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Serious clinical events [SCE] in HIV-positive persons with chronic kidney disease. Modifiable Risk Factors
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AIDS 2019
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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.
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.
a diagnosis of diabetes contributed between 6.4 and 11.5% of all CVD and death events after CKD. A striking 34.9% of deaths and 13.5% of other AIDS events in persons with CKD may have been avoided with optimal HIV-status. An eGFR less than 30 ml/min per 1.73 m2 or less attributed to 7-13% of all deaths, and finally, between 9.9 and 19.3% of deaths and CVD could potentially have been avoided by reducing dyslipidaemia.
Abstract
Objectives:
Predictors of chronic kidney disease (CKD) amongst HIV-positive persons are well established, but insights into the prognosis after CKD including the role of modifiable risk factors are limited.
Design:
Prospective cohort study.
Methods:
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 serious clinical events (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. Poisson regression models considered associations between SCE and modifiable risk factors.
Results:
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.
Conclusion:
In an era where many HIV-positive persons require less monitoring because of efficient antiretroviral treatment, persons with CKD carry a high burden of SCE. Several potentially modifiable risk factors play a central role for CKD-related morbidity and mortality.
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