection and aging are associated with independent increases in between-network FC, HIV infection may be associated with a reorganization of the major brain networks and their functional interactions in a manner similar to aging.

Importance of multidisciplinary collaboration for smooth kidney transplantation in HIV-infected patients with chronic kidney disease: a case report

Background

Antiretroviral therapy (ART) has reduced mortality caused by AIDS resulting from HIV infection. Meanwhile, the prevalence of chronic kidney disease, a chronic HIV complication, is increasing. Antiretroviral therapy has improved the life expectancy of HIV-infected kidney transplant recipients. In Japan, discrimination and prejudice against HIV persist, and few kidney transplants are performed. We report three cases in which kidney transplantation was smoothly performed with multidisciplinary collaboration.

Case presentation

The first case involved a 29-year-old male urgently hospitalized due to severe kidney dysfunction, diagnosed with HIV-associated nephropathy (HIVAN), and placed on maintenance dialysis. The patient was administered oral lamivudine, abacavir, and raltegravir as ART and underwent blood group-matched living donor kidney transplantation at age 32. The second case involved a 49-year-old male diagnosed as HIV-positive at age 33 and placed on maintenance dialysis for HIVAN at age 47. Darunavir, ritonavir, and dolutegravir (DTG) were initially administered. However, the ART was switched to rilpivirine (RPV) and DTG prior to kidney transplantation because of potential ART interactions with calcineurin inhibitors. The patient underwent blood group-matched living donor kidney transplantation. The third case involved a 41-year-old male diagnosed as HIV-positive at 23 years old and treated with RPV and DTG. Due to autosomal dominant polycystic kidney disease (ADPKD), his kidney function gradually worsened, and he was started on hemodialysis. He underwent hemodialysis, followed by blood type-matched living donor kidney transplantation. In all cases, transplant physicians, nephrologists, infectious disease physicians, hepatologists, nurses, pharmacists, nutritionists, and clinical psychologists collaborated to discuss and share medical problems and sociopsychological backgrounds of the patients. There was no rejection, CD4+ lymphocyte counts were maintained, and there was no increase in viral load post-surgery. Information sharing among various departments has continued post-surgery, kidney function has improved, and no increase in viral load has been identified on follow-up.

Conclusions

Kidney transplantation is the kidney replacement therapy of choice for HIV-infected patients with CKD. Specialized support is required for kidney transplantation, including coordinating immunosuppressive therapy to avoid rejection, learning about drug interactions, and providing sociopsychological support. Multidisciplinary collaboration is important to ensure safe and smooth kidney transplantation care for HIV-infected patients.

Reductions in Gray Matter Linked to Epigenetic HIV-Associated Accelerated Aging

A growing literature suggests a relationship between HIV-infection and a molecular profile of age acceleration. However, despite the widely known high prevalence of HIV-related brain atrophy and HIV-associated neurocognitive disorder (HAND), epigenetic age acceleration has not been linked to HIV-related changes in structural MRI. We applied morphological MRI methods to study the brain structure of 110 virally suppressed participants with HIV infection and 122 uninfected controls age 22-72. All participants were assessed for cognitive impairment, and blood samples were collected from a subset of 86 participants with HIV and 83 controls to estimate epigenetic age. We examined the group-level interactive effects of HIV and chronological age and then used individual estimations of epigenetic age to understand the relationship between age acceleration and brain structure. Finally, we studied the effects of HAND. HIV-infection was related to gray matter reductions, independent of age. However, using epigenetic age as a biomarker for age acceleration, individual HIV-related age acceleration was associated with reductions in total gray matter. HAND was associated with decreases in thalamic and hippocampal gray matter. In conclusion, despite viral suppression, accentuated gray matter loss is evident with HIV-infection, and greater biological age acceleration specifically relates to such gray matter loss.

