Reduced renal function is associated with progression to AIDS but not with overall mortality in HIV-infected Kenyan adults not initially requiring combination antiretroviral therapy

Serious clinical events in HIV-positive persons with chronic kidney disease

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.

Prevalence and burden of chronic kidney disease among the general population and high-risk groups in Africa: a systematic review

OBJECTIVES

While increasing attention is paid to the rising prevalence of chronic diseases in Africa, there is little focus on chronic kidney disease (CKD). This systematic review assesses CKD burden among the general population and high-risk groups on the entire African continent.

DESIGN, SETTING AND PARTICIPANTS

We searched Medline and PubMed databases for articles published between 1 January 1995 and 7 April 2017 by sensitive search strategies focusing on CKD surveys at the community level and high-risk groups. In total, 7918 references were evaluated, of which 7766 articles were excluded because they did not meet the inclusion criteria. Thus, 152 studies were included in the final analysis.

OUTCOME MEASUREMENT

The prevalence of CKD in each study group was expressed as a range and pooled prevalence rate of CKD was calculated as a point estimate and 95% CI. No meta-analysis was done. Data were presented for different populations.

RESULTS

In the community-level studies, based on available medium-quality and high-quality studies, the prevalence of CKD ranged from 2% to 41% (pooled prevalence: 10.1%; 95% CI 9.8% to 10.5%). The prevalence of CKD in the high-risk groups ranged from 1% to 46% (pooled prevalence: 5.6%; 95% CI 5.4% to 5.8%) in patients with HIV (based on available medium-quality and high-quality studies), 11%-90% (pooled prevalence: 24.7%; 95% CI 23.6% to 25.7%) in patients with diabetes (based on all available studies which are of low quality except four of medium quality) and 13%-51% (pooled prevalence: 34.5%; 95 % CI 34.04% to 36%) in patients with hypertension (based on all available studies which are of low quality except two of medium quality).

CONCLUSION

In Africa, CKD is a public health problem, mainly attributed to high-risk conditions as hypertension and diabetes. The poor data quality restricts the validity of the findings and draws the attention to the importance of designing future robust studies.

Prevalence of anemia in renal insufficiency among HIV infected patients initiating ART at a hospital in Northeast Ethiopia

BACKGROUND

Anemia is a strong predictor of mortality and poor quality of life among persons with either renal impairment or HIV infection. In this study, we investigated the prevalence of anemia and its association with renal insufficiency among HIV infected patients initiating ART at a hospital in Northeast Ethiopia.

METHODS

In this retrospective cohort study, records of 373 patients on ART were selected in Dessie Referral hospital, South Wollo, Northeast Ethiopia from September 2010 to August 2013. Socio-demographic and clinical characteristics of the study patients were collected using standardized data extraction instrument. The abbreviated 4-variable Modification of Diet in Renal Disease (MDRD) study equation was used to estimate renal function (GFR) from serum creatinine. SPSS version 20.0 statistical software was used for data analysis.

RESULTS

The prevalence of anemia at the time of ART initiation was 34.4%; with 20.5, 12.3 and 1.6% mild, moderate and severe anemia, respectively. Renal insufficiency was present in 27.9% of patients and was associated with a high prevalence of anemia (74%). The prevalence of anemia increased with stage of insufficiency, from 23.7% in stage 1 to 100% in stage 4. Impaired renal function (eGFR < 60 mL/min/1.73 m2) was associated with a higher risk of all forms of anemia; i.e., mild (AOR = 3.96; 95% CI: 2.76-5.69), moderate (AOR = 2.21; 95% CI: 1.16-4.19) and severe anemia (AOR = 5.89; 95% CI: 1.02-12.03).

CONCLUSION

HIV infected patients with renal insufficiency had a higher prevalence of anemia compared to patients with normal renal function. Thus, screening of these patients for anemia and renal insufficiency at base line should be critical not only to reduce mortality but also to improve clinical outcomes.

