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Joel M. Topf, MD
     Clinical Nephrologist
           St John Hospital
              248.470.8163
http:pbfluids.blogspot.com
HIV and the
Kidney
           Joel M. Topf, MD
       Clinical Nephrologist
             St John Hospital
                248.470.8163
  http:pbfluids.blogspot.com
HIV and the
Kidney 2.0
           Joel M. Topf, MD
       Clinical Nephrologist
             St John Hospital
                248.470.8163
  http:pbfluids.blogspot.com
October 2, 1985
November 7, 1991
  quot;I think we sometimes think only gay people can get
  it; it's not going to happen to me. And here I am
  saying that it can happen to anybody, even me,
  Magic Johnson.quot;
1995




       Selik RM, et al. J AIDS 2002; 29: 378-387.
Progression to ESRD
  Pre-HAART vs. HAART Era
• JHHC – clinic-based, all HIV positive
  – N = 3,876
• ALIVE – community-based, all IDU,
  both HIV positive and negative
  – N = 2,379
     •   Median age: 37 y
     •   Female: 32%
     •   IDU: 70%
     •   HIV negative: 28%
     •   Log HIV RNA: 4.4 (median value)
     •   CD4: 287 (median value)
Occurrence rate   Univariate RR      Adjusted RR*
Outcome                                 (per 1000 PYs)     (95% CI)           (95% CI)
Incidence of chronic kidney disease
Pre-HAART era                               22.2               1.0                1.0
HAART era                                   16.0         0.72 (0.55-0.94)   0.64 (0.49-0.85)
Death with chronic kidney disease prior to dialysis
Pre-HAART era                                8.6               1.0                1.0
HAART era                                    5.8         0.67 (0.44-1.04)   0.54 (0.35-0.84)
Period prevalence of chronic kidney disease
Pre-HAART era                               47.7               1.0                1.0
HAART era                                   69.3         1.45 (1.11-1.90)   1.37 (1.05-1.80)
Incident ESRD/RRT
Pre-HAART era                                5.9               1.0                1.0
HAART era                                    9.4         1.59 (0.98-2.59)   1.46 (0.89-2.37)
Incident ESRD/RRT or death with chronic kidney disease prior to dialysis
Pre-HAART era                               14.6               1.0                1.0
HAART era                                   15.3         1.05 (0.76-1.44)   0.91 (0.66-1.25)


*Adjusted for age and AIDS status
Lucas, et al. CROI 2007 poster #829.
Compared to the
 uninfected ESRD was
7x more likely
 w i t hou t AIDS a nd
16x more likely
     w ith AIDS
ESRD increased
  20% in the
  HAART era
des pi t e s i g n i fi c an t
decrease in
incident CKD
are the increased
renal,
hepatic and
cardiac
disease due to


     drugs or
       bugs?
1995 to 2001: admission rate
for cardio- or cerebro-vascular disease

fell from 1.7 to 0.9
admits per 100 patient years
1995 to 2001: the death rate

fell from 21.3 to
5.0 per 100 patient years
the adjusted relative risk
of a myocardial infarction
was 1.15 / year
of exposure to
protease inhibitors
• patients with CD4 > 350 were enrolled
• randomized to
  – continuous HAART (viral suppression
    group)
  – interrupted HAART, drug vacation when
    CD4 > 350 and resumption when CD4 less
    than 250 until CD4 is over 350
• Open label
• end-point: OI or death
• power analysis indicated the study
  would last 6 years to accrue 910 end-
  points
stopped after
Sixteen
Months
the specific way that
drugs are used can
determine the outcome
don’t trust the
rearview mirror
Freq of HIV at initiation of dialysis




       0
             0.01
                    0.02
                            0.03
                                   0.04
                                          0.05
1995