A high likelihood of increase in end-stage renal disease among the Japanese HIV-infected population

Kidneys are affected by human immunodeficiency virus (HIV) infection and its associated therapies. Antiretroviral therapy (ART) has markedly reduced acquired immune deficiency syndrome–related deaths and opportunistic infectious diseases among HIV-infected patients. This contributed to their prolonged survival; however, the improvement in survival has been accompanied by an increase in the incidence of non-infectious chronic complications, including hypertension, metabolic diseases, and chronic kidney disease (CKD). Recent studies showed that estimated prevalence of any CKD and end-stage renal disease (ESRD) among HIV-infected patients is approximately 20% and 0.5%, respectively, in Japan. Both a rapid decrease in renal function and a high positive rate of albuminuria and proteinuria are clinical characteristics of HIV-infected patients. Moreover, considering higher complication rates of hypertension and diabetes compared with non-HIV-infected individuals of the similar aging, HIV-infected patients who develop CKD and ESRD are very likely to increase. Furthermore, as the survival rate is favorable after the initiation of dialysis, the cumulative number of ESRD patients is supposed to increase. The corporation for treatment of HIV-positive hemodialysis patients by general dialysis clinics will be urgently required; however, there still remain some preoccupations and prejudices about HIVper sein Japan, which may provoke hesitation from accepting those patients.

Community-Driven Health Priorities for Healthy Aging With HIV

Palm Springs, CA, is a retirement community with the highest prevalence of gay men living with HIV older than 50 years in the United States. Through a community-academic partnership, we explored the major health issues, resiliencies, and priority research topics related to HIV and aging. We conducted five community facilitated focus groups with different stakeholders, including two focus groups with older adults living with HIV, one with their caregivers, one with HIV-focused community-based organizations, and a joint focus group with researchers and HIV care providers. Using the rigorous and accelerated data reduction technique, five major themes emerged, which included long-term side effects of medication, social determinants of health, mental health, resiliencies, and involving community in research. These data are important for developing effective interventions, conducting useful and impactful research, and providing health care providers with the tools and knowledge to provide optimal care.

Membranous Nephropathy in a Patient with Human Immunodeficiency Virus Shortly After Initiation of HAART with Atripla

A human immunodeficiency virus (HIV) infection has long been associated with kidney disease. The pathogenesis of renal complications may be directly related to the presence of HIV viral particles or may occur secondary to an immune response against the virus. A number of HIV medications have been associated with the development of acute and chronic kidney disease. It has been estimated that approximately 60 percent of patients suffering from HIV/acquired immunodeficiency syndrome (AIDS) will, at some point, manifest clinically significant renal sequelae.The most common kidney disease affecting HIV patients is HIV-associated nephropathy (HIVAN) or focal segmental glomerulonephritis (FSGS). A very small subset of patients suffering from HIV/AIDS does go on to develop membranous glomerulonephritis. We present a case of a 55-year old Caucasian male who presented to the hospital after two weeks of weakness and falling when attempting to stand. The patient had a history of HIV, diagnosed in 1996. The latest cluster differentiation 4 (CD4) count was 245 cells/uL and the HIV-ribonucleic acid (RNA) viral load was reported as less than 75 copies/ml. The physical exam at presentation was insignificant. The laboratory examination revealed elevated creatinine. Potential nephrotoxic home medications, including Atripla and lisinopril, were held. After a brief inpatient stay, he was discharged but was ultimately readmitted for worsening renal function and nephrotic syndrome was diagnosed. Renal biopsy was performed, and membranous glomerulonephritis was confirmed. To this point, there are no associated cases reported of membranous glomerulonephritis after initiation of therapy with Atripla.

We present a case of a rare etiology of membranous nephropathy in an HIV patient. Physicians should be judicious in detecting the etiology of renal dysfunction in HIV patients.

Urinary liver-type fatty acid-binding protein levels as a potential risk factor for renal dysfunction in male HIV-infected Japanese patients receiving antiretroviral therapy: a pilot study

