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Chadwick DR, Barker F, Smith C, Perditer O, Hardy Y, Owusu D, Villa G, Sarfo FS, Geretti AM, Phillips R. Prevalence and predictors of long-term progression of chronic kidney disease in people with HIV in Ghana from 2003-2018. BMC Nephrol 2024; 25:241. [PMID: 39075393 PMCID: PMC11288112 DOI: 10.1186/s12882-024-03537-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 03/06/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND HIV is associated with an increased risk of progression to chronic kidney disease (CKD), and this risk is higher in people of West African descent than many other ethnicities. Our study assessed the rates of eGFR change and predictors of rapid eGFR progression in patients receiving antiretroviral therapy (ART), including tenofovir disoproxil fumarate (TDF), in central Ghana between 2003 and 2018. METHODS This single-centre retrospective study enrolled people with HIV (PWH) initiating ART in Ghana between 2003-2018. Demographics, hepatitis B (HBsAg) status, ART regimens and estimated glomerular filtration rate (eGFR) measurements were recorded, and analyses including multi-level model linear regression were performed to determine predictors of greater levels of eGFR decline and risk of rapid eGFR decline. RESULTS Six hundred and fifty-nine adult participants were included in the study with a median follow-up time of 6 years (IQR 3.6-8.9). 149 participants (22.6%) also had confirmed HBV co-infection. eGFR mean values were lowest at the point of diagnosis and highest on the second measurement taken; mean eGFR slowly decreased over subsequent measures thereafter. TDF use was associated with the highest mean rate of eGFR decline of all nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs) with a statistically significant greater annual decline of -1.08 mL/min/1.73m2/year (CI: -1.92, -0.24) compared with zidovudine. Nevirapine (-0.78mL /min/173m2/year; CI: -1.39, -0.17) and protease inhibitors (-1.55mL/mil/173m2/year; CI: -2.68, -0.41) were associated with greater eGFR declines compared with efavirenz. Negative HBsAg status was associated with greater eGFR decline compared with positive HBsAg status (-1.25mL/mil/173m2/year; CI 0.29. -2.20). CONCLUSIONS Increased rates of eGFR decline amongst PWH in Ghana were associated with TDF, nevirapine, and protease inhibitor use as well as negative HBsAg status. Additional research using mortality outcome data is needed to closely assess long-term predictors of eGFR decline in African populations.
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Affiliation(s)
- David R Chadwick
- Centre for Clinical Infection, James Cook University Hospital, Middlesbrough, TS4 3BW, UK
| | - Fred Barker
- Centre for Clinical Infection, James Cook University Hospital, Middlesbrough, TS4 3BW, UK.
- Tyne and Wear, Northumbria Healthcare Trust, North Shields, NE29 8NH, UK.
| | - Colette Smith
- Institute for Global Health, University College London, London, NW3 2PF, UK
| | - Okyere Perditer
- Department of Medicine, Komfo Anokye Teaching Hospital, 1934, Adum-Kumasi, Kumasi, Ghana
| | - Yasmine Hardy
- Department of Medicine, Komfo Anokye Teaching Hospital, 1934, Adum-Kumasi, Kumasi, Ghana
| | - Dorcas Owusu
- Department of Medicine, Komfo Anokye Teaching Hospital, 1934, Adum-Kumasi, Kumasi, Ghana
- School of Medicine and Dentistry, Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Giovanni Villa
- Department of Genitourinary Medicine and Infectious Diseases (GUIDe Clinic), St. James' Hospital, Dublin, Ireland
| | - Fred Stephen Sarfo
- Department of Medicine, Komfo Anokye Teaching Hospital, 1934, Adum-Kumasi, Kumasi, Ghana
- School of Medicine and Dentistry, Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Anna-Maria Geretti
- School of Immunology & Microbial Sciences, King's College London, London, SE5 9RS, UK
- Tor Vergata University of Rome, 50, 00133, Rome, Italy
| | - Richard Phillips
- Department of Medicine, Komfo Anokye Teaching Hospital, 1934, Adum-Kumasi, Kumasi, Ghana
- School of Medicine and Dentistry, Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
