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Cardiovascular Disease (CVD) and Chronic Kidney Disease (CKD) Event Rates in HIV-positive Persons at high Predicted CVD and CKD Risk: Results from the D:A:D Study - Combining Heart and Kidney Risk Scores Improves Prediction in HIV Group
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Combining Heart and Kidney Risk Scores Improves Prediction in HIV Group
9th IAS Conference on HIV Science (IAS 2017), July 23-26, 2017, Paris
Mark Mascolini
Combining a cardiovascular disease (CVD) risk score and a chronic kidney disease (CKD) risk score improved prediction of CVD and CKD events in a 27,215-person analysis of D:A:D study members [1]. D:A:D investigators encouraged clinicians to combine the risk scores to predict heart and kidney problems.
The researchers noted that CKD (two estimated glomerular filtration rates [eGFRs] below 60 mL/min at least 3 months apart) independently predicts CVD (myocardial infarction, stroke, an invasive procedure, or sudden cardiac death). Conversely, CVD foreshadows CKD. D:A:D investigators developed separate CVD [2] and CKD [3] risk scores for people with HIV. They hypothesized that D:A:D participants with more than 5% CVD and CKD predicted risk "would be at multiplicative risk for CVD and CKD event outcomes."
The analysis focused on D:A:D members with data needed for the CVD and CKD risk equations.
All had an initial eGFR above 60 mL/min and two or more subsequent eGFRs. The researchers stratified 5-year risk into three groups: 1% or less, 1% to 5%, and more than 5%.
The study included 27,215 of 49,717 D:A:D participants (55%), 74.3% of them men, 49.5% current smokers, and 8.3% with a family history of CVD. Median age stood at 42 (interquartile range [IQR] 36 to 49), median CD4 count at 464 (IQR 319 to 650), and median eGFR at 100 mL/min (IQR 86 to 117).
The overall CKD event rate was 7.0 per 1000 person-years (95% confidence interval [CI] 6.6 to 7.7) and the overall CVD event rate 4.5 per 1000 person-years (95% CI 4.2 to 4.8). Being in a higher CKD risk stratum significantly predicted CKD events. Higher CVD risk also significantly predicted CKD events (at the following incidence rate ratios [IRR] and 95% CI):
-- CVD 1-5% vs <1%: IRR 2.70 (2.16 to 3.38), P < 0.001
-- CVD >5% vs <1%: IRR 5.63 (4.47 to 7.09), P < 0.001
Similarly, higher CVD risk significantly predicted CVD events, and higher CKD risk also predicted CVD events (but not as strongly as CVD risk predicted CKD events):
-- CKD 1-5% vs <1%: IRR 1.19 (1.01 to 1.44), P = 0.041
-- CKD >5% vs <1%: IRR 1.31 (1.09 to 1.56), P = 0.005
Poisson regression determined that predicted CKD and CVD risk had a multiplicative effect on both CKD events and CVD events. In other words, combining the prediction equations predicted events more accurately than using either separately.
Further analysis identified other clinical variables that independently predicted CKD events or CVD events after adjustment for CKD or CVD risk group. For CKD events those variables were total cholesterol (IRR 1.48, 95% CI 1.20 to 1.83, P < 0.001), cumulative protease inhibitor use (IRR 1.11, 95% CI 1.06 to 1.15, P < 0.001), cumulative NRTI use (IRR 1.05, 95% CI 1.03 to 1.08, P < 0.001), and higher current CD4 count (IRR 0.90, 95% CI 0.86, 0.95, P < 0.001). For CVD events the predictive variable was every 100-cell high nadir CD4 count (IRR 0.94, 95% CI 0.91 to 0.98, P = 0.002).
The D:A:D investigators believe their findings "suggest CVD and CKD risk in HIV-positive people should be assessed in tandem, and such risk factors treated."
References
1. Boyd MA, Mocroft A, Ryom L, et al. Cardiovascular disease (CVD) and chronic kidney disease (CKD) event rates in HIV-positive persons at high predicted CVD and CKD risk: results from the D:A:D study. 9th IAS Conference on HIV Science (IAS 2017), July 23-26, 2017, Paris. Abstract WEPEB0503.
2. Friis-Moller N, Ryom L, Smith C, et al. An updated prediction model of the global risk of cardiovascular disease in HIV-positive persons: the Data-collection on Adverse Effects of Anti-HIV Drugs (D:A:D) study. Eur J Prev Cardiol. 2016;23:214-223.
3. Mocroft A, Lundgren JD, Ross M, et al. Development and validation of a risk score for chronic kidney disease in HIV infection using prospective cohort data from the D:A:D study. PLoS Med. 2015;12e1001809.
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