Renal dysfunction is recognized with increasing frequency among the non-infectious co-morbidities associated with human immunodeficiency virus (HIV) infection. Recently, urinary liver-type fatty acid-binding protein (L-FABP) was suggested to be a predictor of the progression of renal dysfunction in patients without HIV. However, little is known regarding the utility of urinary L-FABP as a predictor of renal dysfunction in patients with HIV. A retrospective, observational, single-centre study was conducted between July 2014 and December 2016. The primary outcome was renal dysfunction defined as decrease in estimated glomerular filtration rate to less than 60 ml/min/1.73 m². To estimate the effect of urinary L-FABP, proteinuria category, and urinary β2 microglobulin (β2MG) on the time to the first event, a log-rank test was performed. Accuracy, determined by area under the curve and calculated from receiver operating characteristic curves, was also assessed. Thirty Japanese outpatients with HIV receiving antiretroviral therapy (ART) were enrolled. The primary outcome occurred in five patients during the follow-up period. Urinary L-FABP level and proteinuria category were significantly associated with renal dysfunction (p = 0.045 and p = 0.037, respectively). In contrast, urinary β2MG level was not significantly associated with renal dysfunction (p = 0.141). Urinary L-FABP was the most accurate predictor of renal dysfunction among the three urinary parameters. In conclusion, urinary L-FABP levels in HIV patients receiving ART were more accurate for predicting renal dysfunction than proteinuria and urinary β2MG. In addition, urinary L-FABP helped to discriminate those patients with a higher risk for renal dysfunction.

Healthcare utilization and direct costs of non-infectious comorbidities in HIV-infected patients in the USA

OBJECTIVE

To estimate the incremental healthcare utilization and costs associated with common non-infectious comorbid conditions among commercially and Medicaid-insured HIV-infected patients in the US.

METHODS

US administrative claims were used to select adult HIV patients with chronic kidney disease (CKD), cardiovascular disease (CVD) events, or fracture/osteoporosis, three common comorbidities that have been associated with HIV and HIV treatment, between 1 January 2004 and 30 June 2013. Propensity score matched controls with no CKD, no CVD events, and no fracture/osteoporosis were identified for comparison. All-cause healthcare utilization and costs were reported as per patient per month (PPPM).

RESULTS

The commercial cohort comprised 381 CKD patients, 624 patients with CVD events, and 774 fracture/osteoporosis patients, and 1013, 1710, and 2081 matched controls, respectively; while the Medicaid HIV cohort comprised 207 CKD and 271 CVD cases, and 516 and 735 matched controls, respectively. There was insufficient Medicaid data for fracture analyses. Across both payers, HIV patients with CKD or CVD events had significantly higher healthcare utilization and costs than controls. The average incremental PPPM costs in HIV patients with CKD were $1403 in the commercial cohort and $3051 in the Medicaid cohort. In those with CVD events, the incremental costs were $2655 (commercial) and $4959 (Medicaid) for HIV patients compared to controls (p < .001).

CONCLUSIONS

The results suggested a considerable increase in healthcare utilization and costs associated with CKD, CVD and fracture/osteoporosis comorbidities among HIV patients in the past decade. Because these conditions have been associated with treatment, it is critical to consider their impact on costs and outcomes when optimizing patient care.

Survival Benefit of Kidney Transplantation in HIV-infected Patients

OBJECTIVE

To determine the survival benefit of kidney transplantation in human immunodeficiency virus (HIV)-infected patients with end-stage renal disease (ESRD).

SUMMARY BACKGROUND DATA

Although kidney transplantation (KT) has emerged as a viable option for select HIV-infected patients, concerns have been raised that risks of KT in HIV-infected patients are higher than those in their HIV-negative counterparts. Despite these increased risks, KT may provide survival benefit for the HIV-infected patient with ESRD, yet this important clinical question remains unanswered.

METHODS

Data from the Scientific Registry of Transplant Recipients were linked to IMS pharmacy fills (January 1, 2001 to October 1, 2012) to identify and study 1431 HIV-infected KT candidates from the first point of active status on the waiting list. Time-dependent Cox regression was used to establish a counterfactual framework for estimating survival benefit of KT.

RESULTS

Adjusted relative risk (aRR) of mortality at 5 years was 79% lower after KT compared with dialysis (aRR 0.21; 95% CI 0.10-0.42; P <0.001), and statistically significant survival benefit was achieved by 194 days of KT. Among patients coinfected with hepatitis C, aRR of mortality at 5 years was 91% lower after KT compared with dialysis (aRR 0.09; 95% CI 0.02-0.46; P < 0.004); however, statistically significant survival benefit was not achieved until 392 days after KT.

CONCLUSIONS

Evidence suggests that for HIV-infected ESRD patients, KT is associated with a significant survival benefit compared with remaining on dialysis.