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Prevalence, incidence and predictors of renal impairment in persons with HIV receiving protease-inhibitors in rural Tanzania. PLoS One 2021; 16:e0261367. [PMID: 34910776 PMCID: PMC8673654 DOI: 10.1371/journal.pone.0261367] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 11/30/2021] [Indexed: 11/25/2022] Open
Abstract
Objective Ritonavir-boosted protease inhibitors (bPI) in people living with HIV (PLWH) have been associated with renal impairment. Limited data are available from rural sub-Saharan Africa. Methods Using data from the Kilombero and Ulanga Antiretroviral Cohort Study (KIULARCO) in rural Tanzania from 2005-01/2020, we assessed the prevalence of renal impairment (estimated glomerular filtration rate <60 mL/min/1.73m2) at the time of switch from first-line antiretroviral treatment (ART) to bPI-regimen and the incidence of renal impairment on bPI. We assessed risk factors for renal impairment using logistic and Cox regression models. Results Renal impairment was present in 52/687 PLWH (7.6%) at the switch to bPI. Among 556 participants with normal kidney function at switch, 41 (7.4%) developed renal impairment after a median time of 3.5 (IQR 1.6–5.1) years (incidence 22/1,000 person-years (95%CI 16.1–29.8)). Factors associated with renal impairment at switch were older age (adjusted odds ratio (aOR) 1.55 per 10 years; 95%CI 1.15–2.11), body mass index (BMI) <18.5 kg/m2 (aOR 2.80 versus ≥18kg/m2; 95%CI 1.28–6.14) and arterial hypertension (aOR 2.33; 95%CI 1.03–5.28). The risk of renal impairment was lower with increased duration of ART use (aOR 0.78 per one-year increase; 95%CI 0.67–0.91). The renal impairment incidence under bPI was associated with older age (adjusted hazard ratio 2.01 per 10 years; 95%CI 1.46–2.78). Conclusions In PLWH in rural sub-Saharan Africa, prevalence and incidence of renal impairment among those who were switched from first-line to bPI-regimens were high. We found associations between renal impairment and older age, arterial hypertension, low BMI and time on ART.
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Chabala FW, Siew ED, Mutale W, Mulenga L, Mweemba A, Goma F, Banda N, Kaonga P, Wester WC, Heimburger DC, Aliyu MH, Munkombwe D. Prognostic model for nephrotoxicity among HIV-positive Zambian adults receiving tenofovir disoproxil fumarate-based antiretroviral therapy. PLoS One 2021; 16:e0252768. [PMID: 34252117 PMCID: PMC8274919 DOI: 10.1371/journal.pone.0252768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/22/2021] [Indexed: 11/19/2022] Open
Abstract
Persons living with HIV (PLWH) receiving tenofovir disoproxil fumarate (TDF)-based antiretroviral therapy (ART) risk suffering TDF-associated nephrotoxicity (TDFAN). TDFAN can result in short- and long-term morbidity, including permanent loss of kidney function, chronic kidney disease (CKD), and end-stage kidney disease (ESKD) requiring dialysis. Currently, there is no model to predict this risk or discern which patients to initiate TDF-based therapy. Consequently, some patients suffer TDFAN within the first few months of initiating therapy before switching to another suitable antiretroviral or a lower dose of TDF. In a prospective observational cohort study of adult Zambian PLWH, we modelled the risk for TDFAN before initiating therapy to identify individuals at high risk for experiencing AKI after initiating TDF-based therapy. We enrolled 205 HIV-positive, ART-naïve adults initiating TDF-based therapy followed for a median of 3.4 months for TDFAN at the Adult Infectious Disease Research Centre (AIDC) in Lusaka, Zambia. We defined TDFAN as meeting any of these acute kidney disease (AKD) criteria: 1) An episode of estimated glomerular filtration rate (eGFR)< 60ml/ min/1.73m2 within 3 months, 2) reduced eGFR by> 35% within 3 months or 3) increased serum creatinine by> 50% within 3 months. A total of 45 participants (22%) developed acute kidney disease (AKD) after TDF-based therapy. The development of AKD within the first 3 months of commencing TDF-based therapy was associated with an increase in baseline serum creatinine, age, baseline eGFR and female sex. We concluded that baseline characteristics and baseline renal function biomarkers predicted the risk for AKD within the first 3-months of TDF-based therapy.
