Outcome of HIV infected patients on continuous ambulatory peritoneal dialysis

Outcomes of HIV-infected Patients on Dialysis: Experience at a Tertiary Care Center

Background

Human immunodeficiency virus (HIV) infection is a major public health problem. These patients are at an increased risk for end-stage kidney disease. Both hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) are the accepted modalities of treatment.

Materials and Methods

In this retrospective study, we included all HIV-positive end-stage kidney disease (ESKD) patients who were on dialysis - HD or CAPD - for at least 1 month. Data were collected from the dialysis charts and analyzed.

Results

There were 20 patients in the CAPD group and 76 patients in the HD group. Mean age was 49.6 ± 8.73 years in the CAPD group and 46.28 ± 9.02 years in the HD group. Hypertension and diabetes were the common causes for ESKD. Mean survival was slightly better in CAPD group (20.94 vs. 15.46 months). The HD group had higher mortality within 12 months of dialysis initiation, and infection was the cause for early deaths. Mean infection episodes was 2.1 in HD group and 3.1 in CAPD group. CAPD patients with low albumin (<2.5 g/dl) had higher peritonitis rates.

Conclusion

Managing HIV-positive dialysis patients remains challenging. In our study, survival was marginally better in the CAPD group. In both groups, low CD4 count was associated with more infections and low albumin with more peritonitis episodes. A study incorporating more peritoneal dialysis (PD) patients, longer follow-ups, and a matched non-HIV control will throw more light on patient outcomes.

Fungal Peritonitis in Peritoneal Dialysis Patients

Peritonitis is one of the most frequent complications of peritoneal dialysis (PD) and 1% – 15% of episodes are caused by fungal infections. The mortality rate of fungal peritonitis (FP) varies from 5% to 53%; failure to resume PD occurs in up to 40% of patients. The majority of these FP episodes are caused by Candida species. Candida albicans has historically been reported to be a more common cause than non-albicans Candida species, but in recent reports a shift has been observed and non-albicans Candida may now be more common. Unusual, often “nonpathogenic,” fungi are being increasingly reported as etiologic agents in FP. Clinical features of FP are not different from those of bacterial peritonitis. Phenotypic identification of fungi in clinical microbiology laboratories is often difficult and delayed. New molecular diagnostic techniques ( e.g., polymerase chain reaction) are being developed and evaluated, and may improve diagnosis and so facilitate early treatment of infected patients. Abdominal pain, abdominal pain with fever, and catheter left in situ are risk factors for mortality and technique failure in FP. In programs with high baseline rates of FP, nystatin prophylaxis may be beneficial. Each program must examine its own history of FP to decide whether prophylaxis would be beneficial. Catheter removal is indicated immediately after fungi are identified by Gram stain or culture in all patients with FP. Prolonged treatment with antifungal agents to determine response and attempt clearance is not encouraged. Antifungals should be continued for 10 days to 2 weeks after catheter removal. Attempts at reinsertion should be made only after waiting for 4 – 6 weeks.

Peritonitis outcomes in patients with HIV and end-stage renal failure on peritoneal dialysis: a prospective cohort study

BACKGROUND

Few studies have investigated the management of human immunodeficiency virus (HIV)-associated end-stage renal failure particularly in low-resource settings with limited access to renal replacement therapy. We aimed to evaluate the effects of HIV infection on continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis outcomes and technique failure in highly active antiretroviral therapy (HAART)-treated HIV-positive CAPD populations.

METHODS

We conducted a single-center prospective cohort study of consecutive incident CAPD patients recruited from two hospitals in Durban, South Africa from September 2012-February 2015. Seventy HIV-negative and 70 HIV-positive end-stage renal failure patients were followed monthly for 18 months at a central renal clinic. Primary outcomes of peritonitis and catheter failure were assessed for the first 18 months of CAPD therapy. We assessed risk factors for peritonitis and catheter failure using Cox regression survival analysis.

RESULTS

The HIV-positive cohort had a significantly increased rate of peritonitis compared to the HIV-negative cohort (1.86 vs. 0.76 episodes/person-years, respectively; hazard ratio [HR], 2.41; 95% confidence interval [CI], 1.69-3.45, P < 0.001). When the baseline CD4 count was below 200 cells/μL, the peritonitis rate rose to 3.69 episodes/person-years (HR 4.54, 95% CI 2.35-8.76, P < 0.001), while a baseline CD4 count above 350 cells/μL was associated with a peritonitis rate of 1.60 episodes/person-years (HR 2.10, CI 1.39-3.15, P = 0.001). HIV was associated with increased hazards of peritonitis relapse (HR, 3.88; CI, 1.37-10.94; P = 0.010). Independent predictors associated with increased peritonitis risk were HIV (HR, 1.84; CI, 1.07-3.16; P = 0.027), diabetes (HR, 2.09; CI, 1.09-4.03; P = 0.027) and a baseline CD4 count < 200 cells/μL (HR, 3.28; CI, 1.42-7.61; P = 0.006). Catheter failure rates were 0.34 (HIV-positive cohort) and 0.24 (HIV-negative cohort) episodes/person-years (HR, 1.42; 95% CI, 0.73-2.73; P = 0.299). Peritonitis (HR, 14.47; CI, 2.79-75.00; P = 0.001), average hemoglobin concentrations (HR, 0.75; CI, 0.59-0.95; P = 0.016), and average serum C-reactive protein levels were independent predictors of catheter failure.

