While antiretroviral therapy has changed the paradigm for patients with HIV, these individuals still experience an increased risk for comorbid conditions, including kidney disease.

“Antiretroviral therapy (ART) has revolutionized the care of patients living with HIV,” notes Anthony Muiru, MD. “However, these gains are now being threatened by an increased risk for non-infectious comorbidities, including kidney diseases. Therefore, it is very important to understand the epidemiology of these non-infectious comorbidities to not lose gains on the improved life expectancy afforded by ART. There is a particular need to better understand risk factors for kidney disease, which remains a significant comorbid condition among people living with HIV.”

For a study published in HIV Medicine, Dr. Muiru and colleagues aimed to examine the epidemiology of acute kidney injury (AKI) among people with HIV in the setting of modern ART and to identify whether any trends have occurred in the decade between 2005 and 2015.

“We leveraged a long-standing HIV clinical cohort known as the Johns Hopkins HIV Clinical Cohort to conduct a retrospective analysis of patients receiving ART,” Dr. Muiru explains. “We then identified all incidences of hospitalized AKI and assessed associations of risk factors with incident AKI using multivariate Cox regression models.”

Investigators defined the ART index date as the enrollment date for patients currently taking ART and the earliest ART start date after enrollment for new users. Time between the ART index date and the first AKI event hospitalization served as the primary outcome.

Incidence of AKI Particularly High Among Black Patients

The researchers included 1,433 patients in their analysis, including 182 individuals with AKI and 1,251 without AKI. Baseline demographics varied between those with and without AKI; individuals with AKI were older than those without AKI at index (mean age, 46.7 vs 42.7) and more likely to self-identify as Black (N=91 vs N=73). Comorbid conditions, including diabetes mellitus, hypertension, COPD, and a history of AKI, among others, were all more common among individuals with AKI compared with those without AKI.

The incidence of AKI fluctuated annually, peaking at 40 per 1,000 person-years (95% CI, 22-69 per 1,000 person-years) in 2007 and reaching a nadir of 20 per 1,000 person-years (95% CI, 11-34 per 1,000 person-years) in 2010. After multivariable adjustment, characteristics independently associated with AKI included Black race (HR, 2.44; 95% CI, 1.42-4.20), hypertension (HR, 1.62; 95% CI, 1.09-2.38), dipstick proteinuria of greater than 1 (HR, 1.86; 95% CI, 1.07-3.23), history of AIDS (HR, 1.82; 95% CI, 1.29-2.56), a CD4 cell count of less than 200 cells/μL (HR, 1.46; 95% CI, 1.02-2.07), and lower serum albumin (HR, 1.73 per 1 g/dL decrease; 95% CI, 1.02-2.07).

“Previous studies show that treatment of HIV lowers the risk for AKI,” Dr. Muiru says. “Our study shows that physicians should screen for and aggressively treat non-HIV AKI risk factors, such as proteinuria and hypertension. The increased risk associated with Black race is likely a result of racism in our society and in medicine. It is unfortunate that even though the observation that racial disparities in health are due to social conditions produced by racism was first reported in the 19th century,  we are still struggling to address racism today. All physician readers should take initiatives to tackle racism, which is a root cause of racial disparities in health, including the increased risk we observed in this study.”

He also notes that the incidence of AKI did not change from year to year in the present study (Figure), which is a departure from studies conducted in the pre-ART era that demonstrated increased rates of AKI in people with HIV.

Current Tools & Unmet Needs for Those With HIV

“ART remain the cornerstone of HIV management,” says Dr. Muiru. “However, physicians should pay close attention to non-HIV risk factors for AKI, such as proteinuria and hypertension. We have excellent medicines, including angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, that supply all the tools we need to address these conditions.”

Future research should concentrate on determining gaps in care among people with HIV, Dr. Muiru continues, including how many patients receive guideline-concordant care such as screening and treatment for proteinuria and hypertension.

“Forthcoming studies should also identify interventions to address racial disparities in kidney disease among patients with HIV,” he says.

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