Advanced chronic kidney disease, end-stage renal disease and renal death among HIV-positive individuals in Europe

Objectives: Knowledge about advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) in HIV-positive persons is limited. The aim of this study was to investigate incidence, predictors and outcomes for advanced CKD/ESRD and renal death.

Methods: Advanced CKD was defined as confirmed (two consecutive measurements ≥ 3 months apart) estimated glomerular filtration rate (eGFR) ≤ 30 mL/min/1.73 m(2) using Cockcroft-Gault, and ESRD as haemodialysis or peritoneal dialysis for ≥ 1 month or renal transplant. Renal death was death with renal disease as the underlying cause, using Coding Causes of Death in HIV (CoDe) methodology. Follow-up was from 1 January 2004 until last eGFR measurement, advanced CKD, ESRD or renal death, whichever occurred first. Poisson regression was used to identify predictors.

Results: Of 9044 individuals included in the study, 58 (0.64%) experienced advanced CKD/ESRD/renal death [incidence rate 1.32/1000 person-years of follow-up (PYFU); 95% confidence interval (CI) 0.98-1.66]; 52% of those who experienced the endpoint had a baseline eGFR ≤ 60 mL/min/1.73 m(2) compared with 3% of those who did not. Using Kaplan-Meier methods, at 6 years from baseline, 0.83% (95% CI 0.59-1.07%) were estimated to have experienced the endpoint overall and 11.26% (95% CI 6.75-15.78%) among those with baseline eGFR ≤ 60 mL/min/1.73 m(2) . Independent predictors of the endpoint included any cardiovascular event [incidence rate ratio (IRR) 2.16; 95% CI 1.24-3.77], lower eGFR (IRR 0.64 per 5 mL/min/1.73 m(2) ; 95% CI 0.59-0.70) and lower CD4 count (IRR 0.77 per doubling; 95% CI 0.62-0.95). One year after experiencing advanced CKD or ESRD, an estimated 19.21% (95% CI 7.84-30.58%) of patients had died, mostly from extra-renal causes.

Conclusions: The incidence of advanced CKD/ESRD/renal death was low and predictors included traditional renal risk factors, HIV-related factors and pre-existing renal impairment. The prognosis following advanced CKD/ESRD was poor. Larger studies should address possible contributions of specific antiretrovirals.