CONCLUSIONS

HIV infection in end-stage renal disease patients managed by CAPD was associated with increased peritonitis risk; however, HIV infection did not increase the risk for CAPD catheter failure rate at 18 months.

Continuous Ambulatory Peritoneal Dialysis in Patients with HIV and End-Stage Renal Failure

♦ BACKGROUND: This study aimed to evaluate the differences in continuous ambulatory peritoneal dialysis (CAPD)-related outcomes according to human immunodeficiency virus (HIV) status of end-stage renal failure patients. ♦ METHODS: This prospective cohort study included 70 HIV-negative and 70 HIV-positive consecutive patients with renal failure who underwent dialysis with newly inserted Tenckhoff catheters between September 2012 and February 2015. Patients were followed up monthly at a central renal clinic for 1 year or until the primary endpoints of technique failure or death. ♦ RESULTS: Technique failure rates were similar (HIV-negative: 0.270 episodes/person-year; HIV-positive: 0.298 episodes/person-year; hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.51 - 2.32; p = 0.822). However, there were fewer HIV-positive patients with complete 1-year follow-up with a patent catheter (42.9% vs 58.6% in the HIV-negative cohort; p = 0.063) owing to their higher all-cause mortality rate (0.55 vs 0.25 deaths/person-year, respectively; HR, 2.11; CI, 1.07 - 4.14; p = 0.031). Cluster of differentiation 4 count (CD4) < 200/μL (HR, 5.39; CI, 2.20 - 13.21; p < 0.001) and unsuppressed viral load (HR, 3.63; CI 1.72 - 7.67; p = 0.001) were associated with increased mortality hazards. Rates of first peritonitis were 0.616 (HIV-negative) and 1.668 (HIV-positive) episodes/person-year (HR, 2.38; CI, 1.46 - 3.89; p = 0.001). All-cause admission rates were 1.52 (HIV-negative) and 2.97 (HIV-positive) hospital admissions/person-year (HR, 1.66; CI, 1.12 - 2.48; p = 0.013). ♦ CONCLUSION: Although HIV-seropositive status of patients on CAPD did not adversely influence technique failure rates or patency at 1 year, uncontrolled HIV infection may be associated with increased relative risk of mortality and morbidity.

Diagnosis and natural history of HIV-associated nephropathy

HIV-associated nephropathy (HIVAN) is a largely distinctive phenotype induced by HIV-1 infection and is the most recognized and detrimental kidney disease in HIV-infected patients. Host and viral characteristics have been implicated in the pathogenesis of HIVAN that may explain its exclusive predilection to patients of African descent. In untreated patients, the disorder is clinically manifested by an acute decline in kidney function, most often in conjunction with high-grade proteinuria and uncontrolled HIV-1 infection. Histologically, proliferating glomerular epithelial cells are the prominent feature of the disease. Data have evolved over the past decade suggesting that highly active antiretroviral therapy (HAART) can change the natural history of HIVAN, not only by preventing its development but also by halting its progression once developed. Consequently, with the widespread use of HAART, the prevalence of HIVAN is declining in Western countries. In contrast, the epidemiology of the disease is not well defined in the poorest areas in the world, which bear a disproportionate share of the HIV-1 epidemic's burden. Corticosteroids and inhibition of the renin-angiotensin axis are recommended as adjunctive agents in treating patients with established HIVAN and are potentially helpful in delaying the need for renal replacement therapy. However, the long-term value and potential risks of using corticosteroids in this population are unclear.

Management of HIV-infected patients with ESRD

Patients infected with human immunodeficiency virus (HIV) often progress to ESRD. In the era of highly active antiretroviral therapy, the care of these patients has become increasingly complex as survival has improved. Patients infected with HIV who also have ESRD are at risk for critical interactions between medication regimens to treat both of these conditions. Within this population, hemo- and peritoneal dialysis as well as kidney transplantation are life sustaining but present a host of obstacles related to HIV monitoring and risk of transmission, access thrombosis, infection, and rejection. Knowledge of antiretroviral regimens, drug interactions, and HIV resistance as well as the management of ESRD in the presence of HIV infection will improve the care of these unique patients.

