Care of the Human Immunodeficiency Virus–Infected End-Stage Kidney Disease Patient

Introduction

The human immunodeficiency virus (HIV)–infected end-stage kidney disease (ESKD) patient presents specific clinical and logistical challenges to dialysis care providers. In this chapter, we discuss the shifting epidemiology and current management of ESKD in people living with HIV.

Epidemiology

Currently, the only nationally representative data regarding the incidence and prevalence of HIV infection among ESKD patients comes from United States Renal Database System (USRDS) surveillance of HIV-associated nephropathy (HIVAN) and antiretroviral prescriptions for patients enrolled in Medicare part D. Based on these data, the incidence of HIV infection in ESKD patients has plateaued, but the prevalence has continued to increase. In a cohort of 38,354 HIV-infected adults in Canada and the United States, 592 (1.5%) had ESKD. The 286 individuals who developed ESKD during the 9-year study period were more likely to be Black and have a history of diabetes mellitus, hypertension, and intravenous drug use. Additionally, they were less likely to be on antiretrovirals and virologically suppressed.

In the early days of the acquired immunodeficiency syndrome (AIDS) pandemic, HIVAN became a leading cause of kidney failure among HIV-infected individuals. It accounted for a third of biopsy-proven cases of kidney failure in HIV-infected persons between 1995 and 2004 and became the fourth leading cause of ESKD among Black adults between 1994 and 1998. The introduction of combination antiretroviral therapy (cART) in the mid-1990s led to a decrease in the incidence of HIVAN and comorbidities, such as diabetes mellitus, hypertension, hepatitis C virus (HCV) coinfection, intravenous drug use, and nephrotoxicity from antiretroviral agents became major risk factors for the development of ESKD among HIV-infected individuals.

Improved Survival of the Human Immunodeficiency Virus-Infected End-Stage Kidney Disease Patient

One-year survival after starting dialysis in HIV-infected ESKD patients improved from 56% before 1990 to 74% in 1999. In a more recent study of patients who started on dialysis due to HIVAN between 1989 and 2011, 1-year survival increased from 42% in the pre-ART era (1989–1995) to 80% in the modern ART era (2002–2011). Additionally, transplantation offers 1- and 3-year survival rates of 95% and 88%, respectively. These gains are attributed to the increased availability of ART and recent efforts to improve engagement across the HIV continuum of care (i.e., diagnosis, engagement and retention in care, adherence to ART, and virologic suppression). However, these gains are not uniform across all patients; in a study of HIV-infected Black Americans in Baltimore, the median survival after initiation of dialysis remained relatively stable at 19–22 months between 1989 and 2000. Additionally, in a study of a national dialysis population comparing survival rates among HIV-infected, HIV and HCV coinfected, and HIV and HCV noninfected individuals, HIV infection was associated with increased mortality among non-Whites but not among Whites, whereas HIV and HCV coinfection was associated with higher mortality regardless of race.

Hemodialysis and Vascular Access

The most common kidney replacement modality used in HIV-infected patients is hemodialysis. A recent study utilizing the Vascular Quality Initiative Registry between 2011 and 2018 explored arteriovenous (AV) access outcomes, including reintervention, occlusion, and mortality. Individuals with HIV undergoing AV access creation had similar outcomes compared to those without HIV.

Tunneled dialysis catheter infections are associated with an increased risk of infection and a higher risk of death in HIV-infected patients. Therefore, HIV-infected patients with chronic kidney disease (CKD) should be referred to a nephrologist early, and AV access planning should be timely.