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Confirmed kidney deficit tied to rising cardiovascular disease incidence in D:A:D......."need intensified monitoring for all types of emerging cardiovascular disease, in particular in older individuals with continuously low eGFR levels, and cincreased focus on applying different renal and cardiovascular preventive measures in HIV-positive persons"
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CROI 2015, February 23-26, 2015, Seattle, Washington
from Jules: see Figures 2 & 3 below indicating the link between decreasing kidney function as represented by eGFR and increasing risk for cardiovascular disease (CVD)
AUTHORS CONCLUDE: These findings highlight the need for an intensified monitoring for all types of emerging CVD, in particular in older individuals with continuously low eGFR levels, and calls for an increased focus on applying different renal and cardiovascular preventive measures in HIV-positive
persons
Mark Mascolini
Confirmed impaired kidney function predicted development of cardiovascular disease in the D:A:D Study group [1]. Cardiovascular disease developed in 1 in 4 people with a confirmed baseline estimated glomerular filtration rate (eGFR) below 30 mL/min, compared with fewer than 1 in 50 people with a confirmed baseline eGFR above 90 mL/min. The findings confirm the long-established association between kidney function and heart disease in the general population.
D:A:D investigators observed that most previous studies of kidney function and cardiovascular disease in people with HIV relied on unconfirmed individual measures of renal function. To remedy that shortcoming, they conducted this analysis in D:A:D Study members who had two or more eGFRs after January 1, 2004 and follow-up to a first cardiovascular event, death, the last study visit plus 6 months, or January 2, 2013, whichever came first. D:A:D tracks antiretroviral-treated people in 11 cohorts across Europe, Australia, and the United States.
The D:A:D team defined cardiovascular disease as centrally validated myocardial infarction, stroke, coronary angioplasty, bypass, or carotid endarterectomy. They used Kaplan-Meier methods to explore time to cardiovascular disease in four eGFR strata: above 90 mL/min, 60 to 90 mL/min, over 30 to 60 mL/min, and at or below 30 mL/min. The researchers used Poisson regression stratified by confirmed current eGFR to model incidence rate ratios of cardiovascular disease in analyses adjusted for patient demographics, antiretroviral therapy, and traditional HIV, cardiovascular and kidney risk factors.
This study involved 34,793 people with a median 6.3 years of follow-up (interquartile range IQR 4.1 to 7.9). During that time cardiovascular disease developed in 1033 people who had 1251 cardiovascular events to yield an incidence of 5.1 per 1000 person-years (meaning 5 of every 1000 people had new-onset cardiovascular disease every year).
People with new cardiovascular disease were predominantly men (87.6% versus 73.9% without cardiovascular disease), white (53.2% versus 48.2%), and men who have sex with men (53.4% versus 45.8%). Median baseline age in people with a new cardiovascular event stood at 51 years (versus 41 in people without cardiovascular disease) and median CD4 count at 440. Almost three quarters with new cardiovascular disease (71.7%) had a baseline viral load below 400 copies, 50.7% smoked, 20.8% had hypertension, and 13% had diabetes. While 47% had a baseline eGFR above 90 mL/min, 52.3% lay in the 30-to-90 range and 0.8% at or below 30.
The proportion of study participants with a fatal cardiovascular event rose form 8.4% in people with a confirmed current eGFR above 90 mL/min to 29.4% in those with a confirmed current eGFR at or below 30 mL/min. Incident cardiovascular disease in 5 years of follow-up rose in a stepwise fashion from 1.7% in people with a confirmed baseline eGFR above 90 mL/min to 23.4% in those with a baseline eGFR at or below 30 mL/min.
When the D:A:D researchers divided confirmed current eGFR into 10-mL/min increments (starting with above 90 and ending with at or below 30), univariate analysis showed a steady rise in cardiovascular disease incidence rate ratio (IRR) from about 90 mL/min (IRR 1.0, the reference value) to at or below 30 mL/min (IRR above 10). Adjusting the analysis for age attenuated the impact of confirmed current eGFR on cardiovascular event incidence, though a current eGFR of 30 to 40 mL/min or below 30 mL/min (compared with above 90 mL/min) remained independently associated with cardiovascular event incidence. Adjusting the analysis for all other traditional and HIV-related variables considered further attenuated the impact of confirmed current eGFR on cardiovascular event incidence; now only a baseline eGFR at or below 30 mL/min predicted a cardiovascular event.
"In a large contemporary cohort of HIV-positive persons," the D:A:D investigators concluded, "we observed a strong relationship between baseline and current confirmed impaired renal function and incident cardiovascular disease." They proposed that their findings "highlight the need for an intensified monitoring for all types of emerging cardiovascular disease, in particular in older individuals with continuously low eGFR levels, and calls for an increased focus on applying different renal and cardiovascular preventive measures in HIV-positive persons."
Reference
1. Ryom L, Lundgren J, Reiss P, et al. Relationship between confirmed eGFR and cardiovascular disease in HIV-positive persons. CROI 2015. February 23-26, 2015. Seattle, Washington. Abstract 742.
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Reported by Jules Levin
Relationship Between Confirmed eGFR and Cardiovascular Disease in HIV-positive Persons
L Ryom1, JD Lundgren1, P Reiss2, M Ross3, CA Fux4, P Morlat5, O Moranne6, C Smith7, S de Wit8, A d'Arminio Monforte9,
W El Sadr10, M Law11, CA Sabin7 and A Mocroft7 for the D:A:D study group
* Adjusted for age, gender, race, HIV risk group, baseline date, enrolment cohort, HCV, HBV, diabetes, hypertension,
smoking, BMI, family history of CVD, CD4 nadir, CD4, HIV-VL, AIDS events within the past 12 months, all as time-updated
variables. In addition time-updated exposure to antiretrovirals fitted as cumulative (AZT, ddI, ddC, d4T, 3TC, FTC, TDF, ABC,
EFV, NVP, IDV, SQV, RTV, LPV, NFV, APV, ATV, DRV) and current (on and within last 6 months: AZT, ddI, ddC, 3TC, d4T,
FTC, TDF, ABC) exposure according to former D:A:D analyses
[FROM Jules: BUT these factors adjusted for are very present in many individuals with HIV thus emphasizing the concern about heart disease in HIV+; HCV & IDU could be included as well as risk factors]
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