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Affiliation(s)
- Freeman W. Chabala
- Levy Mwanawasa Medical University, Institute of Basic and Biomedical Sciences, Lusaka, Zambia
- The University of Zambia, School of Medicine, Lusaka, Zambia
| | - Edward D. Siew
- Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt O’Brien Center for Kidney Disease, Nashville, Tennessee, United States of America
- Tennessee Valley Health Systems (TVHS), Veterans Affairs, Nashville, TN, United States of America
| | - Wilbroad Mutale
- The University of Zambia, School of Public Health, Lusaka, Zambia
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Lloyd Mulenga
- The University of Zambia, School of Medicine, Lusaka, Zambia
- Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt O’Brien Center for Kidney Disease, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Aggrey Mweemba
- The University of Zambia, School of Medicine, Lusaka, Zambia
- The University Teaching Hospital, Lusaka, Zambia
| | - Fastone Goma
- The University of Zambia, School of Medicine, Lusaka, Zambia
| | | | - Patrick Kaonga
- Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt O’Brien Center for Kidney Disease, Nashville, Tennessee, United States of America
| | - William C. Wester
- Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt O’Brien Center for Kidney Disease, Nashville, Tennessee, United States of America
- The University Teaching Hospital, Lusaka, Zambia
| | - Douglas C. Heimburger
- The University of Zambia, School of Medicine, Lusaka, Zambia
- Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt O’Brien Center for Kidney Disease, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Muktar H. Aliyu
- Vanderbilt University Medical Center, Division of Nephrology and Hypertension, Vanderbilt O’Brien Center for Kidney Disease, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, United States of America
- Meharry Medical College School of Medicine, Nashville, TN, United States of America
| | - Derick Munkombwe
- The University of Zambia, School of Health Sciences, Lusaka, Zambia
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Sarteschi G, Di Biagio A, Focà E, Taramasso L, Bovis F, Celotti A, Mirabella M, Magnasco L, Mora S, Giacomini M, Bassetti M. Viremia copy-years and risk of estimated glomerular filtration rate reduction in adults living with perinatal HIV infection. PLoS One 2020; 15:e0240550. [PMID: 33057418 PMCID: PMC7561100 DOI: 10.1371/journal.pone.0240550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 09/28/2020] [Indexed: 11/18/2022] Open
Abstract
Among people with perinatal HIV infection (PHIV), non-communicable diseases, such as chronic kidney disease, are increasing. Both HIV replication and antiretroviral therapy are recognised causes of renal impairment. Objective of the study is to describe the impact of viremia copy-years (VCY) and antiretroviral therapy on trend of estimated glomerular filtration rate (eGFR) in a cohort of adults with perinatal HIV infection. We conducted a multicentre observational study in sixty adults living with PHIV across a 9-year period, from January 2010 to December 2018. The mean values of eGFR were analysed at the first (T0) and last year of observation (T1). VCY was defined as the area under HIV-RNA curve during the study period. We analysed data according to antiretroviral therapy: tenofovir disoproxil (TDF), non-nucleoside reverse transcriptase inhibitors (NNRTI), boosted protease inhibitors (PI/b), integrase inhibitors (INI). We observed a mean overall eGFR reduction from 126.6 mL/min (95%CI: 119.6–133.5) to 105.0 mL/min (95%CI: 99.55–110.6) (p<0.001). Older age, higher baseline eGFR, higher VCY and longer exposure to INI treatment were associated with eGFR reduction at univariate analysis. In the multivariate model, older age (p = 0.039), baseline eGFR (p<0.001) and VCY (p = 0.069), were retained. We also observed a longer exposure to PI/b and INI in patients with lower control on HIV-RNA, expressed as VCY>2 log10. Our study outlines a progressive eGFR reduction in young adults with PHIV, related to the lower control on HIV-RNA VCY and related to aging.
