Associations between female birth sex and risk of chronic kidney disease development among people with HIV in the USA: A longitudinal, multicentre, cohort study

HIV and CKD in the Tenofovir Era: A Prospective Parallel-Group Cohort Study From Tanzania

Rationale & Objective

Longitudinal research on chronic kidney disease (CKD) in sub-Saharan Africa is sparse, especially among people living with HIV (PLWH). We evaluated the incidence of CKD among PLWH compared with HIV-uninfected controls in Tanzania.

Study Design

Prospective cohort study.

Setting & Participants

A total of 495 newly diagnosed PLWH who initiated antiretroviral therapy (ART) and 505 HIV-uninfected adults enrolled from public HIV clinics and followed from 2016-2021. The control group was recruited from HIV treatment partners from the same HIV clinics.

Exposures

Untreated HIV (at baseline), ART, sociodemographic information, health behaviors, hypertension, and diabetes.

Outcomes

Incident CKD, defined as a follow-up estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2 with ≥25% reduction from baseline; annual eGFR change; incident albuminuria; 3-year all-cause mortality.

Analytical Approach

Multivariable Poisson and linear regression determined the association between HIV and other factors with a baseline prevalent reduced eGFR and albuminuria, incident CKD and albuminuria, and annual eGFR change. Cox hazard regression assessed the association between baseline CKD and mortality.

Results

Median age was 35 years and 67.5% were women. There were 101 incident CKD cases, 71 among PLWH and 30 among HIV-uninfected participants, equivalent to a CKD incidence of 57.9 per 1,000 person-years (95% CI, 44.4-71.4) and 26.2 per 1,000 person-years (95% CI, 16.8-35.5), respectively. PLWH had a more rapid eGFR decline (-6.65 vs -2.61 mL/min/1.73 m2 per year). Female sex and older age were positively associated with incident CKD. Albuminuria incidence did not differ by HIV status. PLWH with albuminuria at baseline had higher mortality (HR, 2.13; 95% CI, 1.08-4.21).

Limitations

As an observational cohort study, there was no comparison group of HIV-positive participants on a nontenofovir disoproxil fumarate-based ART regimen.

Conclusions

PLWH receiving tenofovir disoproxil fumarate-based ART had a very high incidence of CKD and rapid eGFR decline. Conversely, albuminuria stabilized with ART use. Expanding access to less-nephrotoxic ART, such as tenofovir alafenamide, is urgently needed throughout sub-Saharan Africa.

Burden of Kidney Disease in an Aging Population Living with HIV in the United States

Antiretroviral therapy (ART) has significantly improved mortality rates for individuals living with HIV, but kidney disease remains prevalent, especially among older adults. Our study analyzed the burden of kidney disease in individuals aged 65 and older at The Miriam Hospital Immunology Center in Rhode Island. We calculated estimated glomerular filtration rates using the last creatinine values from 2019 and identified chronic kidney disease (CKD) stages. Results showed a 19% prevalence of moderate or severe CKD among adults living with HIV, rising to 39% for those aged 75 and older. Particularly striking was the increased prevalence among African American adults aged 65+, at 30.4%, rising to 50% for those over 75. In comparison, the National Institute of Diabetes and Digestive and Kidney Diseases reports that CKD stage 3 affects 20.1% of adults aged 65+, compared with just 1.2% in those younger than 65. Gender and racial disparities are evident; CKD stage 3 is more prevalent in females (5.8%) than males (4.4%). Our findings indicate that 32% of HIV-positive females have moderate-to-severe kidney disease, compared with 14% of males. Importantly, we did not account for hypertension, diabetes, and hepatitis C virus infection, which may influence renal outcomes. Our study shows that ART has reduced mortality, as more people with HIV now live longer, while also revealing the disproportionate burden of kidney disease among older adults and racial minorities, as well as a concerning trend among women; therefore, emphasizing the need for targeted health care strategies for high-risk groups.

Clinical characteristics of women with HIV in the RESPOND cohort: A descriptive analysis and comparison to men

BACKGROUND

Women with HIV are globally underrepresented in clinical research. Existing studies often focus on reproductive outcomes, seldom focus on older women, and are often underpowered to assess sex/gender differences. We describe CD4, HIV viral load (VL), clinical characteristics, comorbidity burden, and use of antiretroviral therapy (ART) among women with HIV in the RESPOND study and compare them with those of the men in RESPOND.

METHODS

RESPOND is a prospective, multi-cohort collaboration including over 34 000 people with HIV from across Europe and Australia. Demographic and clinical characteristics, including CD4/VL, comorbidity burden, and ART are presented at baseline, defined as the latter of 1 January 2012 or enrolment into the local cohort, stratified by age and sex/gender. We further stratify men by reported mode of HIV acquisition, men who have sex with men (MSM) and non-MSM.