Renal disease in patients with HIV infection: epidemiology, pathogenesis and management

With the introduction of highly active antiretroviral therapy, we have witnessed prolonged survival with the potential for normal life expectancy in HIV-infected individuals. With improved survival and increasing age, HIV-infected patients are increasingly likely to experience co-morbidities that affect the general population, including kidney disease. Although HIV-associated nephropathy, the most ominous kidney disease related to the direct effects of HIV, may be prevented and treated with antiretrovirals, kidney disease remains an important issue in this population. In addition to the common risk factors for kidney disease of diabetes mellitus and hypertension, HIV-infected individuals have a high prevalence of other risk factors, including hepatitis C, cigarette smoking and injection drug use. Furthermore, they have exposures unique to this population, including antiretrovirals and other medications. Therefore, the differential diagnosis is vast. Early identification (through efficient screening) and definitive diagnosis (by kidney biopsy when indicated) of kidney disease in HIV-infected individuals are critical to optimal management. Earlier interventions with disease-specific therapy, often with the help of a nephrologist, are likely to lead to better outcomes. In those with chronic kidney disease, interventions, such as aggressive blood pressure control with the use of ACE inhibitors or angiotensin receptor antagonists where tolerated, tight blood glucose control in those with diabetes, and avoidance of potentially nephrotoxic medications, can slow progression and prevent end-stage renal disease. Only with greater awareness of kidney-disease manifestations and their implications in this particularly vulnerable population will we be able to achieve success in confronting this growing problem.

Survival during renal replacement therapy among African Americans infected with HIV type 1 in urban Baltimore, Maryland

BACKGROUND

African Americans with human immunodeficiency virus type 1 (HIV-1) infection and kidney disease are at increased risk of end-stage renal disease requiring renal replacement therapy (RRT), particularly in urban areas with high rates of poverty and injection drug use. It is unknown how the widespread use of highly active antiretroviral therapy (HAART) has affected survival during RRT in this vulnerable population.

METHODS

African American patients infected with HIV-1 who required RRT were identified from 2 cohorts that included 4509 Africans Americans infected with HIV-1 who were recruited during the period 1988-2004 in Baltimore, Maryland. Survival after initiation of RRT was compared for those who initiated treatment in the pre-HAART and the HAART eras using Kaplan-Meier curves. Cox proportional hazards regression analysis was used to adjust for potential confounders.

RESULTS

RRT was initiated in 162 patients (3.6%) during 10.6 years of follow-up (119 during the HAART era). Compared with patients who started RRT in the pre-HAART era, those in the HAART era were older (P<.001) and more likely to have CD4 cell counts of <or=200 cells/mm(3) (P=.01). A total of 126 patients (78%) died during follow-up; among those who initiated RRT during the HAART era, 87 deaths occurred (73%). Median survival time in the pre-HAART era was 22.4 months (95% confidence interval [CI], 9.3-30.7); during the HAART era, it was 19.9 months (95% CI, 14.7-26.5; P=.94). In the multiple Cox regression model, factors independently associated with increased mortality included age (hazard ratio [HR], 1.30; 95% CI, 1.06-1.60; P=.01), lower serum albumin level (HR, 0.72; 95% CI, 0.57-0.91; P<.007), lower CD4 cell count (HR, 0.90; 95% CI, 0.82-0.99; P<.03), and the lack of HAART (HR, 0.52; 95% CI, 0.33-0.82; P=.005).

CONCLUSIONS

Older age, lower serum albumin level, lower CD4 cell count, and the lack of HAART are independent predictors of poor survival among African Americans infected with HIV-1 undergoing RRT in a resource-limited urban area. RRT survival was similar in the pre-HAART and HAART eras, likely reflecting inadequate HIV treatment in this population.

HIV-1 infection and the kidney: an evolving challenge in HIV medicine

With the advent of highly active antiretroviral therapy (HAART), the incidence of opportunistic infections has declined substantially, and cardiovascular, liver, and renal diseases have emerged as major causes of morbidity and mortality in individuals with human immunodeficiency virus (HIV). Acute renal failure is common in HIV-infected patients and is associated with acute infection and medication-related nephrotoxicity. HIV-associated nephropathy is the most common cause of chronic kidney disease in HIV-positive African American populations and may respond to HAART. Other important HIV-associated renal diseases include HIV immune complex kidney diseases and thrombotic microangiopathy. The increasing importance of non-HIV-associated diseases, such as diabetes mellitus, hypertension, and vascular disease, to the burden of chronic kidney disease has been recognized, focusing attention on prevention and control of these diseases in HIV-positive individuals. HIV-positive individuals who experience progression to end-stage renal disease and who have undetectable HIV-1 viral loads while receiving HAART should be evaluated for renal transplant. Emerging evidence suggests that HIV-positive individuals may have graft and patient survival comparable to HIV-negative individuals. Several studies suggest that HIV-1 can potentially infect renal cells, and HIV transgenic mice have clarified the roles of a number of HIV proteins in the pathogenesis of HIV-associated renal disease. Host factors may modify disease expression at the level of cytokine networks and the renal microvasculature and contribute to the pathogenic effects of HIV-1 infection on the kidney.