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Affiliation(s)
- Giovanni Sarteschi
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- * E-mail: (GS); (ADB)
| | - Antonio Di Biagio
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- * E-mail: (GS); (ADB)
| | - Emanuele Focà
- Infectious and Tropical Diseases Department, University of Brescia and ASST Spedali Civili Hospital, Brescia, Italy
| | - Lucia Taramasso
- Department of Pathophysiology and Transplantation, Infectious Diseases Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
- MultidisciplinAry ResearCh in Health Science (MACH), Milan, Italy
| | - Francesca Bovis
- Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Anna Celotti
- Infectious and Tropical Diseases Department, University of Brescia and ASST Spedali Civili Hospital, Brescia, Italy
| | - Michele Mirabella
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Laura Magnasco
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Sara Mora
- Department of Informatics Bioengineering, Robotics and System Engineering (DIBRIS), University of Genoa, Genoa, Italy
| | - Mauro Giacomini
- Department of Informatics Bioengineering, Robotics and System Engineering (DIBRIS), University of Genoa, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Infectious Diseases Unit, IRCCS Ospedale Policlinico San Martino Hospital, Genoa, Italy
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HIV protease inhibitor ritonavir induces renal fibrosis and dysfunction: role of platelet-derived TGF-β1 and intervention via antioxidant pathways. AIDS 2020; 34:989-1000. [PMID: 32167970 DOI: 10.1097/qad.0000000000002516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Chronic kidney disease (CKD) with tubular injury and fibrosis occurs in HIV infection treated with certain protease inhibitor-based antiretroviral therapies. The pathophysiology is unclear. DESIGN We hypothesized that fibrosis, mediated by platelet-derived transforming growth factor (TGF)-β1, underlies protease inhibitor-associated CKD. We induced this in mice exposed to the protease inhibitor ritonavir (RTV), and intervened with low-dose inhaled carbon monoxide (CO), activating erythroid 2-related factor (Nrf2)-associated antioxidant pathways. METHODS Wild-type C57BL/6 mice and mice deficient in platelet TGF-β1, were given RTV (10 mg/kg) or vehicle daily for 8 weeks. Select groups were exposed to CO (250 ppm) for 4 h after RTV or vehicle injection. Renal disorder, fibrosis, and TGF-β1-based and Nrf2-based signaling were examined by histology, immunofluorescence, and flow cytometry. Renal damage and dysfunction were assessed by KIM-1 and cystatin C ELISAs. Clinical correlations were sought among HIV-infected individuals. RESULTS RTV-induced glomerular and tubular injury, elevating urinary KIM-1 (P = 0.004). It enhanced TGF-β1-related signaling, accompanied by kidney fibrosis, macrophage polarization to an inflammatory phenotype, and renal dysfunction with cystatin C elevation (P = 0.008). Mice lacking TGF-β1 in platelets were partially protected from these abnormalities. CO inhibited RTV-induced fibrosis and macrophage polarization in association with upregulation of Nrf2 and heme oxygenase-1 (HO-1). Clinically, HIV infection correlated with elevated cystatin C levels in untreated women (n = 17) vs. age-matched controls (n = 19; P = 0.014). RTV-treated HIV+ women had further increases in cystatin C (n = 20; P = 0.05), with parallel elevation of HO-1. CONCLUSION Platelet TGF-β1 contributes to RTV-induced kidney fibrosis and dysfunction, which may be amenable to antioxidant interventions.
