Renai Impairment

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 
   

Find out more about causes of RI or about risk factors for the development of RI.

• 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:

• aging
• comorbidities (including high blood pressure, diabetes, and hyperlipidemia)
• adverse effects of ARV drugs.⁷
• poor quality of life.¹⁰ 
   

References

1. 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.
2. Elewa U, Sandri AM, Rizza SA, Fervenza FC. Treatment of HIV-associated nephropathies. Nephron Clin Pract. 2011;118:c346–354.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10. 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.