End-Stage Renal Disease Among HIV-Infected Adults in North America

Since the human immunodeficiency virus (HIV) epidemic began, several renal complications resulting from HIV infection of renal cells, immune dysregulation, and specific medications have been noted among individuals infected with HIV [1, 2]. The most severe of these, HIV-associated nephropathy (HIVAN), caused an estimated 35% of kidney lesions among HIV-infected patients biopsied during 1995–2004 [3] and was the fourth leading cause of end-stage renal disease (ESRD) among black individuals aged 20–64 years in 1994–1998 [4]. The incidence of HIVAN has declined with increased use of potent antiretroviral therapy (ART) [5–7]; however, there are other potential causes of ESRD in HIV-infected persons. Antiretroviral medications have renal effects including nephrotoxicity and stone formation [8]. Comorbidities such as diabetes mellitus, hypertension, and hepatitis C virus (HCV) infection are risk factors for progression to ESRD and are more common among HIV-infected persons [9–11]. Illicit drug use, which is more common among HIV-infected populations, also increases the risk of ESRD [12, 13]. Studies suggest that HIV-infected persons are more likely to experience ESRD than HIV-uninfected persons, with estimated incidence rates (IRs) in the US and Europe of 3–10 per 1000 person-years [14, 15] and 0.5 per 1000 PYs [16, 17], respectively, corresponding to a 2- to 20-fold greater risk compared with the general population. A large racial discrepancy has been noted in the burden of ESRD among HIV-infected and -uninfected individuals, with disproportionately higher risk borne by black individuals [17, 18]. Data from the United States Renal Data System (USRDS) indicated that the age- and sex-adjusted incidence of ESRD was approximately 3.4 times higher among blacks in the general population compared with whites in 2010 [19]. Whether reductions in the incidence of HIVAN have impacted the magnitude of the racial disparity in rates of ESRD among HIV-infected individuals is unknown. There is sparse information on the evolving face of ESRD in the HIV-infected population despite the significant burden of morbidity and mortality that ESRD presents [20–23]. Given the many potential contributors to ESRD risk, the goal of the present study was to assess the relative contributions of clinical and demographic factors to ESRD incidence and describe recent trends in ESRD risk in a cohort of HIV-infected individuals who are representative of HIV patients in care [24]. Our data, which include ESRD cases validated through an extensive medical record review of HIV-infected patients in clinical care through 2009, allowed us to capture changes in ESRD incidence concurrent with, and likely reflective of, modern therapy improvements. We hypothesized that well-documented improvements in HIV treatment in the modern therapy era have led to declines in risk of ESRD over this period, particularly among HIV-infected black individuals in care, given the diminishing role of HIVAN.