RESULTS

Women account for 26.0% (n = 9019) of the cohort, with a median age of 42.2 years (interquartile range [IQR] 34.7-49.1). The majority (59.3%) of women were white, followed by 30.3% Black. Most women (75.8%) had acquired HIV heterosexually and 15.9% via injecting drug use. Nearly half (44.8%) were receiving a boosted protease inhibitor, 31.4% a non-nucleoside reverse transcriptase inhibitor, and 7.8% an integrase strand transfer inhibitor. The baseline year was 2012 for 73.2% of women and >2019 for 4.2%. Median CD4 was 523 (IQR 350-722) cells/μl, and 73.6% of women had a VL <200 copies/mL. Among the ART-naïve population, women were more likely than MSM but less likely than non-MSM (p < 0.001) to have CD4 <200 cells/μL and less likely than both MSM and non-MSM (p < 0.001) to have VL ≥100 000 copies/mL. Women were also more likely to be free of comorbidity than were both MSM and non-MSM (p < 0.0001).

CONCLUSION

RESPOND women are diverse in age, ethnicity/race, CD4/VL, and comorbidity burden, with important differences relative to men. This work highlights the importance of stratification by sex/gender for future research that may help improve screening and management guidelines specifically for women with HIV.

Quantifying the association of individual-level characteristics with disparities in kidney transplant waitlist addition among people with HIV

BACKGROUND

Over 45% of people with HIV (PWH) in the United States at least 50 years old and are at heightened risk of aging-related comorbidities including end-stage kidney disease (ESKD), for which kidney transplant is the optimal treatment. Among ESKD patients, PWH have lower likelihood of waitlisting, a requisite step in the transplant process, than individuals without HIV. It is unknown what proportion of the inequity by HIV status can be explained by demographics, medical characteristics, substance use history, and geography.

METHODS

The United States Renal Data System, a national database of all individuals ESKD, was used to create a cohort of people with and without HIV through Medicare claims linkage (2007-2017). The primary outcome was waitlisting. Inverse odds ratio weighting was conducted to assess what proportion of the disparity by HIV status could be explained by individual characteristics.

RESULTS

Six thousand two hundred and fifty PWH were significantly younger at ESKD diagnosis and more commonly Black with fewer comorbidities. PWH were more frequently characterized as using tobacco, alcohol and drugs. Positive HIV-status was associated with 57% lower likelihood of waitlisting [adjusted hazard ratio (aHR): 0.43, 95% confidence interval (CI): 0.46-0.48, P  < 0.001]. Controlling for demographics, medical characteristics, substance use and geography explained 39.8% of this observed disparity (aHR: 0.69, 95% CI: 0.59-0.79, P  < 0.001).

CONCLUSION

PWH were significantly less likely to be waitlisted, and 60.2% of that disparity remained unexplained. HIV characteristics such as CD4 + counts, viral loads, antiretroviral therapy adherence, as well as patient preferences and provider decision-making warrant further study.

African American/Black race, apolipoprotein L1 , and serum creatinine among persons with HIV

OBJECTIVE

Accurate estimation of kidney function is critical among persons with HIV (PWH) to avoid under-dosing of antiretroviral therapies and ensure timely referral for kidney transplantation. Existing estimation equations for kidney function include race, the appropriateness of which has been debated. Given advancements in understanding of race and the necessity of accuracy in kidney function estimation, this study aimed to examine whether race, or genetic factors, improved prediction of serum creatinine among PWH.

DESIGN

This cross-sectional study utilized data from the Center for AIDS Research Network of Integrated Clinical Systems cohort (2008-2018). The outcome was baseline serum creatinine.

METHODS

Ordinary least squares regression was used to examine whether inclusion of race or genetic factors [ apolipoprotein-L1 ( APOL1 ) variants and genetic African ancestry] improved serum creatinine prediction. A reduction in root mean squared error (RMSE) greater than 2% was a clinically relevant improvement in predictive ability.

RESULTS

There were 4183 PWH included. Among PWH whose serum creatinine was less than 1.7 mg/dl, race was significantly associated with serum creatinine ( β  = 0.06, SE = 0.01, P  < 0.001) but did not improve predictive ability. African ancestry and APOL1 variants similarly failed to improve predictive ability. Whereas, when serum creatinine was at least 1.7 mg/dl, inclusion of race reduced the RMSE by 2.1%, indicating improvement in predictive ability. APOL1 variants further improved predictive ability by reducing the RMSE by 2.9%.

CONCLUSION

These data suggest that, among PWH, inclusion of race or genetic factors may only be warranted at higher serum creatinine levels. Work eliminating existing healthcare disparities while preserving the utility of estimating equations is needed.