Survival and morbidity of HIV patients on hemodialysis and peritoneal dialysis: one center's experience and review of the literature

BACKGROUND

Controversy continues concerning the morbidity and mortality of HIV-infected ESRD patients on the two dialysis options. This article presents our experience with complications and survival rate among our HIV-infected ESRD patients on peritoneal dialysis and hemodialysis. We reviewed the literature on this subject.

METHODS

The charts of seven and eight HIV-infected ESRD patients on peritoneal dialysis and hemodialysis respectively, between January 1989 and November 2004, were reviewed retrospectively for specific clinical and demographic data. Their survival was calculated using the Kaplan-Meier method.

RESULTS

Total follow-up of HIV-infected PD and HD patients was 248.3 and 207 patient months, respectively. There was no significant difference in hospitalization rate between HIV-infected PD and HD patients (1.01 and 1.39 admission/year, respectively, P = NS). Survival of HIV-infected patients on PD at one, two and three years was 100, 83, and 50%, and for HD patients was 75, 33, and 33%, respectively. HIV-infected patients on HD had more prevalent advanced HIV disease. Two out of seven PD patients were on PD for more than five years and one of the HD patients was on that form of dialysis for more than nine years. Median survival of patients with advanced (Stage IV) AIDS (both HD and PD) was 15.1 months (range 1.6-17.3) while this value for non-advanced (Stage II, III) patients was 61.2 months (range 6.8-116.6).

CONCLUSION

Type of renal replacement therapy does not have a significant effect on the morbidity and mortality of HIV-infected ESRD patients. Survival is worse in patients with advanced HIV disease. Both dialysis options provide similar results in HIV patients; hence, the choice of dialysis modality should be based on patient's preference and social conditions.

Trasplante renal en pacientes infectados por el VIH

The prevalence of human immunodeficience virus (HIV) infection among patients under renal replacement therapy varies, with estimates of 1% for Europe and 1.5% for the United States. Survival in HIV infected individuals receiving renal replacement therapy has improved since the introduction of high activity antiretroviral therapy (HAART). Current experience in renal transplantation in HIV-infected patients in the United States indicates that the three-year survival rate is similar to that of HIV-negative transplant recipients, with virological and immunological control of the infection by HAART and no increase in the number of opportunistic infections or tumors. The criteria for selecting renal transplantation candidates in this population are the following: no aids-defining events, CD4 cells > 200 cells/.l and undetectable viral load under HAART. In Spain, where most of these patients are former drug abusers, a two-year period of abstinence from cocaine and heroine abuse is also required, although patients can be participating in the methadone program. The main problems in the post-transplantation period have been interactions between HAART and immunosuppressive drugs, management of hepatitis C virus (HCV) coinfection and the high rate of acute rejection. To date, seven such renal transplantations have been performed in Spain, with favorable patient and graft survival and no progression to aids.

Dialyzing a patient with human immunodeficiency virus infection: what a nephrologist needs to know

The percentage of dialysis centers that have reported dialyzing human immunodeficiency virus (HIV)-infected patients increased from 11% in 1985 to 37% in 2000. Being primary care physicians for the dialysis patients, nephrologists are frequently confronted with the management of HIV-infected dialysis patients especially in urban centers. The aims of the present review are to discuss issues that are unique to HIV infection and end-stage renal disease, and to provide dialysis caretakers with sufficient information to help them optimize care and improve outcomes of these patients. Issues related to the choice of renal replacement therapy, vascular access, management of anemia, vaccination, and antiretroviral therapies are discussed in detail.

The HIV-associated renal diseases: current insight into pathogenesis and treatment

Since the description of a new renal syndrome in patients with the acquired immunodeficiency syndrome (AIDS) in the middle 1980s, much has been learned regarding the association of human immunodeficiency virus (HIV) infection and renal disease. The HIV-associated renal diseases represent a spectrum of clinical and histopathologic conditions. In this review, epidemiologic and clinical aspects of HIV-associated renal diseases are presented. Particular attention is placed on the pathologic and pathophysiologic mechanisms involved in HIV-associated focal glomerulosclerosis, immune complex-mediated disease, and thrombotic microangiopathies. Pharmaceutical treatment options, including the use of glucocorticoids, angiotensin-converting enzyme (ACE) inhibitors, and highly active antiretroviral therapy, are discussed. The therapeutic option of renal transplantation is presented, with insight into new clinical and basic research supporting a possible role of immunosuppressive therapy in this already immunocompromised patient population.

