Low prevalence of end-stage kidney disease in European HIV patients

The prevalence of end-stage renal disease among HIV-positive patients in Europe is low, investigators report in an advance online publication in the Journal of Acquired Immune Deficiency Syndromes.

Only 0.5% of patients had irreversible kidney damage requiring dialysis or transplant. Most of the patients were young, black men. Only a third of patients on dialysis were considered candidates for a kidney transplant. The most common reason for exclusion was poor control of HIV.

Since the introduction of effective antiretroviral therapy in the mid-1990s, the prognosis of HIV-positive patients in Europe has improved dramatically. The prognosis of many patients is now considered normal. However, end-stage organ disease is becoming an increasingly important cause of serious illness and death in HIV-positive individuals.

Information about end-stage kidney disease in HIV-positive patients in Europe is currently sparse.

Investigators from the EuroSIDA cohort study therefore undertook a cross-sectional study to determine the prevalence and characteristics of end-stage renal disease among HIV-positive patients in Europe.

Information was obtained from 41 clinics which provided care to 62, 306 patients.

Overall prevalence of end-stage kidney disease was low at just 0.46% (number = 122). Most  patients (76%) were receiving dialysis. However, there were regional differences. Prevalence was highest in Northern Europe (0.8%), and lowest in Eastern Europe (0.13%). The investigators suggest that this difference in prevalence could be due to the availability of dialysis, different risk factors, “or it could be a consequence of differences in survival and access to HIV-related care, and competing risks for HIV associated mortality and morbidity.”

The patients had a median age was 47 years and the majority (73%) were men of black race (53%). The median duration of HIV infection was eleven years, and a third of patients had received an AIDS diagnosis.

However, current control of HIV infection was good. Almost all (94%) of patients were taking antiretroviral therapy, 88% had a viral load below 500 copies/ml and the median CD4 cell count was 341 cells/mm³.

There was a high prevalence of other serious illnesses, and 23 patients were co-infected with hepatitis C virus, 13 with hepatitis B virus, and two with both.

HIV associated nephropathy was the most common cause of serious kidney disease and was present in 46% of patients. The prevalence of nephropathy was significantly higher in black patients than those of white race (67% vs. 22%, p  = 0.003).

Hemodialysis was used in 109 (93%) of patients. The majority of dialysis patients (75%) were receiving erythropoietin for the treatment of anaemia.

Thirty (34%) of the patients on dialysis were reported to be on the waiting list for a kidney transplant. However, 58 patients were excluded from consideration for a transplant.

Poor control of HIV (a low CD4 cell count or detectable viral load) was the reason for 22% of patients, and 21% were excluded because of cardiovascular disease or diabetes. However, two patients were excluded because their clinics reported that transplant was contraindicated because of HIV. The investigators emphasise that this is no longer the case. Guidelines such as those of the British HIV Association have a transplant criteria of a CD4 cell count above 200 cells/mm³ and an undetectable viral load.

A total of 26 patients had had a kidney transplant. Rejection was reported in eight (30%) patients. Survival information was available for 25 patients. All were still alive, the median duration of survival post transplant being 2.4 years.

“This is the first multinational cross-sectional study among end-stage renal disease patients with HIV infection in Europe. The overall prevalence…was low”, note the investigators.