Urinary Markers of Tubular Injury in HIV-Infected Patients

Renal disease is a common complication of HIV-infected patients, associated with increased risk of cardiovascular events, progression to AIDS, AIDS-defining illness, and mortality. Early and accurate identification of renal disease is therefore crucial to improve patient outcomes. The use of serum creatinine, along with proteinuria, to detect renal involvement is essentially to screen for markers of glomerular disease and may not be effective in detecting earlier stages of renal injury. Therefore, more sensitive and specific markers are needed in order to early identify HIV-infected patients at risk of renal disease. This review article summarizes some new and important urinary markers of tubular injury in HIV-infected patients and their clinical usefulness in the renal safety follow-up of TDF-treated patients.

Markers of renal disease and function are associated with systemic inflammation in HIV infection

OBJECTIVES

Both renal disease and systemic inflammation predict non-AIDS-defining events and overall mortality in HIV-infected patients. Here, we sought to determine the relationships between renal disease and circulating inflammation markers.

METHODS

We performed a secondary analysis of AIDS Clinical Trials Group Study A5224s to determine if markers of renal disease [urine protein:creatinine ratio (uPCR), urine albumin:creatinine ratio (uACR), and estimated glomerular filtration rate (eGFR), using Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine and cystatin C-creatinine] were associated with markers of systemic inflammation [high-sensitivity C-reactive protein, interleukin-6, tumour necrosis factor (TNF)-α, soluble TNF-α receptor I (sTNFRI), sTNFRII, and soluble vascular cellular and intercellular adhesion molecules]. We correlated these renal and inflammatory markers prior to antiretroviral initiation and after 96 weeks of therapy.

RESULTS

We found that eGFR (estimated using CKD-EPI cystatin C-creatinine), uPCR, and uACR were significantly correlated with most assessed markers of systemic inflammation prior to antiretroviral initiation. uPCR and eGFR (using CKD-EPI cystatin C-creatinine), but not uACR, remained significantly correlated with most of the assessed inflammatory markers after 96 weeks of antiretroviral therapy (ART). Most of these correlations, although statistically significant, were < 0.50. eGFR using CKD-EPI creatinine was much less frequently associated with inflammation markers and only significantly correlated with sTNFR1 at week 0 and with sTNFRI and II at week 96.

CONCLUSIONS

Renal disease and function were associated with systemic inflammation in HIV infection, both before and after ART. Systemic inflammation may partially explain the relationships between proteinuria, albuminuria, and reduced renal function and future adverse outcomes.

Evaluation of the Prognostic Value of Impaired Renal Function on Clinical Progression in a Large Cohort of HIV-Infected People Seen for Care in Italy

Whilst renal dysfunction, especially mild impairment (60<eGFR<90 ml/min), has been often described in HIV-infected population, its potential contribution to HIV evolution and risk of cerebro-cardiovascular disease (CCVD) has not been clarified. Data from HIV-1 infected patients enrolled in the Italian Cohort of Antiretroviral-Naïve (Icona) Foundation Study collected between January 2000 and February 2014 with at least two creatinine values available. eGFR (CKD-epi) and renal dysfunction defined using a priori cut-offs of 60 (severely impaired) and 90 ml/min/1.73m² (mildly impaired). Characteristics of patients were described after stratification in these groups and compared using chi-square test (categorical variables) or Kruskal Wallis test comparing median values. Follow-up accrued from baseline up to the date of the CCVD or AIDS related events or death or last available visit. Kaplan Meier curves were used to estimate the cumulative probability of occurrence of the events over time. Adjusted analysis was performed using a proportional hazards Cox regression model. We included 7,385 patients, observed for a median follow-up of 43 months (inter-quartile range [IQR]: 21-93 months). Over this time, 130 cerebro-cardiovascular events (including 11 deaths due to CCVD) and 311 AIDS-related events (including 45 deaths) were observed. The rate of CCVD events among patients with eGFR >90, 60-89, <60 ml/min, was 2.91 (95% CI 2.30-3.67), 4.63 (95% CI 3.51-6.11) and 11.9 (95% CI 6.19-22.85) per 1,000 PYFU respectively, with an unadjusted hazard ratio (HR) of 4.14 (95%CI 2.07-8.29) for patients with eGFR <60 ml/min and 1.58 (95%CI 1.10-2.27) for eGFR 60-89 compared to those with eGFR ≥90. Of note, these estimates are adjusted for traditional cardio-vascular risk factors (e.g. smoking, diabetes, hypertension, dyslipidemia). Incidence of AIDS-related events was 9.51 (95%CI 8.35-10.83), 6.04 (95%CI 4.74-7.71) and 25.0 (95%CI 15.96-39.22) per 1,000 PYFU, among patients with eGFR >90, 60-89, <60 ml/min, respectively, with an unadjusted HR of 2.49 (95%CI 1.56-3.97) for patients with eGFR <60 ml/min and 0.68 (95%CI 0.52-0.90) for eGFR 60-89. The risk of AIDS events was significantly lower in mild renal dysfunction group even after adjustment for HIV-related characteristics. Our data confirm that impaired renal function is an important risk marker for CCVD events in the HIV-population; importantly, even those with mild renal impairment (90<eGFR<60) seem to be at increased risk of cerebro-cardiovascular morbidity and mortality.