HIV and aging

With the wider availability of antiretrovirals, the world's HIV population is aging. More than 10% of the 34.5 million HIV-positive individuals worldwide are over the age of 50 years and the average age continues to increase. In the USA more than 50% of the 1.3 million people with HIV are over 50 years old and by the year 2030 it is estimated that 70% will be over the age of 50 years. Although the life expectancy of HIV-positive people has increased dramatically, it still lags behind that of HIV-negative individuals. There is controversy about whether HIV itself accelerates the aging process. Elevated rates of inflammation seen in people with HIV, even if their viral loads are suppressed and their CD4 counts are preserved, are associated with greater rates of cardiovascular, renal, neurocognitive, oncological, and osteoporotic disease. These conditions increase exponentially in the elderly and will represent a major challenge for HIV patients. In addition, conditions such as geriatric syndromes including frailty are also seen at higher rates. Management of the aging HIV patient includes an emphasis on early diagnosis and treatment, preventative measures for co-morbidities, and avoiding polypharmacy. Finally, the issue of quality of life, prioritization of medical issues, and end of life care become increasingly important as the patient grows older.

Exploratory Analysis for the Evaluation of Estimated Glomerular Filtration Rate, Cholesterol and Triglycerides after Switching from Tenofovir/Emtricitabine plus Atazanavir/Ritonavir (ATV/r) to Abacavir/Lamivudine plus ATV/r in Patients with Preserved Renal Function

BACKGROUND AND OBJECTIVES

Renal toxicity due to tenofovir (TDF) has been largely described in patients with HIV infection. However, other antiretroviral drugs (such as atazanavir [ATV], especially when boosted by ritonavir, ATV/r) could perpetuate some degrees of renal impairment with or without TDF co-administration. Also, possible benefits of stopping TDF in patients without renal diseases is not well known. This study aimed at exploring evolution of renal function and lipid profile after switching from tenofovir/emtricitabine (TDF/FTC) to abacavir/lamivudine (ABC/3TC), maintaining the ATV/r component of the regimen.

METHODS

Patients in the Italian MASTER Cohort, who switched from TDF/FTC plus ATV/r to ABC/3TC plus ATV/r were included, provided that major renal diseases were not diagnosed before switching (i.e., baseline). Serum creatinine, estimated glomerular filtration rate (eGFR), total cholesterol, HDL and triglycerides were evaluated at baseline and at month 18 after switching.

RESULTS

126 patients were selected (80% males). Patients were mostly Italians (92%). 79% had undetectable HIV-RNA and 44% were co-infected by HBV and/or HCV. Median age at switch was 47 years (IQR 43-55). A small but significant decrease in serum creatinine [from 1.06 mg/dl (SD: 0.3) to 0.94 mg/dl (SD: 0.2); p<0.001] with an improvement in eGFR [from 86.8 ml/min (SD: 33) to 96.4 ml/min (SD: 37); p<0.001] were observed in per protocol analysis at month 18. Also ITT analysis showed a decrease in mean serum creatinine [from 1.08 mg/dl (SD: 0.35) to 0.95 mg/dl (SD: 0.24); p<0.001] with an improvement in mean eGFR [from 86.9 ml/min/1.73m2 (SD: 24.11) to 95.8 ml/min/1.73m2 (SD: 19.99); p<0.001]. Total cholesterol increased [from 188 mg/dl (SD: 42) to 206 mg/dl (SD: 44); p<0.001] but also HDL increased as well [from 46 mg/dl (SD: 14) to 54 mg/dl (SD: 19); p=0.015]. An increase in triglycerides concentration was observed [from 162 mg/dl (SD: 144) to 214 mg/dl (SD: 109); p=0.027] in per protocol analysis. Also ITT analysis showed increases of both total cholesterol [from 187 mg/dl (SD: 43.69) to 203 mg/dl (SD: 44.10); p<0.001] and HDL fraction [from 46 mg/dl (SD: 15.49) to 52 mg/dl (SD: 17.13); p=0.002] at month 18.