Determinants of survival among HIV-infected chronic dialysis patients

Over 100 HIV-infected patients have initiated chronic dialysis at San Francisco General Hospital (SFGH) since 1985. This study employed retrospective analysis to identify determinants of and trends in survival among HIV-infected patients who have initiated chronic dialysis at SFGH from January 1, 1985 to November 1, 2002 (n = 115). Cohort patient survival was compared with survival after an AIDS-opportunistic illness in all HIV-infected patients in San Francisco during the study period. Higher CD4 count (hazard ratio [HR], 0.86 per 50 cells/mm(3) increase; 95% confidence interval [CI], 0.80 to 0.93) and serum albumin (HR, 0.53 per 1 g/dl increase; CI, 0.36 to 0.78) at initiation of dialysis were strongly associated with lower mortality. Survival for those initiating dialysis during the era of highly active antiretroviral therapy (HAART) was 16.1 mo versus 9.4 mo for those initiating dialysis before this time, but this difference was not statistically significant. In adjusted analysis, only a non-statistically significant trend toward improved survival during the HAART era was noted (HR, 0.59; CI, 0.34 to 1.04). By comparison, survival for all HIV-infected patients after an AIDS-opportunistic illness in San Francisco increased from 16 mo in 1994 to 81 mo in 1996. The dramatic improvement in survival that has occurred since the mid-1990s for patients with HIV appears to be greatly attenuated in the sub-group undergoing dialysis. Although this may partly reflect confounding by race, injection drug use and HCV co-infection, future attempts to improve survival among HIV-infected dialysis patients should focus on barriers to the effective use of HAART in this group.

Human immunodeficiency virus infection in end-stage renal disease patients

Human immunodeficiency virus (HIV) infection in patients with end-stage renal disease (ESRD) offers many diagnostic and therapeutic challenges to nephrologists. Renal failure may be a direct consequence of viral infection (HIV-associated nephropathy), or intrinsic renal diseases may occur in previously infected individuals. Patients receiving renal replacement therapy (RRT) may acquire HIV infection from blood transfusions, renal allografts, sexual contacts, or needle sharing by drug addicts. In the early 1980s, the overall prognosis of patients with the acquired immunodeficiency syndrome (AIDS) was very poor, and survival of those with ESRD was dismal. Consequently many even questioned the value of providing maintenance dialysis to patients with AIDS. With advances in diagnostic techniques in serologic and viral markers of disease, and deployment of highly effective antiretroviral agents, the prognosis of HIV-infected patients has dramatically improved. Over the past two decades, experiences in the management of HIV patients with ESRD is accumulating. Both peritoneal dialysis and hemodialysis are effective modes of therapy and many centers are now beginning to perform renal transplantation in HIV-infected patients. This article deals with various aspects of HIV infection in patients with ESRD.

Current Concepts in the Management of Fungal Peritonitis

Fungal pathogens are uncommon isolates in the setting of peritonitis. Secondary peritonitis results from a breach in the gastrointestinal tract with gross contamination of the peritoneum. Peritonitis in patients undergoing peritoneal dialysis represents a unique form of secondary peritonitis often caused by nosocomial bacteria and fungi. Regardless of the clinical circumstances, most cases of fungal peritonitis are caused by Candida species, however, other yeasts and filamentous fungi have been uncommonly reported. Treatment of secondary peritonitis consists of appropriate surgical intervention and systemic antifungal therapy. Systemic antifungals such as amphotericin B or fluconazole are also essential for the treatment of fungal peritonitis in patients who are peritoneal dialysis dependent. Salvage of the peritoneal dialysis catheter may be attempted, however, removal is usually required to achieve cure. Prophylaxis with fluconazole in patients with recurrent gastrointestinal perforations or anastomotic leakages has reduced the incidence of Candida peritonitis. Benefit of nystatin for fungal peritonitis prophylaxis in peritoneal dialysis patients is questionable.

Changing trends in the survival of dialysis patients with human immunodeficiency virus in the United States

HIV-infected patients with end-stage renal disease have a very high morbidity and mortality. In the last decade, survival of HIV-infected patients in the United States has remarkably improved. To determine whether similar improvement in survival has occurred in HIV-infected dialysis patients, their survival was evaluated by using the United States Renal Data System database. Survival of HIV-infected dialysis patients in the United States was determined and the influence of year of initiation of dialysis, and demographic characteristics on the survival were analyzed by the Kaplan-Meier method. The effects of above variables on survival were also examined in a Cox proportional hazards model. Identified were 6166 HIV-infected patients with end-stage renal disease who received dialysis in the United States. Eighty-nine percent of the patients were black, 7.4% white, and 3% other. From 1990 to 1999, 1-yr survival of HIV-infected patients on dialysis improved from 56 to 74%, and the annual death rates declined from 458 deaths to 240 deaths per 1000 patient-years. The hazard ratio declined significantly in patients who initiated dialysis in years 1999-2000 compared with patients who initiated dialysis < or = 1990 (hazard ratio, 0.49; 95% confidence interval, 0. 40 to 0.60). Survival of HIV-infected dialysis patients has remarkably improved in the United States.

