End-Stage Kidney Disease and Transplantation in HIV Patients
End-Stage Kidney Disease and Transplantation in HIV Patients
Between January 2000 and December 2011, 28,630 patients received HIV care at the participating clinics. The median [interquartile range (IQR)] number of available creatinine measurements was 16 (5–30) and 18 (7–35) for those of black and white/other ethnicity, respectively (P < 0.0001). Median (IQR) follow-up was 6.4 (2.5–11.1) years, during which 1732 individuals (6.0%) died. During the study period, 117 UK CHIC participants received pRRT at the associated renal centers. Of these, 2 patients had not yet contributed data to the latest UK CHIC data set. The commonest renal diagnoses were HIV-associated nephropathy (HIVAN), present in 54 patients (46%), followed by immune complex kidney disease (n = 15), diabetic nephropathy (n = 13), and amyloidosis (n = 6).
The clinical characteristics of 115 ESKD cases (0.4%) present in the UK CHIC study data set and the 28,515 patients without ESKD are shown in Table 1. Patients with ESKD were more likely to be female, of black ethnicity, and to have acquired HIV heterosexually. At cohort entry, ESKD cases were older, had lower CD4 cell counts, and markedly worse renal function [median estimated glomerular filtration rate (eGFR), 22 mL·min·1.73 m]. During the study period, a steady increase in ESKD prevalence was observed among patients of black ethnicity {from 0.44% [95% confidence interval (CI): 0.25 to 0.78] in 2000/2001 to 1.09% (95% CI: 0.85 to 1.41) in 2010/2011, P = 0.008}, whereas the ESKD prevalence among those of white/other ethnicity remained stable [0.09% (95% CI: 0.05 to 0.17) to 0.15% (95% CI: 0.10 to 0.22), P = 0.87]. After adjusting for age, the prevalence of ESKD seemed to increase over time in those of black ethnicity [0.36% (95% CI: 0.18% to 0.65%) 2000/2001 to 1.35% (95% CI: 1.01 to 1.77) 2010/2011] but not in those of other ethnicities [0.09% (95% CI: 0.04 to 0.18) to 0.11% (95% CI: 0.07 to 0.17)]. Reflecting the risk associated with black ethnicity, a 4–5 fold higher ESKD incidence rate [1.14 (95% CI: 0.81 to 1.47) vs. 0.24 (95% CI: 0.16 to 0.32) per 1000 person-years for black vs. white/other patients] was observed in this population. For both patient groups, the incidence of ESKD remained unchanged throughout the study period.
From 2005 onwards, KT was increasingly used to treat ESKD. Before January 2005, 10 patients had died or became lost to follow-up. Of the 107 patients who received pRRT from 2005 onwards, 69 (64%) were considered suitable for KT, 30 (28%) were unsuitable for KT, and the status could not be confirmed for the remaining 8 patients. The reasons for not being suitable for KT were persistent HIV replication (n = 16), prior diagnosis of progressive multifocal leucoencephalopathy (n = 2), or the presence of medical comorbidities [liver, cardiovascular or urological disease, recent history of cancer, or general frailty (n = 10)]. Two patients declined to be considered for KT.
Of those suitable for KT, 34 (49%) had received a kidney allograft by December 2012 (10 from a live donor) after a median of 38.6 months (IQR, 17.1–54.7 months) since being deemed suitable for KT; the median follow-up after KT was 25.2 months (IQR, 12.8–56.9 months). The other 35 patients considered suitable for KT were being worked up for or awaiting KT; they had been followed up for a median of 35.8 months (IQR, 15.0–66.9 months) from the date of becoming suitable for KT. The clinical characteristics of patients awaiting KT (pre-KT) and those who received a KT (post-KT) are displayed in Table 1.
Figure 1 shows survival for the pre-KT and post-KT patients and for those who were unsuitable for KT. Survival pre-KT and post-KT was similar (Kaplan–Meier estimates of 100% and 94% at 1 year and 89% and 85% at 5 years, respectively, P = 0.53). As expected, survival for patients with comorbidities or persistent viremia who were thus ineligible for KT was significantly worse (83% at 1 year and 46% and 5 years, P < 0.0001).
(Enlarge Image)
Figure 1.
Kaplan–Meier plots showing survival of patients with ESKD, stratified by KT status. Follow-up was measured in years from the date patients became suitable for KT (pre-KT), received their first kidney allograft (post-KT), or initiated pRRT (unsuitable). Patients who underwent KT contributed time to both the pre-KT (with follow-up censored at the time of KT) and post-KT cohorts. Overall, P = 0.0001; pre-KT vs. post-KT, P = 0.55.
We reviewed the cART regimens of the 69 patients with ESKD who were suitable for KT (pre-KT or post-KT); 38 (55%) were on a protease inhibitor (PI) and 31 on non-PI (nonnucleoside/nucleotide reverse transcriptase inhibitor, nucleoside/nucleotide reverse transcriptase inhibitor, and/or integrase strand transfer inhibitor) containing cART at the most recent clinic visit. Lamivudine and abacavir were the commonest prescribed nucleoside/nucleotide reverse transcriptase inhibitor (in 74% and 51%, respectively) and darunavir and lopinavir the commonest prescribed PI (in 33% and 18%, respectively). Tenofovir and atazanavir were included in the cART regimen of 11 (16%) and 4 (6%) patients, respectively.