CONCLUSION

This analysis reports an improvement in eGFR and an increase in total cholesterol and HDL fraction at month 18 after switching to ABC/3TC plus ATV/r. Given the fact that renal function was not significantly affected at baseline, our findings may suggest the utility of a proactive switch from TDF to ABC, when otherwise indicated, in patients who cannot avoid using a nucleoside backbone.

Renal abnormalities in a cohort of HIV-infected children and adolescents

BACKGROUND

This study aimed to identify the prevalence of renal abnormalities and the evolution of glomerular filtration rate (GFR) among human immunodeficiency virus (HIV)- infected children and adolescents followed up in an infectious disease outpatient pediatric clinic.

METHODS

We performed a cohort study of 115 children and adolescents. Outcomes of two evaluations for urinalysis, microalbuminuria/urinary creatinine ratio, urinary retinol-binding protein (uRBP) concentration, and estimated GFR (eGFR) were obtained for each patient, with an average interval of 6 months between evaluations. These changes were correlated with gender, age, race, body mass index (BMI), height-for-age (H/A) percentile, clinical and immunological classification of HIV infection, use of antiretroviral therapy (ART), HIV viral load (VL), and CD4+ T-lymphocyte count.

RESULTS

Mean patient age at the time of inclusion in the study was 12.6 ± 3.2 years; 50.4 % were male, 81.7 % had acquired immune defeciency syndrome (AIDS), 80.9 % had CD4+ < 500 cells/mm(3), and 87.8 % were on ART. Urinary changes included hematuria (11.3 %), proteinuria (7 %), and microalbuminuria (11.6 %); uRBP was present in 3.8 %; and mean eGFR was 163 ± 32 ml/min/1.73 m(2).

CONCLUSIONS

The subclinical renal abnormalities found in this study may indicate early manifestations of a broad spectrum of renal dysfunction associated with HIV and involves the decision to initiate or modify ART.

Elevation of Non-Classical (CD14+/lowCD16++) Monocytes Is Associated with Increased Albuminuria and Urine TGF-β1 in HIV-Infected Individuals on Stable Antiretroviral Therapy

OBJECTIVE

High rates of albuminuria are observed among HIV-infected individuals on stable antiretroviral therapy (ART). Though pro-inflammatory and pro-fibrotic responses are described as components of albuminuria in the general population, it is unclear how these responses are associated to albuminuria in ART-treated chronic HIV. We investigated the relationship of monocyte subsets and urine inflammatory and fibrotic biomarkers to albuminuria in ART-treated HIV-infected participants.

DESIGN AND METHODS

Cross-sectional analyses were performed on Hawaii Aging with HIV-cardiovascular disease study cohort participants who were required at entry to be ≥40 years old and on ART ≥3 months. Monocyte subpopulations were determined in banked peripheral blood mononuclear cells (PBMC) using multi-parametric flow-cytometry. Entry random urine samples were assessed for albumin-to-creatinine ratios (UACR). Urine samples were measured for inflammatory and fibrotic biomarkers using Luminex technology.

RESULTS

Among 96 HIV-infected subjects with measured UACR (87% male, 59% Caucasian, and 89% undetectable HIV RNA with median CD4 of 495.5 cells/μL), 18 patients (19%) had albuminuria. Non-classical (CD14low/+CD16++) monocytes were significantly elevated in subjects with albuminuria (p = 0.034) and were correlated to UACR (r = 0.238, p = 0.019). Elevated non-classical monocyte counts were significant predictors of worsening albuminuria, independent of traditional- and ART-associated risk factors (β = 0.539, p = 0.007). Urine TGF-β1 and collagen-IV were significantly higher in albuminuric compared to non-albuminuric participants (TGF-β1; p = 0.039 and collagen-IV; p = 0.042). Urine TGF-β1 was significantly correlated with non-classical monocyte counts (r = 0.464, p = 0.017).

CONCLUSION

Alterations in monocyte subpopulations and urine pro-fibrotic factors may play a role in kidney dysfunction during chronic HIV infection and warrants further study.

Renal Function in Chinese HIV-Positive Individuals following Initiation of Antiretroviral Therapy

Aim

To identify the prevalence and predictors of abnormal renal function among HIV-positive Chinese patients prior to antiretroviral therapy (ART) initiation and to evaluate subsequent changes in renal function after ART exposure.