Predictors of proteinuria and renal failure among women with HIV infection

BACKGROUND

Glomerular disease with proteinuria and renal failure are complications of human immunodeficiency virus (HIV) infection. While studies suggest risk factors for both include black race and lower CD4 lymphocyte count, they have not been established in population-based cohorts. This study examines the risk factors for proteinuria and renal failure in a large cohort of HIV-infected women not selected for the presence of renal disease.

METHODS

This prospective cohort includes 2059 women enrolled in the Women's Interagency HIV study (WIHS). WIHS is a longitudinal study of the clinical course of HIV infection in which subjects are followed biannually with a detailed exam including urine analysis, serum creatinine, CD4 lymphocyte count, and HIV RNA level. Proteinuria was defined as > or =+1 on urine dipstick exam on at least two consecutive urine analyses, and renal failure was defined as a doubling of serum creatinine. Multivariable logistic regression was used to estimate the associations between clinical variables and the presence of proteinuria on initial evaluation in a cross-sectional analysis. Cox proportional hazards regression was used to estimate the associations between clinical variables and time to renal failure among study participants with proteinuria in a prospective longitudinal analysis.

RESULTS

Of 2057 HIV-positive women, 32% (N=671) had proteinuria on initial evaluation. Predictors of proteinuria include increasing (log) HIV RNA level [odds ratio (OR)=1.05], black race (OR=2.0), absolute CD4 lymphocyte count < or =200 cells/mm3 (OR=1.41), and the presence of hepatitis C antibody (OR=1.27; all P < 0.0001). Absolute CD4 lymphocyte count < or =200 cells/mm3 [hazard ratio (HR)=3.57, P=0.001], detectable HIV RNA level (HR=2.33, P=0.02), increasing systolic blood pressure (HR=1.02, P=0.002), and decreasing albumin (HR=3.33, P=0.0001) and increasing creatinine (1.67, P=0.0001) were all associated with the development of renal failure.

CONCLUSIONS

This analysis establishes the associations between both increasing HIV RNA level and decreasing CD4 lymphocyte count with the presence of proteinuria and occurrence of renal failure. Additionally, it demonstrates an association between proteinuria and a positive hepatitis C antibody. To lessen the presence and progression of renal disease among HIV-infected patients, future research should focus on suppression of the HIV RNA level and improvement in CD4 lymphocyte count.

Renal diseases associated with human immunodeficiency virus infection: epidemiology, clinical course, and management

Human immunodeficiency virus (HIV)--associated nephropathy (HIVAN) and other glomerular lesions (e.g., immunoglobulin A nephropathy and immune complex glomerulonephritis) are frequent complications of HIV infection. These renal diseases usually present as a nephrotic syndrome with progressive loss of renal function and an increased risk of mortality. The prevalence and epidemiology of these renal lesions remain largely undefined; however, most studies agree that black race is a major risk factor for HIVAN. Observational studies have suggested that antiretroviral medications and angiotensin-converting enzyme inhibitors have beneficial effects on slowing the progression of renal disease among patients with HIVAN; however, little is known about the effect of these therapies on other renal lesions. Future research should focus on gaining a better understanding of the distribution and determinants of renal disease among HIV-infected patients as well as on performing controlled studies to test treatment strategies.

Highly active antiretroviral therapy improves survival of HIV-infected hemodialysis patients

Human immunodeficiency virus (HIV)-infected hemodialysis (HD) patients have a very high morbidity and mortality. Reports from the last few years have suggested that highly active antiretroviral therapy (HAART) has remarkably improved the survival of HIV-infected patients. To determine whether the beneficial effects of HAART have also extended to HIV-infected HD patients, we retrospectively evaluated the survival of all HIV-infected patients who underwent chronic maintenance HD between 1992 and 1999 at our institution. Twenty-two HIV-infected patients were started on chronic maintenance HD at our institute during this period. The mean age of the patients was 36 +/- 9 (SD) years (range, 21 to 58 years). Seven patients were treated with only one or two antiretroviral drugs (patients 1 and 5 were administered two antiretroviral drugs), and the remaining 15 patients were treated with HAART (three antiretroviral drugs or more). Fifty-seven percent (4 of 7 patients) of the patients on suboptimal therapy died after a mean time on HD therapy of 13 +/- 10 months compared with only 20% (3 of 15 patients) of those on HAART after a mean period on HD therapy of 28 +/- 17 months. Plasma viral load was significantly less in patients on HAART compared with patients on suboptimal therapy (3.35 +/- 0.92 versus 4.63 +/- 1.3 log(10) copies/mL; P = 0.03). Patients with diagnoses other then HIV-associated nephropathy and those on HAART had statistically longer survival times (P = 0.02 and P = 0.04, respectively). We conclude that HAART is successful in suppressing viral load in HIV-infected HD patients, and the survival of HIV-infected HD patients on HAART is better than that of patients on suboptimal antiretroviral therapy.