1996


1997


1998


1999


2000


2001


2002


2003


2004
HIVAN
• first readily identified renal
  manifestation of HIV
• rapidly progressing renal failure
• heavy proteinuria
• usually
  – low CD4
  – high viral load
• BP tends to be low
• large echogenic kidneys             31
HIVAN. a black person disease.
• United States
  – African Americans 12.2 times more likely to
    develop HIVAN than whites
  – Among those with ESRD secondary to HIV/AIDS:
    88.4% African American
• Europe
  – France: 97/102 with HIVAN were black
  – London 17/17 with HIVAN were black
  – Switzerland 239 autopsies with dx of AIDS
     • 1 case of HIVAN in a black individual
The only cause or ESRD more
associated with African descent is

         Sickle
        Cell
        Anemia
Definitive diagnosis
Definitive diagnosis
HIVAN Pathophysiology
                               HIV-1

• HIV infects podocytes           • HIV infects tubular
                                    epithelial cells
   – Loss of differentiation
     markers                           – Loss of differentiation
                                         markers
   – Loss of foot processes
                                       – Apoptosis
   – Immature forms of
     collagen are expressed            – Proliferation




Capillary loop collapse           Tubular degeneration and
                                    regeneration and
                                    microcyst formation
the epidemiology is in doubt
• HIVAN is found in 40-60% of renal
  biopsies done for cause
• Autopsy study of organs from HIV-
  infected persons in Texas found that the
  overall prevalence of HIVAN was 6.9%
• Screening protocols for HIVAN based
  on biopsies in HIV-infected patients with
  >1.5 g/day of proteinuria have found an
  overall prevalence of 3.5%.
              Shahinian V, Rajaraman S, et al. Am J Kidney Dis. 2000; 35(5):884-8
                      Ahuja TS, Borucki M, et al. Am J Nephrol. 1999 19(6):655-9
Kidney International 2006; 69: 2243-2250.

                                                        615 HIV+
                                                  Black South Africans


                     No proteinuria                                                 + Proteinuria
                       577 (94%)                                                       38 (6%)


 90 patients tested for               487 No further              10 lost to follow-up              23 kidney biopsies
     Microalbumin                        testing             5 refused consent for biopsy


32 had Microalbuminuria                                                                                 19 HIVAN
          36%


   7 had persistant
microalbuminuria (8%)


   7 kidney biopsies


       6 HIVAN
Kidney International 2006; 69: 2243-2250.

                                                        615 HIV+
                                                  Black South Africans


                     No proteinuria                                                 + Proteinuria
                       577 (94%)                                                       38 (6%)


 90 patients tested for               487 No further              10 lost to follow-up              23 kidney biopsies
     Microalbumin                        testing             5 refused consent for biopsy


32 had Microalbuminuria                                                                                 19 HIVAN
          36%


                                                                                                         83%
   7 had persistant
microalbuminuria (8%)


   7 kidney biopsies


       6 HIVAN
Kidney International 2006; 69: 2243-2250.

                                                        615 HIV+
                                                  Black South Africans


                     No proteinuria                                                 + Proteinuria
                       577 (94%)                                                       38 (6%)


 90 patients tested for               487 No further              10 lost to follow-up              23 kidney biopsies
     Microalbumin                        testing             5 refused consent for biopsy


32 had Microalbuminuria                                                                                 19 HIVAN
          36%


                                                                                                         83%
   7 had persistant
microalbuminuria (8%)


   7 kidney biopsies


       6 HIVAN
Kidney International 2006; 69: 2243-2250.

                                                        615 HIV+
                                                  Black South Africans


                     No proteinuria                                                 + Proteinuria
                       577 (94%)                                                       38 (6%)


 90 patients tested for               487 No further              10 lost to follow-up              23 kidney biopsies
     Microalbumin                        testing             5 refused consent for biopsy


32 had Microalbuminuria                                                                                 19 HIVAN
          36%


                                                                                                         83%
   7 had persistant
microalbuminuria (8%)


   7 kidney biopsies


       6 HIVAN
Kidney International 2006; 69: 2243-2250.

                                                        615 HIV+
                                                  Black South Africans


                     No proteinuria                                                 + Proteinuria
                       577 (94%)                                                       38 (6%)


 90 patients tested for               487 No further              10 lost to follow-up              23 kidney biopsies
     Microalbumin                        testing             5 refused consent for biopsy