Methods

We conducted a nationwide cohort study of subjects who enrolled in the national Chinese ART program from January 1, 2012 to December 31, 2012. We estimated the glomerular filtration rate (eGFR) of subjects prior to and after initiating ART. Risk factors for abnormal renal function, as defined by eGFR <60 ml/min/1.73m², at baseline and follow-up were assessed by logistic regression and Cox proportional hazards regression models, respectively.

Results

Among 41,862 subjects, at ART baseline, 3.3% had a baseline eGFR <60 ml/min/1.73m² and 24.2% had eGFR = 60–90 ml/min/1.73m². Adjusted baseline risk factors for baseline eGFR <60 ml/min/1.73m² were older age (Adjusted odds ratio [AOR] = 5.19, 95% confidence interval [CI]: 4.52–5.67), female (AOR = 1.68, 95% CI: 1.47–1.93), hemoglobin <120g/L (AOR = 1.68, 95% CI: 1.47–1.93), blood glucose >6.1 mmol/L (AOR = 1.46, 95% CI: 1.25–1.72), and hepatitis C co-infection (AOR = 1.36, 95% CI: 1.06–1.73). Among subjects with baseline eGFR >90 ml/min/1.73m², the incidence of the eGFR falling to <60 ml/min/1.73m² was 0.92/100 person-years after a median of 15.0 months of ART. Being on a tenofovir with lopinavir/ritonavir regimen (Adjusted hazard ratio [AHR] = 3.02, 95% CI: 1.96–4.66) and having an unsuppressed viral load (AHR = 2.70, 95% CI: 1.80–4.03) were independent predictors for eGFR <60 ml/min/1.73m² after ART initiation as well as older age, female, and hemoglobin <120 g/L.

Conclusion

A high proportion of HIV-positive subjects in China presented with abnormal renal function prior to ART initiation. But the incidence of the eGFR decrease after ART was low. Patient renal function should be regularly monitored by eGFR before initiating and during ART.

Atazanavir nephrotoxicity

Atazanavir is commonly used as one of the key drugs in combination antiretroviral therapy for human immunodeficiency virus (HIV). However, atazanavir has the potential to yield its crystalline precipitation in urine and renal interstitial tissues, leading to crystalluria, urolithiasis, acute kidney injury (AKI) or chronic kidney disease (CKD). In epidemiological studies, atazanavir/ritonavir alone or in combination with tenofovir has been associated with increased risk of progression to CKD. However, renal biopsies were not provided in these studies. Case reports showing an association between atazanavir use and tubulointerstitial nephritis among HIV-infected individuals provide clues as to the potential causes of atazanavir nephrotoxicity. We now review atazanavir-related kidney disease including urolithiasis, renal dysfunction and interstitial nephritis and illustrate the review with a further case of atazanavir-associated kidney injury with sequential renal biopsies. There are two forms of atazanavir-associated tubulointerstitial nephritis: acute tubulointerstitial nephritis that may develop AKI rapidly (in weeks) after initiation of atazanavir, and chronic tubulointerstitial nephritis that may develop progressive CKD slowly (in years) with granuloma and intrarenal precipitation of atazanavir crystals as well as crystalluria. Caution should be exercised when prescribing atazanavir to patients at high risk of CKD, and therapy should be reevaluated if renal function deteriorates, especially associated with crystalluria and hematuria.