Screening for decreased glomerular filtration rate and associated risk factors in a cohort of HIV-infected patients in a middle-income country

With the introduction of combined active antiretroviral therapy and the improved survival of HIV-infected patients, degenerative diseases and drug toxicity have emerged as long-term concerns. We studied the prevalence of decreased glomerular filtration rate (GFR) and associated risk factors in a cohort of HIV-infected patients from a middle-income country. Our cross-sectional study included all adult patients who attended an urban outpatient clinic in 2008. GFR was estimated using the CKD-EPI equation. The prevalence ratio (PR) of decreased GFR (defined as <60 mL/min/1.73 m²) was estimated using generalizing linear models assuming a Poisson distribution. We analyzed data from 1,970 patients, of which 82.9% had been exposed to ART. A total of 249 patients (12.6%) had a GFR between 60 and 89 mL/min/1.73 m², 3.1% had a GFR between 30 and 59, 0.3% had a GFR between 15 and 29, and 0.4% had a GFR <15. Decreased GFR was found in only 74 patients (3.8%). In the multivariate regression model, the factors that were independently associated with a GFR below 60 mL/min/1.73 m² were as follows: age ≥50 years (PR = 3.4; 95% CI: 1.7–6.8), diabetes (PR = 2.0; 95% CI: 1.2–3.4), hypertension (PR = 2.0; 95% CI: 1.3–3.2), current CD4+ cell count <350 cells/mm3 (PR = 2.1; 95% CI: 1.3–3.3), past exposure to tenofovir (PR = 4.7; 95% CI: 2.3–9.4) and past exposure to indinavir (PR = 1.7; 95% CI: 1.0–2.8). As in high-income countries, CKD was the predominant form of kidney involvement among HIV-infected individuals in our setting. The risk factors associated with decreased glomerular filtration were broad and included virus-related factors as well as degenerative and nephrotoxic factors. Despite the potential for nephrotoxicity associated with some antiretroviral drugs, in the short-term, advanced chronic renal disease remains very rare.

Deteriorating renal function and clinical outcomes in HIV-positive persons

OBJECTIVES

To determine the relationship between measures of renal function [current estimated glomerular filtration rate (eGFR) and proportion of follow-up with a low eGFR (%FU ≤60 ml/min)] and fatal/ nonfatal AIDS, non-AIDS events and all-cause mortality.

DESIGN

An observational, longitudinal cohort study of 12 155 persons from EuroSIDA.

METHODS

Persons with at least one eGFR measurement after 1 January 2004, using the CKD-EPI formula, were included. Poisson regression analyses were used to determine whether current eGFR or %FU of 60 ml/min or less were independent prognostic markers for clinical events.

RESULTS

During 61 425 person-years of follow-up (PYFU), the crude incidence of deaths was 11.1/1000 PYFU [95% confidence interval (CI) 10.0-12.1] at current eGFR more than 90 ml/min and 199.6 (95% CI 1144.3-254.3/1000 PYFU) when current eGFR was 30 ml/min or less. Corresponding figures for AIDS were 12.2 (11.1-13.3) and 63.9 (36.5-103.7) and for non-AIDS were 16.0 (14.8-17.3) and 203.6 (147.7-259.5). After adjustment, current eGFR of 30 ml/min or less was a strong predictor of death [adjusted incidence rate ratios (aIRR) 4.35; 95% CI 3.20-5.91] and non-AIDS events (3.63; 95% CI 2.57-5.13), although the relationship with AIDS was less strong (1.45; 95% CI 1.01-2.08). After adjustment, %FU of 60 ml/min or less was associated with a 22% increased incidence of death (aIRR 1.22 per 10% longer; 95% CI 1.18-1.27), a 13% increased incidence of non-AIDS events (95% CI 1.08-1.18) and a 15% increased incidence of AIDS events (95% CI 1.06-1.24).