32 had Microalbuminuria                                                                                 19 HIVAN
          36%


                                                                                                         83%
   7 had persistant
microalbuminuria (8%)


   7 kidney biopsies


       6 HIVAN


       86%
Diagnosis: Size doesn’t matter

                                      HIVAN         No HIVAN

               Ave. Length            11.3 cm       11.5 cm
               Sensitivity (>12 cm)   28% (12-49)
               Specificity (>12 cm)   75% (58-88)
               PPV (>12 cm)           44% (20-70)
               NPV (>12 cm)           60% (44-74)
Diagnosis: echodensity does
0    I




     III
II
Diagnosis: echodensity does
Diagnosis: echodensity does



Operating
Characteristic     Grade II/III      Grade III
Sensitivity      96% (80-100)     40% (21-61)
Specificity       28% (12-49)     95% (82-99)

PPV               57% (41-72)     83% (52-98)

NPV              95% (75-100)     70% (55-82)
Diagnosis: echodensity does



Operating
Characteristic     Grade II/III      Grade III
Sensitivity      96% (80-100)     40% (21-61)
Specificity       28% (12-49)     95% (82-99)

PPV               57% (41-72)     83% (52-98)

NPV              95% (75-100)     70% (55-82)
Treatment: ART/HAART




    Nagajothi, et al. ASN 2005. Renal Week. Philadelphia, PA Abstract #TH-FC041.
                                        Lucas GM, et al. AIDS 2004; 20:541-546.
Treatment: Steroids




        Eustace JA, et al. Kidney International (2000) 58, 1253–1260;
Schwartz EJ. J Am Soc Nephrol 16: 2412-2420, 2005.
Schwartz EJ. J Am Soc Nephrol 16: 2412-2420, 2005.
Hispanic
              18%




                                                                       African American
                                                                             50%




  White
  30%




  Race/ethnicity of persons (including children)
with HIV/AIDS diagnosed during 2004 (N = 38,730)
          CDC. HIV/AIDS Surveillance Report, 2004. Vol. 16. Atlanta: US16: 2412-2420, 2005.
                                      Schwartz EJ. J Am Soc Nephrol
           Department of Health and Human Services, CDC: 2005:1–46.
The changing nature of HIV
        renal disease


• Other HIV Nephropathies
• Importance and frequency of proteinuria
• Drug induced toxicity
HIV+ renal biopsy Findings
42 HIVAN
13 Immune complex GN
 8 Membranous nephropathy
 6 Diabetic glomerulopathy
 5 Membranoproliferative GN
 5 Hypertensive nephrosclerosis
 3 Interstitial nephritis
 2 Amyloid
 1 FSGS without HIVAN
 1 Minimal change disease
 1 Acute renal failure related to indinavir
 1 IgA nephropathy
 1 Chronic pyelonephritis




                                              Szczech LA, et al. Kidney Int. 2004 Sep;66(3):1145-52.
HIV+ renal biopsy Findings
42 HIVAN
13 Immune complex GN
 8 Membranous nephropathy
 6 Diabetic glomerulopathy
 5 Membranoproliferative GN
 5 Hypertensive nephrosclerosis                                                     HIVAN
                                                                                     47%
                                                Non-HIVAN
 3 Interstitial nephritis
                                                   53%
 2 Amyloid
 1 FSGS without HIVAN
 1 Minimal change disease
 1 Acute renal failure related to indinavir
 1 IgA nephropathy
 1 Chronic pyelonephritis




                                              Szczech LA, et al. Kidney Int. 2004 Sep;66(3):1145-52.
HIV+ renal biopsy Findings                                    Non-HIVAN vs HIVAN
42 HIVAN
                                                 White                   5% vs       0%
13 Immune complex GN
                                                 Hepatitis B           27% vs 10%
 8 Membranous nephropathy
                                                 Hepatitis C           61% vs 41%
 6 Diabetic glomerulopathy
 5 Membranoproliferative GN                      Higher CD4            287 vs 187
 5 Hypertensive nephrosclerosis                                                      HIVAN
                                                Hypertension           51% vs       74%
                                                                                      47%
                                                Non-HIVAN
 3 Interstitial nephritis
                                                   53%
                                                 Lower Cr              2.6    vs 4.7
 2 Amyloid
 1 FSGS without HIVAN
 1 Minimal change disease
 1 Acute renal failure related to indinavir
 1 IgA nephropathy
 1 Chronic pyelonephritis