Results
Between January 2000 and December 2011, 28,630 patients received HIV care at the participating clinics. The median [interquartile range (IQR)] number of available creatinine measurements was 16 (5–30) and 18 (7–35) for those of black and white/other ethnicity, respectively (P < 0.0001). Median (IQR) follow-up was 6.4 (2.5–11.1) years, during which 1732 individuals (6.0%) died. During the study period, 117 UK CHIC participants received pRRT at the associated renal centers. Of these, 2 patients had not yet contributed data to the latest UK CHIC data set. The commonest renal diagnoses were HIV-associated nephropathy (HIVAN), present in 54 patients (46%), followed by immune complex kidney disease (n = 15), diabetic nephropathy (n = 13), and amyloidosis (n = 6).
Prevalence and Incidence of ESKD
The clinical characteristics of 115 ESKD cases (0.4%) present in the UK CHIC study data set and the 28,515 patients without ESKD are shown in Table 1. Patients with ESKD were more likely to be female, of black ethnicity, and to have acquired HIV heterosexually. At cohort entry, ESKD cases were older, had lower CD4 cell counts, and markedly worse renal function [median estimated glomerular filtration rate (eGFR), 22 mL·min·1.73 m]. During the study period, a steady increase in ESKD prevalence was observed among patients of black ethnicity {from 0.44% [95% confidence interval (CI): 0.25 to 0.78] in 2000/2001 to 1.09% (95% CI: 0.85 to 1.41) in 2010/2011, P = 0.008}, whereas the ESKD prevalence among those of white/other ethnicity remained stable [0.09% (95% CI: 0.05 to 0.17) to 0.15% (95% CI: 0.10 to 0.22), P = 0.87]. After adjusting for age, the prevalence of ESKD seemed to increase over time in those of black ethnicity [0.36% (95% CI: 0.18% to 0.65%) 2000/2001 to 1.35% (95% CI: 1.01 to 1.77) 2010/2011] but not in those of other ethnicities [0.09% (95% CI: 0.04 to 0.18) to 0.11% (95% CI: 0.07 to 0.17)]. Reflecting the risk associated with black ethnicity, a 4–5 fold higher ESKD incidence rate [1.14 (95% CI: 0.81 to 1.47) vs. 0.24 (95% CI: 0.16 to 0.32) per 1000 person-years for black vs. white/other patients] was observed in this population. For both patient groups, the incidence of ESKD remained unchanged throughout the study period.
Kidney Transplantation as a Treatment Modality for ESKD
From 2005 onwards, KT was increasingly used to treat ESKD. Before January 2005, 10 patients had died or became lost to follow-up. Of the 107 patients who received pRRT from 2005 onwards, 69 (64%) were considered suitable for KT, 30 (28%) were unsuitable for KT, and the status could not be confirmed for the remaining 8 patients. The reasons for not being suitable for KT were persistent HIV replication (n = 16), prior diagnosis of progressive multifocal leucoencephalopathy (n = 2), or the presence of medical comorbidities [liver, cardiovascular or urological disease, recent history of cancer, or general frailty (n = 10)]. Two patients declined to be considered for KT.
Of those suitable for KT, 34 (49%) had received a kidney allograft by December 2012 (10 from a live donor) after a median of 38.6 months (IQR, 17.1–54.7 months) since being deemed suitable for KT; the median follow-up after KT was 25.2 months (IQR, 12.8–56.9 months). The other 35 patients considered suitable for KT were being worked up for or awaiting KT; they had been followed up for a median of 35.8 months (IQR, 15.0–66.9 months) from the date of becoming suitable for KT. The clinical characteristics of patients awaiting KT (pre-KT) and those who received a KT (post-KT) are displayed in Table 1.
Figure 1 shows survival for the pre-KT and post-KT patients and for those who were unsuitable for KT. Survival pre-KT and post-KT was similar (Kaplan–Meier estimates of 100% and 94% at 1 year and 89% and 85% at 5 years, respectively, P = 0.53). As expected, survival for patients with comorbidities or persistent viremia who were thus ineligible for KT was significantly worse (83% at 1 year and 46% and 5 years, P < 0.0001).
(Enlarge Image)
Figure 1.
Kaplan–Meier plots showing survival of patients with ESKD, stratified by KT status. Follow-up was measured in years from the date patients became suitable for KT (pre-KT), received their first kidney allograft (post-KT), or initiated pRRT (unsuitable). Patients who underwent KT contributed time to both the pre-KT (with follow-up censored at the time of KT) and post-KT cohorts. Overall, P = 0.0001; pre-KT vs. post-KT, P = 0.55.
We reviewed the cART regimens of the 69 patients with ESKD who were suitable for KT (pre-KT or post-KT); 38 (55%) were on a protease inhibitor (PI) and 31 on non-PI (nonnucleoside/nucleotide reverse transcriptase inhibitor, nucleoside/nucleotide reverse transcriptase inhibitor, and/or integrase strand transfer inhibitor) containing cART at the most recent clinic visit. Lamivudine and abacavir were the commonest prescribed nucleoside/nucleotide reverse transcriptase inhibitor (in 74% and 51%, respectively) and darunavir and lopinavir the commonest prescribed PI (in 33% and 18%, respectively). Tenofovir and atazanavir were included in the cART regimen of 11 (16%) and 4 (6%) patients, respectively.
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