A National Study of Outcomes among HIV-Infected Kidney Transplant Recipients

Kidney transplantation is a viable treatment for select patients with HIV and ESRD, but data are lacking regarding long-term outcomes and comparisons with appropriately matched HIV-negative patients. We analyzed data from the Scientific Registry of Transplant Recipients (SRTR; 2002-2011): 510 adult kidney transplant recipients with HIV (median follow-up, 3.8 years) matched 1:10 to HIV-negative controls. Compared with HIV-negative controls, HIV-infected recipients had significantly lower 5-year (75.3% versus 69.2%) and 10-year (54.4% versus 49.8%) post-transplant graft survival (GS) (hazard ratio [HR], 1.37; 95% confidence interval [95% CI], 1.15 to 1.64; P<0.001) that persisted when censoring for death (HR, 1.43; 95% CI, 1.12 to 1.84; P=0.005). However, compared with HIV-negative/hepatitis C virus (HCV)-negative controls, HIV monoinfected recipients had similar 5-year and 10-year GS, whereas HIV/HCV coinfected recipients had worse GS (5-year: 64.0% versus 52.0%, P=0.02; 10-year: 36.2% versus 27.0%, P=0.004 [HR, 1.38; 95% CI, 1.08 to 1.77; P=0.01]). Patient survival (PS) among HIV-infected recipients was 83.5% at 5 years and 51.6% at 10 years and was significantly lower than PS among HIV-negative controls (HR, 1.34; 95% CI, 1.08 to 1.68; P<0.01). However, PS was similar for HIV monoinfected recipients and HIV-negative/HCV-negative controls at both times. HIV/HCV coinfected recipients had worse PS compared with HIV-negative/HCV-infected controls (5-year: 67.0% versus 78.6%, P=0.007; 10-year: 29.3% versus 56.23%, P=0.002 [HR, 1.57; 95% CI, 1.11 to 2.22; P=0.01]). In conclusion, HIV-negative and HIV monoinfected kidney transplant recipients had similar GS and PS, whereas HIV/HCV coinfected recipients had worse outcomes. Although encouraging, these results suggest caution in transplanting coinfected patients.

Protease Inhibitors and Renal Function in Patients with HIV Infection: a Systematic Review

INTRODUCTION

Despite antiretroviral (ARV) therapy reducing renal disease in human immunodeficiency virus overall, there is concern that certain ARVs, particularly tenofovir disoproxil fumarate (TDF) with or without a boosted protease inhibitor (PI), may reduce renal function over time. It is not known whether effects seen with PI-based regimens are independent, result from interactions with TDF coadministration, or are artefactual owing to inhibition of renal tubular creatinine transport by ritonavir or cobicistat pharmacoenhancement. The aim of this review was to conduct a systematic review of studies, weighted toward high-quality evidence, examining changes in renal function over time with PI-based regimens.

METHODS

PubMed, Embase, and Medline databases and conference abstracts were searched using pre-defined terms for English language articles, published up to and including August 12, 2013, describing changes in renal function over time with PI-based regimens. All available randomized controlled trials (RCTs) were selected; however, to reduce bias, only observational studies recruiting from more than one center and analyzing data from more than 1,000 patients were included. Evidence was qualitatively evaluated according to levels established by the Oxford Centre for Evidence-Based Medicine (OCEBM).

RESULTS

A total of 2,322 articles were retrieved by the initial search. Of these, 37 were selected for full review, comprising 24 RCTs (OCEBM Level 1 evidence: 4 reports of fully double-blinded or blinded with respect to the PI component). The remaining 20 RCTs and 13 observational studies qualified as OCEBM Level 2 evidence. Level 1 evidence showed initial but non-progressive increases in serum creatinine and corresponding decreases in estimated glomerular filtration rate (eGFR), suggesting an effect on renal tubular transport of creatinine. Level 2 evidence suggested that atazanavir and lopinavir especially in combination with TDF were associated with non-progressive reductions in eGFR over time, with a decreased risk for the development of chronic kidney disease (CKD) on cessation and without the development of advanced CKD or end-stage renal disease (ESRD); whether these reductions were independent or associated with interactions with coadministered TDF could not be established with certainty. Data on darunavir were insufficient to draw any conclusions. The principal limitation of the reviewed studies was the lack of standardization of creatinine measurements in virtually all studies and the lack of corroborative data on changes in proteinuria or other indices of renal function.

DISCUSSION

In this review, there was little evidence for progressive changes in eGFR, or the development of advanced CKD, or ESRD with lopinavir or atazanavir. Further long-term studies, employing a wide range of validated renal function assessments, are required to fully evaluate potential association of PIs with CKD.

A consensus statement on the renal monitoring of Australian patients receiving tenofovir based antiviral therapy for HIV/HBV infection

A number of antiviral agents used against Human Immunodeficiency Virus (HIV) infection and hepatitis B virus (HBV) mono or co-infection have been associated with real nephrotoxicity (including tenofovir disoproxil fumarate (TDF), atazanavir, indinavir and lopinavir) or apparent changes in renal function (e.g. cobicistat, ritonavir, rilpivirine and dolutegravir). Patients with HIV are at higher risk of acute and chronic renal dysfunction, so baseline assessment and ongoing monitoring of renal function is an important part of routine management of patients with HIV.