                                              Szczech LA, et al. Kidney Int. 2004 Sep;66(3):1145-52.
HIV+ renal biopsy Findings                                    Non-HIVAN vs HIVAN
42 HIVAN
                                                 White                   5% vs       0%
13 Immune complex GN
                                                 Hepatitis B           27% vs 10%
 8 Membranous nephropathy
                                                 Hepatitis C           61% vs 41%
 6 Diabetic glomerulopathy
 5 Membranoproliferative GN                      Higher CD4            287 vs 187
 5 Hypertensive nephrosclerosis                                                      HIVAN
                                                Hypertension           51% vs       74%
                                                                                      47%
                                                Non-HIVAN
 3 Interstitial nephritis
                                                   53%
                                                 Lower Cr              2.6    vs 4.7
 2 Amyloid
 1 FSGS without HIVAN
 1 Minimal change disease
 1 Acute renal failure related to indinavir
 1 IgA nephropathy
 1 Chronic pyelonephritis

“…[in] lesions other than HIVAN, the use of anti

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HIV and the Kidney 2009

  • 1. Joel M. Topf, MD Clinical Nephrologist St John Hospital 248.470.8163 http:pbfluids.blogspot.com
  • 2. HIV and the Kidney Joel M. Topf, MD Clinical Nephrologist St John Hospital 248.470.8163 http:pbfluids.blogspot.com
  • 3. HIV and the Kidney 2.0 Joel M. Topf, MD Clinical Nephrologist St John Hospital 248.470.8163 http:pbfluids.blogspot.com
  • 4.
  • 5.
  • 6.
  • 8. November 7, 1991 quot;I think we sometimes think only gay people can get it; it's not going to happen to me. And here I am saying that it can happen to anybody, even me, Magic Johnson.quot;
  • 9. 1995 Selik RM, et al. J AIDS 2002; 29: 378-387.
  • 10.
  • 11.
  • 12.
  • 13.
  • 14. Progression to ESRD Pre-HAART vs. HAART Era • JHHC – clinic-based, all HIV positive – N = 3,876 • ALIVE – community-based, all IDU, both HIV positive and negative – N = 2,379 • Median age: 37 y • Female: 32% • IDU: 70% • HIV negative: 28% • Log HIV RNA: 4.4 (median value) • CD4: 287 (median value)
  • 15. Occurrence rate Univariate RR Adjusted RR* Outcome (per 1000 PYs) (95% CI) (95% CI) Incidence of chronic kidney disease Pre-HAART era 22.2 1.0 1.0 HAART era 16.0 0.72 (0.55-0.94) 0.64 (0.49-0.85) Death with chronic kidney disease prior to dialysis Pre-HAART era 8.6 1.0 1.0 HAART era 5.8 0.67 (0.44-1.04) 0.54 (0.35-0.84) Period prevalence of chronic kidney disease Pre-HAART era 47.7 1.0 1.0 HAART era 69.3 1.45 (1.11-1.90) 1.37 (1.05-1.80) Incident ESRD/RRT Pre-HAART era 5.9 1.0 1.0 HAART era 9.4 1.59 (0.98-2.59) 1.46 (0.89-2.37) Incident ESRD/RRT or death with chronic kidney disease prior to dialysis Pre-HAART era 14.6 1.0 1.0 HAART era 15.3 1.05 (0.76-1.44) 0.91 (0.66-1.25) *Adjusted for age and AIDS status Lucas, et al. CROI 2007 poster #829.
  • 16. Compared to the uninfected ESRD was 7x more likely w i t hou t AIDS a nd 16x more likely w ith AIDS
  • 17. ESRD increased 20% in the HAART era des pi t e s i g n i fi c an t decrease in incident CKD
  • 18. are the increased renal, hepatic and cardiac disease due to drugs or bugs?
  • 19.
  • 20.
  • 21. 1995 to 2001: admission rate for cardio- or cerebro-vascular disease fell from 1.7 to 0.9 admits per 100 patient years
  • 22. 1995 to 2001: the death rate fell from 21.3 to 5.0 per 100 patient years
  • 23.
  • 24.
  • 25.
  • 26.
  • 27. the adjusted relative risk of a myocardial infarction was 1.15 / year of exposure to protease inhibitors