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Abstract
PURPOSE OF REVIEW To identify recent data that inform the management of individuals with HIV and chronic kidney disease. RECENT FINDINGS Several nonnucleoside reverse transcriptase, protease, and integrase strand transfer inhibitors inhibit tubular creatinine secretion resulting in stable reductions in creatinine clearance of 5-20 ml/min in the absence of other manifestations of kidney injury. Progressive renal tubular dysfunction is observed with tenofovir disoproxil fumarate in clinical trials, and more rapid decline in estimated glomerular filtration rate in cohort studies of tenofovir disoproxil fumarate and atazanavir, with stabilization, improvement or recovery of kidney function upon discontinuation. Results from clinical trials of tenofovir alafenamide (TAF) in individuals with chronic kidney disease suggest that TAF is well tolerated in those with mild to moderate renal impairment (creatinine clearance >30 ml/min) but results in very high tenofovir exposures in those on haemodialysis. SUMMARY Standard antiretroviral regimens remain appropriate for individuals with normal and/or stable, mildly impaired kidney function. In those with chronic kidney disease or progressive decline in estimated glomerular filtration rate, antiretrovirals with nephrotoxic potential should be avoided or discontinued. Although TAF provides a tenofovir formulation for individuals with impaired kidney function, TAF is best avoided in those with severe or end-stage kidney disease.
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Abstract
OBJECTIVES Predictors of chronic kidney disease (CKD) amongst HIV-positive persons are well established, but insights into the prognosis after CKD including the role of modifiable risk factors are limited. DESIGN Prospective cohort study. METHODS D:A:D participants developing CKD (confirmed, >3 months apart, eGFR ≤ 60 ml/min per 1.73 m or 25% eGFR decrease when eGFR ≤ 60 ml/min per 1.73 m) were followed to incident serious clinical events (SCE); end stage renal and liver disease (ESRL and ESLD), cardiovascular disease (CVD), AIDS-defining and non-AIDS-defining malignancies (NADM), other AIDS or death, 6 months after last visit or 1 February 2016. Poisson regression models considered associations between SCE and modifiable risk factors. RESULTS During 2.7 (IQR 1.1-5.1) years median follow-up 595 persons with CKD (24.1%) developed a SCE [incidence rate 68.9/1000 PYFU (95% confidence interval 63.4-74.4)] with 8.3% (6.9-9.0) estimated to experience any SCE at 1 year. The most common SCE was death (12.7%), followed by NADM (5.8%), CVD (5.6%), other AIDS (5.0%) and ESRD (2.9%). Crude SCE ratios were significantly higher in those with vs. without CKD, strongest for ESRD [65.9 (43.8-100.9)] and death [4.8 (4.3-5.3)]. Smoking was consistently associated with all CKD-related SCE. Diabetes predicted CVD, NADM and death, whereas dyslipidaemia was only significantly associated with CVD. Poor HIV-status predicted other AIDS and death, eGFR less than 30 ml/min per 1.73 m predicted CVD and death and low BMI predicted other AIDS and death. CONCLUSION In an era where many HIV-positive persons require less monitoring because of efficient antiretroviral treatment, persons with CKD carry a high burden of SCE. Several potentially modifiable risk factors play a central role for CKD-related morbidity and mortality.
