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End-Stage Renal Disease Up in Whites,
Down in Blacks in 22-Year German Study
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19th Conference on Retroviruses and Opportunistic Infections, March 5-8, 2012, Seattle
Mark Mascolini
Incidence of end-stage renal disease (ESRD) rose from 1989 through 2010 among white patients in the Frankfurt HIV Cohort Study, but incidence fell among blacks over the same years [1]. Still, black race independently raised the risk of ESRD. Mortality with ESRD fell after the advent of combination antiretroviral therapy (cART)
Renal disease remains a common and serious complication of HIV infection in the current cART era. A US study of 284 people with chronic kidney disease found that 100 (35%) went on to ESRD [2]. Compared with whites, African Americans had a doubled risk of newly diagnosed chronic kidney disease over an average 4.5 years of follow-up (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.2 to 2.8). Once chronic kidney disease developed, African Americans had almost an 18 times higher risk of ESRD (HR 17.7, 95% CI 2.5 to 127.0).
Because data on ESRD in HIV-positive people in Europe remains limited, especially among blacks, Markus Bickel (Goethe University, Frankfurt) and colleagues undertook this 22-year review of the Frankfurt HIV Cohort Study. They divided the study period into the pre-cART era (1989-1996), the early-cART era (1997-2003), and the late-cART era (2004-2010).
The analysis included 9198 HIV-positive people in the Frankfurt Cohort, 39 of whom had ESRD. Among people with ESRD, age at HIV diagnosis averaged 35.7 years, 32 (82%) were men, 29 (74%) were white, and 10 (26%) were black. Thirteen people with ESRD (33%) acquired HIV while injecting drugs. Fifteen people (38.5%) had HCV coinfection and 5 (13%) HBV coinfection. Mortality was 2550.5 per 10,000 patient-years among people with ESRD versus 258.8 in the entire Frankfurt cohort (P < 0.000001).
ESRD incidence fell in blacks over the three study periods, from 788.8 per 100,000 person-years in 1989-1996 to 130.5 in 1997-2003 and 164.1 in 2004-2010. Over the same three periods ESRD incidence rose among whites from 29.9 to 41.0 to 43.4 per 100,000 person-years. ESRD prevalence rose over time and reached 1.9 per 1000 patients in 2010.
ESRD mortality fell nonsignificantly from 1989-1996 to 1997-2003 (relative risk [RR] 0.72, P = 0.52), but the drop from 1989-1996 to 2004-2010 was significant (RR 0.24, P = 0.006). In Frankfurt Cohort members without ESRD, mortality dropped significantly across all three study periods. Kaplan-Meier estimates of survival with ESRD showed an overall trend to longer survival over time (P = 0.069). But ESRD raised the risk of death almost 10 times (RR 9.9, 95% CI 6.3 to 14.5, P < 0.0001).
Multivariate analysis identified two independent predictors of incident ESRD. Black race compared with white race inflated the risk more than 6 times (RR 6.68, 95% CI 2.82 to 14.83, P < 0.00001). And injection drug use raised the risk 5 times (RR 4.99, 95% CI 1.42 to 16.87, P < 0.02). Variables that did not affect ESRD risk in this analysis were gender, AIDS, or hepatitis B or C.
Because of longer survival with HIV, the Frankfurt group concluded, ESRD prevalence is rising. But ESRD remains strongly associated with high mortality. The decline in ESRD incidence in blacks but not whites suggested to the investigators that ESRD has a different pathogenesis in these groups.
References
1. Bickel M, Stephan C, Nisius G. ESRD and dialysis in HIV+ patients--observations from a long-term cohort study with 22 years of follow-up. 19th Conference on Retroviruses and Opportunistic Infections. March 5-8, 2012. Seattle. Abstract 867. http://www.retroconference.org/2012b/PDFs/867.pdf.
2. Lucas GM, Lau B, Atta MG, Fine DM, Keruly J, Moore RD. Chronic kidney disease incidence, and progression to end-stage renal disease, in HIV-infected individuals: a tale of two races. J Infect Dis. 2008;197:1548-1557. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2553209/?tool=pubmed.
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