  • 28.
  • 29. • patients with CD4 > 350 were enrolled • randomized to – continuous HAART (viral suppression group) – interrupted HAART, drug vacation when CD4 > 350 and resumption when CD4 less than 250 until CD4 is over 350 • Open label • end-point: OI or death • power analysis indicated the study would last 6 years to accrue 910 end- points
  • 30.
  • 32.
  • 33.
  • 34.
  • 35. the specific way that drugs are used can determine the outcome don’t trust the rearview mirror
  • 36.
  • 37.
  • 38. Freq of HIV at initiation of dialysis 0 0.01 0.02 0.03 0.04 0.05 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
  • 39.
  • 40. HIVAN • first readily identified renal manifestation of HIV • rapidly progressing renal failure • heavy proteinuria • usually – low CD4 – high viral load • BP tends to be low • large echogenic kidneys 31
  • 41.
  • 42.
  • 43.
  • 44. HIVAN. a black person disease. • United States – African Americans 12.2 times more likely to develop HIVAN than whites – Among those with ESRD secondary to HIV/AIDS: 88.4% African American • Europe – France: 97/102 with HIVAN were black – London 17/17 with HIVAN were black – Switzerland 239 autopsies with dx of AIDS • 1 case of HIVAN in a black individual
  • 45. The only cause or ESRD more associated with African descent is Sickle Cell Anemia
  • 48. HIVAN Pathophysiology HIV-1 • HIV infects podocytes • HIV infects tubular epithelial cells – Loss of differentiation markers – Loss of differentiation markers – Loss of foot processes – Apoptosis – Immature forms of collagen are expressed – Proliferation Capillary loop collapse Tubular degeneration and regeneration and microcyst formation
  • 49. the epidemiology is in doubt • HIVAN is found in 40-60% of renal biopsies done for cause • Autopsy study of organs from HIV- infected persons in Texas found that the overall prevalence of HIVAN was 6.9% • Screening protocols for HIVAN based on biopsies in HIV-infected patients with >1.5 g/day of proteinuria have found an overall prevalence of 3.5%. Shahinian V, Rajaraman S, et al. Am J Kidney Dis. 2000; 35(5):884-8 Ahuja TS, Borucki M, et al. Am J Nephrol. 1999 19(6):655-9
  • 50. Kidney International 2006; 69: 2243-2250. 615 HIV+ Black South Africans No proteinuria + Proteinuria 577 (94%) 38 (6%) 90 patients tested for 487 No further 10 lost to follow-up 23 kidney biopsies Microalbumin testing 5 refused consent for biopsy 32 had Microalbuminuria 19 HIVAN 36% 7 had persistant microalbuminuria (8%) 7 kidney biopsies 6 HIVAN
  • 51. Kidney International 2006; 69: 2243-2250. 615 HIV+ Black South Africans No proteinuria + Proteinuria 577 (94%) 38 (6%) 90 patients tested for 487 No further 10 lost to follow-up 23 kidney biopsies Microalbumin testing 5 refused consent for biopsy 32 had Microalbuminuria 19 HIVAN 36% 83% 7 had persistant microalbuminuria (8%) 7 kidney biopsies 6 HIVAN
  • 52. Kidney International 2006; 69: 2243-2250. 615 HIV+ Black South Africans No proteinuria + Proteinuria 577 (94%) 38 (6%) 90 patients tested for 487 No further 10 lost to follow-up 23 kidney biopsies Microalbumin testing 5 refused consent for biopsy 32 had Microalbuminuria 19 HIVAN 36% 83% 7 had persistant microalbuminuria (8%) 7 kidney biopsies 6 HIVAN
  • 53. Kidney International 2006; 69: 2243-2250. 615 HIV+ Black South Africans No proteinuria + Proteinuria 577 (94%) 38 (6%) 90 patients tested for 487 No further 10 lost to follow-up 23 kidney biopsies Microalbumin testing 5 refused consent for biopsy 32 had Microalbuminuria 19 HIVAN 36% 83% 7 had persistant microalbuminuria (8%) 7 kidney biopsies 6 HIVAN