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Petersen N, Knudsen AD, Mocroft A, Kirkegaard-Klitbo D, Arici E, Lundgren J, Benfield T, Oturai P, Nordestgaard BG, Feldt-Rasmussen B, Nielsen SD, Ryom L. Prevalence of impaired renal function in virologically suppressed people living with HIV compared with controls: the Copenhagen Comorbidity in HIV Infection (COCOMO) study. HIV Med 2019; 20:639-647. [PMID: 31359592 DOI: 10.1111/hiv.12778] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES While renal impairment is reported more frequently in people living with HIV (PLWH) than in the general population, the PLWH samples in previous studies have generally been dominated by those at high renal risk. METHODS Caucasian PLWH who were virologically suppressed on antiretroviral treatment and did not have injecting drug use or hepatitis C were recruited from the Copenhagen Comorbidity in HIV Infection (COCOMO) study. Sex- and age-matched controls were recruited 1:4 from the Copenhagen General Population Study up to November 2016. We defined renal impairment as one measurement of estimated glomerular filtration rate ≤ 60 mL/min/1.73 m2 , and assessed associated factors using adjusted logistic regression models. The impact of HIV-related factors was explored in a subanalysis. RESULTS Among 598 PLWH and 2598 controls, the prevalence of renal impairment was 3.7% [95% confidence interval (CI) 2.3-5.5%] and 1.7% (95% CI 1.2-2.2%; P = 0.0014), respectively. After adjustment, HIV status was independently associated with renal impairment [odds ratio (OR) 3.4; 95% CI 1.8-6.3]. In addition, older age [OR 5.4 (95% CI 3.9-7.5) per 10 years], female sex [OR 5.0 (95% CI 2.6-9.8)] and diabetes [OR 2.9 (95% CI 1.3-6.7)] were strongly associated with renal impairment. The association between HIV status and renal impairment became stronger with older age (P = 0.02 for interaction). Current and nadir CD4 counts, duration of HIV infection and previous AIDS-defining diagnosis were not associated with renal impairment among virologically suppressed PLWH. CONCLUSIONS The prevalence of renal impairment is low among low-risk virologically suppressed Caucasian PLWH, but remains significantly higher than in controls. Renal impairment therefore remains a concern in all PLWH and requires ongoing attention.
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Affiliation(s)
- N Petersen
- Department of Infectious Diseases, Viro-immunology Research Unit, Rigshospitalet, Copenhagen, Denmark
| | - A D Knudsen
- Department of Infectious Diseases, Viro-immunology Research Unit, Rigshospitalet, Copenhagen, Denmark
| | - A Mocroft
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, UCL, London, UK
| | | | - E Arici
- Department of Infectious Diseases, Viro-immunology Research Unit, Rigshospitalet, Copenhagen, Denmark
| | - J Lundgren
- Department of Infectious Diseases, CHIP, Center of Excellence for Health, Immunity and Infections, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - T Benfield
- Department of Infectious Diseases, Hvidovre Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - P Oturai
- Department of Clinical Physiology, Nuclear Medicine and PET, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - B G Nordestgaard
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,The Copenhagen General Population Study and Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - B Feldt-Rasmussen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - S D Nielsen
- Department of Infectious Diseases, Viro-immunology Research Unit, Rigshospitalet, Copenhagen, Denmark
| | - L Ryom
- Department of Infectious Diseases, CHIP, Center of Excellence for Health, Immunity and Infections, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Prevalence of chronic kidney disease among HIV-1-infected patients receiving a combination antiretroviral therapy. Clin Exp Nephrol 2019; 23:1272-1279. [PMID: 31327092 DOI: 10.1007/s10157-019-01768-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 07/12/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) has become one of the most frequent non-infectious comorbidities in the aging HIV-infected population on long-standing combination antiretroviral therapy (cART). METHODS We conducted a retrospective, cross-sectional study including HIV-infected adult patients attending our HIV outpatient clinic during the years 2017 and 2018 to assess prevalence and associated risk factors of CKD. Estimated glomerular filtration rate (eGFR) was measured by Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation. CKD was diagnosed and classified according to the National Kidney Foundation guidelines. Logistic regression was employed to identify factors associated with CKD. RESULTS We enrolled 2339 HIV-infected patients (91% were Caucasian) with a mean age of 45.3 years and a mean current CD4 lymphocyte count of 531 cells/mm3. CKD was diagnosed in 311 subjects (13.3%). Overall, 294 (12.6%) patients had albuminuria, 108 (4.6%) had eGFR < 60 mL/min/1.73 m2, and 78 (3.3%) had albuminuria plus eGFR < 60 mL/min/1.73 m2. Stages 4-5 of CKD were documented in 23 (1%) cases. Age greater than 50 years, male gender, hypertension, diabetes mellitus, high triglycerides, nadir CD4 cell count < 200 cells/mm3, current use of tenofovir disoproxyl fumarate (TDF) and of TDF plus a ritonavir-boosted protease inhibitors were independently associated with CKD, while current use of abacavir plus one integrase inhibitor was associated with a reduced risk of CKD. CONCLUSION There is a significant prevalence of CKD among HIV-infected persons in association with both traditional and HIV-specific risk factors, requiring a careful periodic monitoring of renal function in these patients.
