Key considerations for people living with HIV
HIV-related renal impairment (RI) can present as acute renal failure (ARF) or chronic kidney disease (CKD), caused directly or indirectly by HIV and/or due to drug-related effects.1
- ARF may be associated with antiretroviral therapy (ART), or treatment for HIV- associated opportunistic infections.1
CKD disease can be caused by multiple pathophysiological mechanisms, including HIV-associated nephropathy (HIVAN).1
Find out more on the spectrum of kidney diseases in HIV-infected patients.2
In the HIV outpatient study (HOPS), the proportion of deaths involving renal disease significantly increased during the period from 1996 to 2004 (p=0.037) as deaths from AIDS declined with the introduction of effective antiretroviral therapy.3
Markers of kidney function are abnormal in up to 30% of HIV-infected patients.4 AIDS-related kidney disease has become a common cause of end stage renal disease (ESRD) requiring dialysis4, and kidney disease may be associated with hospitalisation, progression to AIDS and death.4,5
- Diabetes mellitus and hypertension are the commonest causes of CKD in the general population and the prevalence of these conditions is increasing in HIV-infected people.5
- Abnormal renal function has been shown to be an independent predictor of mortality in people living with HIV (PLWHIV).6
- The higher prevalence of RI in HIV-infected patients has been demonstrated in a study in which RI prevalence was higher in women, older patients (>50 years), and those with a low body mass index (BMI).7
- CKD occurs at an increased frequency and with accelerated progression in HIV-infected people of black race.5 HIVAN has been shown to occur primarily in patients of African descent, suggesting a genetic predisposition.1
- Exposure to certain ARV drugs such as indinavir and tenofovir may be associated with a higher RI prevalence in PLWHIV.7
although there are a number of studies that demonstrate an association of tenofovir with renal impairment,8 other studies have demonstrated no such association. The subject remains under investigation.1
A retrospective observational study in Europe found a 3% prevalence of CKD in PLWHIV. In this study CKD development was associated with:
- >50 years age
lower CD4 cell counts.9
ARVs may be directly nephrotoxic or may lead to changes in renal function by inducing metabolic vasculopathy and/or renal damage.1 The overall survival improvement of HIV-infected patients receiving ARVs leads to an increase in factors associated with deterioration in renal function – these include:
- comorbidities (including high blood pressure, diabetes, and hyperlipidemia)
- adverse effects of ARV drugs.7
poor quality of life.10
- Röling J, Schmid H, Fischereder M, Draenert R, Goebel FD. HIV-associated renal diseases and highly active antiretroviral therapy-induced nephropathy. Clin Infect Dis. 2006;42:1488–1495.
- Elewa U, Sandri AM, Rizza SA, Fervenza FC. Treatment of HIV-associated nephropathies. Nephron Clin Pract. 2011;118:c346–354.
- Palella FJ Jr, Baker RK, Moorman AC, et al. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. J Acquir Immune Defic Syndr. 2006;43:27–34.
- Gupta SK, Eustace JA, Winston JA, et al. Guidelines for the Management of Chronic Kidney Disease in HIV-Infected Patients: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2005;40:1559–1585.
- Winston J, Deray G, Hawkins T, Szczech L, Wyatt C, Young B. Kidney disease in patients with HIV infection and AIDS. Clin Infect Dis. 2008;47:1449–1457.
- Szczech LA, Hoover DR, Feldman JG, et al. Association between renal disease and outcomes among HIV-infected women receiving or not receiving antiretroviral therapy. Clin Infect Dis. 2004;39:1199–1206.
- Déti EK, Thiébaut R, Bonnet F, et al. Prevalence and factors associated with renal impairment in HIV-infected patients, ANRS C03 Aquitaine Cohort, France. HIV Med. 2010;11:308–317.
- Mocroft A, Kirk O, Reiss P, et al. Estimated glomerular filtration rate, chronic kidney disease and antiretroviral drug use in HIV-positive patients. AIDS. 2010;24:1667–1678.
- Colson AW, Florence E, Augustijn H, Verpooten GA, Lynen L, Gheuens E. Prevalence of chronic renal failure stage 3 or more in HIV-infected patients in Antwerp: an observational study. Acta Clin Belg. 2010;65:392–398.
- Boulware LE, Jaar BG, Tarver-Carr ME, Brancati FL, Powe NR. Screening for proteinuria in US adults: a cost-effectiveness analysis. JAMA. 2003;290:3101–3114.