  • 54. Kidney International 2006; 69: 2243-2250. 615 HIV+ Black South Africans No proteinuria + Proteinuria 577 (94%) 38 (6%) 90 patients tested for 487 No further 10 lost to follow-up 23 kidney biopsies Microalbumin testing 5 refused consent for biopsy 32 had Microalbuminuria 19 HIVAN 36% 83% 7 had persistant microalbuminuria (8%) 7 kidney biopsies 6 HIVAN 86%
  • 55. Diagnosis: Size doesn’t matter HIVAN No HIVAN Ave. Length 11.3 cm 11.5 cm Sensitivity (>12 cm) 28% (12-49) Specificity (>12 cm) 75% (58-88) PPV (>12 cm) 44% (20-70) NPV (>12 cm) 60% (44-74)
  • 57. 0 I III II
  • 59. Diagnosis: echodensity does Operating Characteristic Grade II/III Grade III Sensitivity 96% (80-100) 40% (21-61) Specificity 28% (12-49) 95% (82-99) PPV 57% (41-72) 83% (52-98) NPV 95% (75-100) 70% (55-82)
  • 60. Diagnosis: echodensity does Operating Characteristic Grade II/III Grade III Sensitivity 96% (80-100) 40% (21-61) Specificity 28% (12-49) 95% (82-99) PPV 57% (41-72) 83% (52-98) NPV 95% (75-100) 70% (55-82)
  • 61. Treatment: ART/HAART Nagajothi, et al. ASN 2005. Renal Week. Philadelphia, PA Abstract #TH-FC041. Lucas GM, et al. AIDS 2004; 20:541-546.
  • 62. Treatment: Steroids Eustace JA, et al. Kidney International (2000) 58, 1253–1260;
  • 63. Schwartz EJ. J Am Soc Nephrol 16: 2412-2420, 2005.
  • 64. Schwartz EJ. J Am Soc Nephrol 16: 2412-2420, 2005.
  • 65. Hispanic 18% African American 50% White 30% Race/ethnicity of persons (including children) with HIV/AIDS diagnosed during 2004 (N = 38,730) CDC. HIV/AIDS Surveillance Report, 2004. Vol. 16. Atlanta: US16: 2412-2420, 2005. Schwartz EJ. J Am Soc Nephrol Department of Health and Human Services, CDC: 2005:1–46.
  • 66. The changing nature of HIV renal disease • Other HIV Nephropathies • Importance and frequency of proteinuria • Drug induced toxicity
  • 67. HIV+ renal biopsy Findings 42 HIVAN 13 Immune complex GN 8 Membranous nephropathy 6 Diabetic glomerulopathy 5 Membranoproliferative GN 5 Hypertensive nephrosclerosis 3 Interstitial nephritis 2 Amyloid 1 FSGS without HIVAN 1 Minimal change disease 1 Acute renal failure related to indinavir 1 IgA nephropathy 1 Chronic pyelonephritis Szczech LA, et al. Kidney Int. 2004 Sep;66(3):1145-52.
  • 68. HIV+ renal biopsy Findings 42 HIVAN 13 Immune complex GN 8 Membranous nephropathy 6 Diabetic glomerulopathy 5 Membranoproliferative GN 5 Hypertensive nephrosclerosis HIVAN 47% Non-HIVAN 3 Interstitial nephritis 53% 2 Amyloid 1 FSGS without HIVAN 1 Minimal change disease 1 Acute renal failure related to indinavir 1 IgA nephropathy 1 Chronic pyelonephritis Szczech LA, et al. Kidney Int. 2004 Sep;66(3):1145-52.
  • 69. HIV+ renal biopsy Findings Non-HIVAN vs HIVAN 42 HIVAN White 5% vs 0% 13 Immune complex GN Hepatitis B 27% vs 10% 8 Membranous nephropathy Hepatitis C 61% vs 41% 6 Diabetic glomerulopathy 5 Membranoproliferative GN Higher CD4 287 vs 187 5 Hypertensive nephrosclerosis HIVAN Hypertension 51% vs 74% 47% Non-HIVAN 3 Interstitial nephritis 53% Lower Cr 2.6 vs 4.7 2 Amyloid 1 FSGS without HIVAN 1 Minimal change disease 1 Acute renal failure related to indinavir 1 IgA nephropathy 1 Chronic pyelonephritis Szczech LA, et al. Kidney Int. 2004 Sep;66(3):1145-52.
  • 70. HIV+ renal biopsy Findings Non-HIVAN vs HIVAN 42 HIVAN White 5% vs 0% 13 Immune complex GN Hepatitis B 27% vs 10% 8 Membranous nephropathy Hepatitis C 61% vs 41% 6 Diabetic glomerulopathy 5 Membranoproliferative GN Higher CD4 287 vs 187 5 Hypertensive nephrosclerosis HIVAN Hypertension 51% vs 74% 47% Non-HIVAN 3 Interstitial nephritis 53% Lower Cr 2.6 vs 4.7 2 Amyloid 1 FSGS without HIVAN 1 Minimal change disease 1 Acute renal failure related to indinavir 1 IgA nephropathy 1 Chronic pyelonephritis “…[in] lesions other than HIVAN, the use of anti

