Serious clinical events in HIV-positive persons with chronic kidney disease (CKD). AIDS
Ryom et al. on behalf of the D:A:D study group aimed to investigate the disease spectrum and the prognosis after a diagnosis of chronic kidney disease (CKD) stage G3+ in people living with HIV (PLWH) with focus on the incidence of serious clinical events (SCE) and the role of modifiable risk factors.
D:A:D participants developing CKD (confirmed, >3 months apart, eGFR <= 60 ml/min per 1.73 m2 or 25% eGFR decrease when eGFR <= 60 ml/min per 1.73 m2) were followed to incident SCE; end stage renal and liver disease (ESRL and ESLD), cardiovascular disease (CVD), AIDS-defining and non-AIDS-defining malignancies (NADM), other AIDS or death, 6 months after last visit or 1 February 2016.
During 2.7 (IQR 1.1-5.1) years median follow-up, 595 persons with CKD (24.1%) developed a SCE [incidence rate 68.9/1000 PYFU (95% confidence interval 63.4-74.4)] with 8.3% (6.9-9.0) estimated to experience any SCE at 1 year. The most common SCE was death (12.7), followed by NADM (5.8%), CVD (5.6%), other AIDS (5.0%) and ESRD (2.9%). Crude SCE ratios were significantly higher in those with vs. without CKD, strongest for ESRD [65.9 (43.8-100.9)] and death [4.8 (4.3-5.3)]. Smoking was consistently associated with all CKD-related SCE. Diabetes predicted CVD, NADM and death, whereas dyslipidaemia was only significantly associated with CVD. Poor HIV-status predicted other AIDS and death, eGFR less than 30 ml/min per 1.73 m2 predicted CVD and death and low BMI predicted other AIDS and death.
In conclusion, this study shows that in an era where many PLWH require less monitoring because of effective and well tolerated ART, those living with even moderate levels of CKD have a high morbidity and mortality burden with almost one in three developing a SCE within just 5 years. Our data further suggest the modifiable risk factors smoking, dyslipidaemia, poor HIV-status, diabetes and low BMI in addition to eGFR less than 30 ml/min per 1.73 m2 play a central role for CKD-related morbidity, and highlight the need of increased monitoring, targeted interventions and focus on preventive measures for those living with both HIV and CKD.