Validation of the D:A:D chronic kidney disease risk score in people living with HIV: the IeDEA West Africa Cohort Collaboration

"Validation of the D:A:D Chronic Kidney Disease Risk Score Incorporating Proteinuria in People Living with HIV in Harare, Zimbabwe"​​

OBJECTIVE

We sought to validate the D:A:D risk score for chronic kidney disease (CKD) in people living with HIV (PLWH) in a cohort from Harare, Zimbabwe. Additionally, we aimed to evaluate proteinuria as a predictive variable in the risk score model, being the first study to do so.

DESIGN

Data from PLWH attending a clinic in Harare was evaluated. Those with a baseline estimated glomerular filtration rate >60ml/min/1.73m2 and at least two subsequent eGFR measurements were included. A modified version of the D:A:D risk score model was applied to categorise participants as 'low', 'medium' and 'high-risk' of progression to CKD. Potential predictors of renal impairment were assessed by logistic regression in univariate and multivariate models. Proteinuria was evaluated in a nested model using D:A:D risk categories.

RESULTS

2793 participants were included. 40 participants (1.4% of the cohort) progressed to CKD during the median follow-up time of 4.2 years. Progression rates were 1%, 3% and 12% in the low, medium, and high-risk groups respectively. Proteinuria data was available for 2251 participants. Presence of proteinuria was strongly associated with progression to CKD [OR 7.8, 95% CI 3.9-15.7], and its inclusion in the risk score improved the discrimination of the model with the c-statistic increasing from 0.658 to 0.853).

CONCLUSION

A modified version of the D:A:D CKD risk score performed well in predicting CKD events among this Sub-Saharan African cohort of people living with HIV. Inclusion of proteinuria into the risk score model significantly improved predictability.

APOL1 Renal Risk Variants and Kidney Function in HIV-1–Infected People From Sub-Saharan Africa

Introduction

APOL1 G1 and G2 alleles have been associated with kidney-related outcomes in people living with HIV (PLHIV) of Black African origin. No APOL1-related kidney risk data have yet been reported in PLHIV in West Africa, where high APOL1 allele frequencies have been observed.

Methods

We collected clinical data from PLHIV followed in Burkina Faso (N = 413) and in the ANRS-12169/2LADY trial (Cameroon, Senegal, Burkina Faso, N = 369). APOL1 G1 and G2 risk variants were genotyped using TaqMan assays, and APOL1 high-risk (HR) genotype was defined by the carriage of 2 risk alleles.

Results

In West Africa (Burkina Faso and Senegal), the G1 and G2 allele frequencies were 13.3% and 10.7%, respectively. In Cameroon (Central Africa), G1 and G2 frequencies were 8.7% and 8.9%, respectively. APOL1 HR prevalence was 4.9% in West Africa and 3.4% in Cameroon. We found no direct association between APOL1 HR and estimated glomerular filtration rate (eGFR) change over time. Nevertheless, among the 2LADY cohort participants, those with both APOL1 HR and high baseline viral load had a faster eGFR progression (β = −3.9[−7.7 to −0.1] ml/min per 1.73 m² per year, P < 0.05) than those with low-risk (LR) genotype and low viral load.

Conclusion

Overall, the APOL1 risk allele frequencies in PLHIV were higher in the West African countries than in Cameroon, but much lower than previously reported in some Nigeria ethnic groups, which strongly advocates for further investigation in the African continent. This study suggested that the virological status could modulate the APOL1 impact on kidney function, hence reinforcing the need for early therapeutic interventions.

Renal adverse drug reactions

PURPOSE OF REVIEW

Chronic kidney disease (CKD) is common in people living with HIV (PLWH) and is related to a multitude of factors. The aim of this review is to provide an overview of the most recent evidence of renal adverse effects of antiretroviral drugs, predictors of CKD risk and areas for future research.

RECENT FINDINGS

Advancing age, cardiometabolic risk factors and adverse effects of antiretroviral drugs contribute to the higher prevalence of CKD in PLWH. Genetic factors and baseline clinical CKD risk are strongly correlated to risk of incident CKD, although it is unclear to what extent gene polymorphisms explain renal adverse effects related to tenofovir disoproxil fumarate (TDF). Switching from TDF to tenofovir alafenamide (TAF) in people with baseline renal dysfunction improves renal parameters; however, the long-term safety and benefit of TAF in individuals at low risk of CKD is an area of ongoing research.

SUMMARY

Several factors contribute to estimated glomerular function decline and CKD in PLWH. Clinical risk scores for CKD may be useful to inform selection of ART in an ageing population. In people with baseline renal dysfunction, potentially nephrotoxic antiretroviral drugs should be avoided.