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Older HIV-infected adults: complex patients-comorbidity (I). Eur Geriatr Med 2019; 10:189-197. [PMID: 34652750 DOI: 10.1007/s41999-018-0152-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/04/2018] [Indexed: 12/16/2022]
Abstract
Life expectancy in people living with HIV has increased in the past decades, since the introduction of highly active antiretroviral treatment. Increased survival comes along with new challenges for the HIV physician, as these patients will present comorbidities inherent to ageing that can appear more frequently and at younger age than the general population. The older HIV patient poses a unique challenge, as management should take into account different factors, some related to global ageing such as geriatric syndromes, traditional risk factors, social vulnerability, and age-related diseases, and others related to HIV infection like ART toxicity, drug-drug interactions, immune dysregulation and chronic inflammation. All the above can amount to great polypharmacy and multimorbidity that physician have to be aware of. Little is known about the best screening, management and treatment strategies to improve long-term health outcomes in this ageing population. The following article briefly reviews the main comorbidities that can affect the ageing HIV patient.
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Abstract
PURPOSE OF REVIEW Human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) was identified as the major renal manifestation of HIV infection early in the HIV epidemic. However, HIV infection now is associated with a different spectrum of renal lesions leading to chronic kidney disease. This review examines the changes in kidney injury occurring in the current HIV era and the factors involved in this transformation of disease expression. RECENT FINDINGS The incidence of HIVAN and opportunistic infections in HIV-infected individuals has declined in concert with the use of effective combination antiretroviral agents. Chronic kidney disease has become more prevalent as patients infected with HIV are living longer and developing non-HIV-associated diseases such as hypertension and diabetes. Additionally, noncollapsing focal and segmental glomerulosclerosis, co-infection with hepatitis C, HIV-associated immune complex kidney disease, HIV-related accelerated aging, and antiretroviral therapies contribute to progressive loss of renal function. SUMMARY HIV infection is now associated with a variety of renal lesions causing chronic kidney disease, not all of which are virally induced. It is important to determine the cause of renal functional decline in an HIV-infected patient, as this will impact patient management and prognosis.
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Abstract
OBJECTIVES To describe changes in the prevalence of comorbidities and risk factors among HIV-positive individuals in the EuroSIDA study. DESIGN Comparison of two cross-sectional cohorts of HIV-positive adults under active follow-up in 2006 and 2014. METHODS Baseline demographics and prevalence of comorbidities were described. Factors associated with the prevalence of chronic kidney disease (CKD) and cardiovascular disease (CVD) were assessed by logistic regression modelling using generalized estimating equations. RESULTS Nine thousand, seven hundred and ninety-eight individuals were under active follow-up in EuroSIDA during 2006 and 12 882 during 2014. Compared with study participants in 2006, those in 2014 were older [median age 48.6 years (IQR 40.3-55.1) vs. 43.1 years (37.2-50.0) in 2006] and had higher prevalence of hypertension (59.6 vs. 47% in 2006), diabetes (6.3 vs. 5.4%), CKD (6.9 vs. 4.1%) and CVD (5.0 vs. 3.7%). Individuals in the 2014 cohort had higher odds for CKD (unadjusted OR 2.62, 95% CI 2.30-2.99, P < 0.0001) and CVD (OR 1.88, CI 1.68-2.10, P < 0.0001), but after multivariable adjustment for age group, comorbidities and other factors, year of cohort was no longer significantly associated with the odds of CKD [adjusted OR (aOR) 0.97, CI 0.52-1.82, P = 0.92) or of CVD (aOR 0.94, CI 0.54-1.63, P = 0.82). CONCLUSION Between 2006 and 2014, the population aged and experienced an overall higher prevalence of non-AIDS comorbidities, including CKD and CVD. The increase in CVD could be explained by the aging population, and the increase in CKD by aging and changes in other factors. Treatment strategies balancing HIV outcomes with long-term management of comorbidities remain a priority.