HIV-1 survival kinetics in peritoneal dialysis effluent

Viable and potentially infectious HIV-1 has been recovered from the peritoneal dialysis effluent (PDE) of patients with end-stage renal disease (ESRD) who are infected with the human immunodeficiency virus (HIV). No information had previously been available as to how long HIV-1 could survive in this environment, and no data were available as to how long HIV-1 could survive on peritoneal dialysis exchange tubing (PDET). Therefore, this study was designed to answer these questions. HIV-1 Mn was added to PDE and allowed to incubate at room temperature for 0 to 14 days. Following centrifugation, the cellular component of the PDE mixture was placed in co-culture with peripheral blood mononuclear cells (PBMC) from HIV negative donors. Aliquots from the co-cultures were removed after 14 days and assayed for the HIV-1-P24 antigen. High levels of HIV P24 antigen were recovered up to and including seven days of room temperature incubation. HIV could not be recovered from PDE that had been incubated at room temperature for 10 to 14 days. Ten milliters of HIV-PDE mixture was placed within PDET and incubated at room temperature for 10 minutes. The solution was then removed by gravity drainage. After drying times of 0 to 168 hours, the tubing was flushed with HIV culture medium and placed in co-culture with PBMCs from HIV negative donors. The culture supernatant was assayed for the HIV-1 P24 antigen as a marker of viral replication. High levels of HIV-1 P24 antigen were recovered from the PDET wash for up to and including 48 hours of drying time. No viable virus could be detected for drying times of between 72 and 168 hours. To determine if common disinfectants found in the dialysis unit could inactivate HIV, dilutions of Amukin 50% and household bleach were prepared at final concentrations ranging from 1:32 to 1:2048. These disinfectant solutions were incubated with PDE containing HIV for 10 minutes. The cellular fraction of the PDE was isolated by centrifugation, washed, and placed in co-cultures with peripheral blood mononuclear cells. HIV P24 antigen levels were assayed every three days for 28 days. Amukin 50% and a 10% household bleach solution were effective in killing HIV in PDE at dilutions up to and including 1:512. These results indicate that HIV can survive in PDE at room temperature for up to seven days. HIV can survive on peritoneal dialysis exchange tubing for up to 48 hours. Final dilutions of 1:512 Amukin 50% and 10% household bleach, after 10 minutes of exposure, are effective viricidal agents in disinfecting PDE.

Patients with HIV infection and end-stage renal disease

There has been a steady increase in the number of dialysis patients with human immunodeficiency viral (HIV) infection. HIV-associated nephropathy (HIVAN) is the most common cause of end-stage renal disease in this patient population. Although the major potential category of risk of HIV transmission is from the dialysis patient to staff, there are no data to indicate that this has occurred. Dialysis of patients with HIV infection is challenging and requires effective care to prolong survival.

Disposal of dialysate in HIV-positive patients: an update

One of the concerns with the use of peritoneal dialysis in human immunodeficiency virus (HIV)-positive patients is disposal of the peritoneal effluents. This article reviews survival characteristics of HIV in dialysate effluents and current disinfectant strategies.

Prednisone improves renal function and proteinuria in human immunodeficiency virus-associated nephropathy

PURPOSE

To determine if prednisone ameliorates the course of human immunodeficiency virus-associated nephropathy (HIV-AN).

PATIENTS AND METHODS

Twenty consecutive HIV-infected adults with biopsy-proven HIV-AN (n = 17) or clinical characteristics of HIV-AN (n = 3) with serum creatinine concentrations > 177 mumol/L (2 mg/dL) or proteinuria > 2.0 g/d or both were prospectively evaluated and treated with prednisone at a dose of 60 mg/d for 2 to 11 weeks, followed by a tapering course of prednisone over a 2- to 26-week period. Serum creatinine concentration, 24-hour protein excretion, serum albumin, and steroid-related adverse effects were assessed before and after treatment.

