Risk of chronic kidney disease and cardiovascular disease in people with HIV should be assessed together

People with HIV should have their risk of cardiovascular disease (CVD) and chronic kidney disease (CKD) assessed together, results from the D:A:D study published in PLOS Medicine show. Investigators found that individuals with a high predicted risk for both CVD and CKD had a much greater risk of developing both CVD and CKD events, compared to people with a high predicted risk for CVD or CKD alone and people assessed as low risk for either morbidity.

“In this analysis we found that HIV-positive people with high predicted CVD or CKD risk were at significant risk for a future CVD or CKD event, and that this risk was multiplicative for those with greater degrees of risk,” comment the authors. “We observed a far higher CKD event rate for those at high risk of both CVD and CKD…the CKD event rate in those with a high CKD risk was highly sensitive to the degree of CVD risk.”

Improvements in treatment and care mean that many people living with HIV have a normal or near-normal life expectancy. However, there is accumulating evidence that HIV-positive individuals are more likely to develop diseases of ageing at an earlier age than their HIV-negative peers.

In the general population, there is a well-established connection between CKD and increased risk for CVD. Moreover, CVD is in turn associated with an elevated risk of CKD. A similar relationship between CKD and CVD risk has been reported in HIV-positive people.

Investigators from the D:A:D collaboration of eleven cohorts in Europe, the US, Argentina and Australia have developed HIV-specific risk models for CVD and CKD. Investigators  hypothesised that people enrolled in D:A:D with a high (5% or greater) five-year risk of both CVD and CKD would have especially high rates of events for both conditions.

They therefore designed a study involving 27,215 people who were in care between 2004 and 2015. The rates of CKD and CVD events were calculated according to five-years risk for these conditions (low = 1% and below; medium = 1-5%; high = above 5%). Analyses were conducted to see if CKD and CVD risk had a multiplicative effect on the incidence of events.

Participants contributed a total of 202,034 person-years of follow-up. Three-quarters were male and the median age at baseline was 42 years. Overall, 13% of people were assessed as having a high CVD risk, with 18% having a high CKD risk and 6% having a high risk for both morbidities.

Overall, the CKD event rate was 7 per 1000 person-years and CVD event rate was 4.5 per 1000 person-years.

People with a high risk of CVD had an almost six-fold (5.63; 95% CI, 4.47-7.09, p < 0.001) increase in their risk of a CKD event compared to low CVD-risk patients. People with a high CKD risk had significant increase in their risk of a CVD event compared to low-risk patients (1.31-fold; 95% CI, 1.09-1.56, p = 0.005).

“We found that both chronic diseases were associated with an elevated risk of the other,” comment the authors. “Overall, our results suggest that among people living with HIV, the association between CVD risk and a future CKD event is stronger than the association between CKD and a future CVD event.”

The conditions had a multiplicative effect for CVD. For people with a low risk of both CKD and CVD, the CVD event rate was just 0.45 per 1000 person-years, but for people with a high risk of both conditions, the CVD rate was 16.5 per 1000 years. 

“CVD and CKD risk in HIV-positive persons should be assessed together,” conclude the investigators. “These data also suggest that the primary prevention and effective management of those with comorbidities, prioritising those interventions that have been repeatedly shown to be effective in the general population, will convey the same if not greater benefits for the population of HIV-positive persons.” The researchers also recommend that prevention and management of co-morbidities should be incorporated into HIV treatment and care guidelines.