Given the paucity of evidence in this area, we sought to establish a consensus view on how routine monitoring could be performed in Australian patients on ART regimens, especially those involving TDF. A group of nephrologists and prescribers (an HIV physician and a hepatologist) were assembled by Gilead to discuss practical and reasonable renal management strategies for patients particularly those on TDF-based combination regimens (in the case of those with HIV-infection) or on TDF-monotherapy (in the case of HBV-mono infection). The group considered which investigations should be performed as part of routine practice, their frequency, and when specialist renal referral is warranted. The algorithm presented suggests testing for serum creatinine along with plasma phosphate and an assessment of urinary protein (rather than albumin) and glucose.

Here we advocate baseline tests of renal function at initiation of therapy. If creatinine excretion inhibitors (e.g. cobicistat or rilpivirine) are used as part of the ART regimen, we suggest creatinine is rechecked at 4 weeks and this value used as the new baseline. Repeat testing is suggested at 3-monthly intervals for a year and then at least yearly thereafter if no abnormalities are detected. In patients with abnormal baseline results, renal function assessment should be performed at least 6 monthly. In HBV mono-infected patients advocate that a similar testing protocol may be logical.

Comparison of renal changes with lopinavir/ritonavir plus raltegravir or tenofovir/emtricitabine in the PROGRESS study

ABSTRACT 

Aim: To assess renal function changes among 172 treatment-naive subjects treated with lopinavir/ritonavir (LPV/r) plus raltegravir (RAL) or LPV/r plus tenofovir/emtricitabine in the PROGRESS study, a prospective, randomized controlled trial. Patients & methods: Serum creatinine, creatinine clearance and chronic kidney disease category were compared between groups. Results: Mean change from baseline to week 96 in creatinine clearance was smaller with LPV/r plus RAL versus LPV/r plus tenofovir/emtricitabine (-1.4 vs -7.3 ml/min; p = 0.035). Chronic kidney disease category improvement was more frequent and the mean increase in serum creatinine was smaller for the LPV/r plus RAL group. Differences in estimated renal function were also detected when the analysis was performed according to baseline demographics. Conclusion: Smaller renal function declines were observed with LPV/r plus RAL. The results from this study warrant further evaluation of the renal safety profile of nucleotide reverse transcriptase inhibitor-sparing regimens.

Association between tenofovir exposure and reduced kidney function in a cohort of HIV-positive patients: results from 10 years of follow-up

BACKGROUND

Some studies have shown that tenofovir disoproxil fumarate (TDF), a drug widely used in highly active antiretroviral therapy, is associated with kidney dysfunction, but the magnitude of the effect and its clinical impact is still being debated. Our objective was to evaluate the association between long-term TDF exposure and kidney dysfunction in a cohort of 1043 human immunodeficiency virus-positive patients followed up for 10 years and to quantify the loss in estimated glomerular filtration rate (eGFR) in patients exposed to TDF in comparison with those exposed to other antiretroviral therapies.

METHODS

Adjusted hazard ratios (HR) and odds ratios (OR) for the association between TDF and kidney dysfunction (defined as eGFR <90 mL/min/1.73 m(2)) were calculated using the Cox proportional hazards model and generalized estimating equations. Mean loss in eGFR attributable to TDF by cumulative years of exposure was estimated using linear regressions.

RESULTS

Tenofovir exposure increased the risk of kidney dysfunction by 63% (HR, 1.63; 95% confidence interval, 1.26-2.10). The cumulative eGFR loss directly attributable to TDF after 1, 2, 3, and 4 years of TDF exposure was -3.05 (P = .017), -4.05 (P = .000), -2.42 (P = .023), and -3.09 mL/min/1.73 m(2) (P = .119), respectively, which shows that most of the loss occurred during the first years of exposure.

CONCLUSIONS

In this cohort, TDF exposure was associated with reduced kidney function, but the loss in eGFR attributable to TDF is relatively mild in a long-term perspective.