by Jeffrey T. Kirchner, DO, AAHIVS, AAHIVM Chief Medical Officer

September 17, 2019

Featured Literature:

Ryom, al. for the D:A:D study group. Serious clinical events in HIV-positive persons with chronic kidney disease. AIDS: August 2, 2019. Published ahead of print – Issue – p doi: 10.1097/QAD.0000000000002331

As the HIV population ages, chronic kidney disease (CKD) along with other comorbidities have become highly prevalent among PLWH. Clinical predictors of CKD including diabetes mellitus and hypertension are well-established, however clinical information regarding prognosis after the onset of CKD is limited with most data coming from non-HIV patients.  This prospective study from the D:A:D cohort included 595 persons with CKD (eGFR < 60 orwho sustained a 25% decrease in eGFR if they were already < 60 at baseline). The subjects were followed for a median of 3 years until they had a serious clinical event (SCE).  These events included end-stage renal disease, liver disease, CVD, AIDS and non-AIDS malignancies, other AIDS-defining condition, or death.  During follow-up which ranged from 1 to 5 years, 24% developed at least one SCE with 8% estimated to experience a SCE event by one year following a diagnosis of CKD. The most SCEs were death (13%), non-AIDS malignancy (6%), CVD (6%), other AIDS conditions (5%) and ESRD (3%).  Cigarette smoking had the strongest association with all SCEs while diabetes was most predictive of CVD, non-AIDS malignancy, and death. Dyslipidemia was only significantly associated with CVD. Having an eGFR of < 30 was highly predictive of CVD and death.

Author’s Commentary:

The D:A:D cohort continues to provide important, long-term observational data for HIV clinicians and researchers. As our patients age with HIV, chronic kidney disease will continue to be an important issue and it carries a large burden of serious clinical events as seen in this study. Regular monitoring of renal function, at least twice a year, is recommended for all persons living with HIV. Dosing adjustment or medication changes may need to be done based on GFR.  As with many other co-morbidities, smoking has a significant impact and from this study is the most important modifiable risk factor.

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