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Laurence J. Pre-Exposure Prophylaxis (PrEP) for HIV: Opportunities, Challenges, and Future Directions. AIDS Patient Care STDS 2018; 32:487-489. [PMID: 30265577 DOI: 10.1089/apc.2018.29003.jl] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jeffrey Laurence
- Division of Hematology and Medical Oncology, Weill Cornell Medical College, New York
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Renal health after long-term exposure to tenofovir disoproxil fumarate (TDF) in HIV/HBV positive adults in Ghana. J Infect 2018; 76:515-521. [PMID: 29702139 DOI: 10.1016/j.jinf.2018.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/11/2018] [Accepted: 03/14/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The study assessed markers of renal health in HIV/HBV co-infected patients receiving TDF-containing antiretroviral therapy in Ghana. METHODS Urinary protein-to-creatinine ratio (uPCR) and albumin-to-protein ratio (uAPR) were measured cross-sectionally after a median of four years of TDF. At this time, alongside extensive laboratory testing, patients underwent evaluation of liver stiffness and blood pressure. The estimated glomerular filtration rate (eGFR) was measured longitudinally before and during TDF therapy. RESULTS Among 101 participants (66% women, median age 44 years, median CD4 count 572 cells/mm3) 21% and 17% had detectable HIV-1 RNA and HBV DNA, respectively. Overall 35% showed hypertension, 6% diabetes, 7% liver stiffness indicative of cirrhosis, and 18% urinary excretion of Schistosoma antigen. Tubular proteinuria occurred in 16% of patients and was independently predicted by female gender and hypertension. The eGFR declined by median 1.8 ml/min/year during TDF exposure (IQR -4.4, -0.0); more pronounced declines (≥ 5 ml/min/year) occurred in 22% of patients and were associated with receiving ritonavir-boosted lopinavir rather than efavirenz. HBV DNA, HBeAg, transaminases, and liver stiffness were not predictive of renal function abnormalities. CONCLUSIONS The findings mandate improved diagnosis and management of hypertension and suggest targeted laboratory monitoring of patients receiving TDF alongside a booster in sub-Saharan Africa.
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Kidney disease in the setting of HIV infection: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2018; 93:545-559. [PMID: 29398134 DOI: 10.1016/j.kint.2017.11.007] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/23/2017] [Accepted: 11/08/2017] [Indexed: 12/12/2022]
Abstract
HIV-positive individuals are at increased risk for kidney disease, including HIV-associated nephropathy, noncollapsing focal segmental glomerulosclerosis, immune-complex kidney disease, and comorbid kidney disease, as well as kidney injury resulting from prolonged exposure to antiretroviral therapy or from opportunistic infections. Clinical guidelines for kidney disease prevention and treatment in HIV-positive individuals are largely extrapolated from studies in the general population, and do not fully incorporate existing knowledge of the unique HIV-related pathways and genetic factors that contribute to the risk of kidney disease in this population. We convened an international panel of experts in nephrology, renal pathology, and infectious diseases to define the pathology of kidney disease in the setting of HIV infection; describe the role of genetics in the natural history, diagnosis, and treatment of kidney disease in HIV-positive individuals; characterize the renal risk-benefit of antiretroviral therapy for HIV treatment and prevention; and define best practices for the prevention and management of kidney disease in HIV-positive individuals.
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