Editor's Notes

  1. Methods: AA participants in 2 Baltimore-based cohort studies were included in this analysis: the
  2. Johns Hopkins HIV Cohort, a clinic-based cohort of HIV(+) participants, and the ALIVE study, a
  3. community-based cohort of HIV(-) and HIV(+) injection drug users. ESRD/RRT was determined by
  4. matching participant identifiers with the US Renal Data System. Standardized incidence ratios (SIR)
  5. and poison regression were used to compare to age-matched AA in the general population and to
  6. assess for temporal trends, respectively. We compared ESRD/RRT trends with those of chronic
  7. kidney disease (CKD) incidence and prevalence. CKD was defined as GFR<60ml/min/1.73m2 for > 3
  8. months.
  9. Results: RRT was initiated in 24 HIV(-) subjects during 13,415 person-years (PY) of follow-up, 51
  10. HIV(+) participants without AIDS during 10,780 PY, and 125 participants with AIDS during 9,833 PY,
  11. corresponding to SIRs of 2.3 (95% CI 1.5-3.4), 6.9 (95% CI 5.1-9.0), and 16.1 (95% CI 13.4-19.2),
  12. respectively. In HIV(+) African American participants RRT incidences were 5.8 and 9.7 per 1,000 PY
  13. in the pre-HAART and HAART eras, respectively (adjusted incidence rate ratio 1.2, 95% 0.8-1.9). In
  14. supplementary analyses, we found that, while CKD incidence declined significantly in the HAART era
  15. compared to the pre-HAART era, CKD period prevalence increased.
  16. Conclusions: The ESRD/RRT rate is high in HIV(+) AAs and has not decreased appreciably in this
  17. cohort with the widespread use of HAART. While CKD incidence has declined significantly in the
  18. HAART era, CKD prevalence has increased as patients live longer.
  19. In this population the incidence of CKD is decreasing. TDF use is increasing.
  20. VA study which raised the question does haart reduce mortality despite increasing metabolic abnormalities
  21. retrospective study
  22. 36,766 who received care at VA from 93-2001
  23. DAD study prospective observational of 23,000 11 cohorts europe and NA
  24. looked at association of AMI and exposure to nonNucs and PIs
  25. better vetted events than VA study
  26. Average GFR > 100
  27. CD4 250
  28. No patients on ART
  29. No outcome data