RESULTS

Nineteen patients had serum creatinine concentrations > 117 mumol/L (2 mg/dL). Two of them progressed to end stage renal disease (ESRD) in 4 to 5 weeks. In 17 patients serum creatinine levels decreased from 717 +/- 103 mumol/L (8.1 +/- mg/dL) (mean +/- SE) to 262 +/- 31 mumol/L (3.0 +/- 0.4 mg/dL) (P < 0.001). Five patients relapsed after prednisone was discontinued and were retreated. In these 5 the serum creatinine declined from 728 +/- 107 mumol/L (8.2 +/- 1.2 mg/dL) to 344 +/- 47 mumol/L (3.9 +/- 0.5 mg/dL) (P < 0.01) in response to the second course of prednisone. Twelve of 13 tested patients showed a reduction in 24-hour urinary protein excretion with an average decrement from 9.1 +/- 1.8 g/d to 3.2 +/- 0.6 g/d (P < 0.005). Serum albumin increased from 24.4 +/- 3.6 g/L to 29.3 +/- 2.6 g/L (P = NS) in the 11 patients with paired 24-hour urine collections for whom pre- and post-treatment determinations were available. In one non-azotemic patient with nephrotic syndrome, protein excretion declined from 15.2 to 2.2 g/day and the serum albumin increased from 4.0 g/L to 31.0 g/L. The 20 patients have been followed for a median of 44 weeks (range 8 to 107). Eight ultimately required maintenance dialysis. Eleven died from complications of HIV disease 14 to 107 weeks after institution of prednisone; none was receiving prednisone at the time of death. Seven are alive and free from ESRD a median of 25 weeks (range 8 to 81) from the initiation of prednisone therapy. Six patients developed a total of seven serious infections while receiving prednisone, including Mycobacterium avium-complex infection in 2 and CMV retinitis in 3.

CONCLUSION

Prednisone improves serum creatinine and proteinuria in a substantial proportion of adults with HIV-AN. Corticosteroid-related side effects are not prohibitive. A prospective, randomized controlled trial is required to confirm these preliminary results.

Ascites and the acquired immunodeficiency syndrome. Report of 54 cases

We identified 54 patients with AIDS and ascites seen over a 4.5-year period at a university hospital. This retrospective study is the largest reported series of patients with AIDS and ascites. Patients with AIDS who are evaluated for ascites should be stratified by the CD4 + cell count and the presence or absence of portal hypertension based upon the serum-ascites albumin gradient and clinical presentation. Awareness of possible surgery-related causes of ascites is crucial, as these patients may not manifest the usual signs and symptoms of peritonitis or abdominal catastrophes seen in immunocompetent hosts. Patients with evidence of portal hypertension due to hepatic cirrhosis and an elevated ascitic neutrophil count should be suspected to be infected with common bacterial pathogens associated with peritonitis unless the CD4 + cell count is below 50 cells/mm3. When the CD4 + cell count declines below this threshold, infections due to Mycobacterium avium complex, cytomegalovirus, and other opportunistic infections should be considered.

Human immunodeficiency virus-associated glomerulosclerosis

The constellation of nephrotic proteinuria, FSGS, and rapid loss of renal function in a patient infected with HIV-1 has been sufficiently widespread and well documented to justify identification as a specific renal syndrome, HIV-associated nephropathy. The position paper of the National Kidney Foundation-National Institutes of Health task force estimated in 1990 that 10,000 to 15,000 persons will develop renal disease in association with AIDS [94]. Management of these patients is complex, and many will reach ESRD and require dialysis treatment, posing additional care problems. Greater understanding of the pathogenesis of the renal disease should lead to treatments which will forestall the development of HIVAN and possibly other forms of fibrotic renal disease. The ultimate eradication of AIDS will consign this renal syndrome to an interesting footnote in the history of nephrology. Since that time is still far in the future, nephrologists will continue to be faced with the need to diagnose and treat HIV-1-infected patients with renal involvement.

Outcome of polymicrobial peritonitis in continuous ambulatory peritoneal dialysis patients

Polymicrobial peritonitis is a relatively uncommon, but potentially serious complication that develops in continuous ambulatory peritoneal dialysis (CAPD) patients. Its cause and optimal management remain controversial. The authors reviewed the frequency and natural history of polymicrobial peritonitis in 432 CAPD patients. Of 1,405 episodes of peritonitis, 80 were polymicrobial (6%). Patients with polymicrobial peritonitis were similar to all CAPD patients in age, gender, race, and underlying renal disease. Diabetes mellitus, human immunodeficiency virus (HIV) status, and clinically apparent gastrointestinal disease did not predisposes patients to polymicrobial peritonitis. Thirty days after the polymicrobial peritonitis, 64 patients remained on CAPD (80%), and at 180 days 48 patients continued CAPD. Prior exit-site infections were present in 12 patients (14%) with polymicrobial peritonitis. Only 22% of patients required catheter removal to treat the infection. We conclude that polymicrobial peritonitis accounts for 6% of the total episodes of peritonitis; diabetes, HIV infection, and underlying gastrointestinal disease are not more prevalent in patients with multiorganism infections. Most patients continue CAPD therapy at 30 and 180 days after the episode of polymicrobial peritonitis.