CONCLUSION

Both current eGFR and %FU of 60 ml/min or less were associated with death and non-AIDS events in HIV-positive persons. Our findings highlight the association between underlying renal dysfunction and morbidity and mortality in HIV infection, although reverse causality cannot be excluded.

Estimating kidney function in HIV-infected adults in Kenya: comparison to a direct measure of glomerular filtration rate by iohexol clearance

Background

More than two-thirds of the world's HIV-positive individuals live in sub-Saharan Africa, where genetic susceptibility to kidney disease is high and resources for kidney disease screening and antiretroviral therapy (ART) toxicity monitoring are limited. Equations to estimate glomerular filtration rate (GFR) from serum creatinine were derived in Western populations and may be less accurate in this population.

Methods

We compared results from published GFR estimating equations with a direct measure of GFR by iohexol clearance in 99 HIV-infected, ART-naïve Kenyan adults. Iohexol concentration was measured from dried blood spots on filter paper. The bias ratio (mean of the ratio of estimated to measured GFR) and accuracy (percentage of estimates within 30% of the measured GFR) were calculated.

Results

The median age was 35 years, and 60% were women. The majority had asymptomatic HIV, with median CD4+ cell count of 355 cells/mm³. Median measured GFR was 115 mL/min/1.73 m². Overall accuracy was highest for the Chronic Kidney Disease Epidemiology Consortium (CKD-EPI) equation. Consistent with a prior report, bias and accuracy were improved by eliminating the coefficient for black race (85% of estimates within 30% of measured GFR). Accuracy of all equations was poor in participants with GFR 60–90 mL/min/1.73 m² (<65% of estimates within 30% of measured GFR), although this subgroup was too small to reach definitive conclusions.

Conclusions

Overall accuracy was highest for the CKD-EPI equation. Eliminating the coefficient for race further improved performance. Future studies are needed to determine the most accurate GFR estimate for use in individuals with GFR <90 mL/min/1.73 m², in whom accurate estimation of kidney function is important to guide drug dosing. Direct measurement of GFR by iohexol clearance using a filter paper based assay is feasible for research purposes in resource-limited settings, and could be used to develop more accurate GFR estimates in African populations.

Cancer and the 'other' noncommunicable chronic diseases in older people living with HIV/AIDS in resource-limited settings: a challenge to success

OBJECTIVE

There is considerable research around the morbidity and mortality related to noncommunicable diseases (NCDs), particularly cardiovascular disease and diabetes, among people living with HIV/AIDS (PLWHA) in resource-richer settings. Less is known about the burden and appropriate management of NCDs, particularly 'other' NCDs including cancer, renal, pulmonary, neurocognitive and mental health conditions, among older PLWHA in resource-limited settings (RLSs). We undertook a literature review of these other NCDs to explore what is currently known about them and identify areas of further research.

METHODS

Systematic literature review of published manuscripts and selected conference abstracts and reports.

RESULTS

Although there is growing recognition of the importance of these NCDs among the aging population of PLWHA in RLSs, significant gaps remain in understanding the epidemiology and risk factors among older PLWHA in these settings. Even more concerning is the limited available evidence for effective and feasible approaches to prevention, screening and treatment of these conditions. The burden of these NCDs is related to both the aging of the population of PLWHA and an increased risk due to HIV infection, other comorbidities associated with HIV infection or transmission risk and underlying risk factors in the general community. Results from resource-richer settings and RLSs highlight malignancies, neurocognitive and mental health as well as renal disease as the most significant challenges currently and likely to increase in the future.

CONCLUSION

Although some lessons can be taken from the growing experience with NCDs in older PLWHA in resource-richer settings, additional research is needed to better understand their risk and impact and identify optimal models of care to effectively address this challenge in the areas where the majority of older PLWHA will be receiving care.