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Human immunodeficiency virus and dialysis

Paul E Klotman, MD
Christina M Wyatt, MD
Section Editors
Steve J Schwab, MD
Martin S Hirsch, MD
Deputy Editor
Alice M Sheridan, MD


Kidney disease is an important complication of human immunodeficiency virus (HIV) infection, particularly in African Americans [1]. A collapsing form of focal segmental glomerulosclerosis (FSGS) with associated tubular microcysts and interstitial inflammation is the classic form of HIV-related kidney disease, known as HIV-associated nephropathy (HIVAN). HIV infection has also been associated with other forms of kidney disease, in particular, immune complex disease [2]. With prolonged survival and aging of the population, HIV-positive patients are also at increasing risk for kidney disease due to comorbid conditions, such as diabetes and hypertension.

Some of these kidney diseases can result in end-stage renal disease (ESRD). Issues relating to HIV and dialysis will be reviewed here. HIV-related disorders of the kidney are discussed separately. (See "Overview of kidney disease in HIV-positive patients" and "HIV-associated nephropathy (HIVAN)".)


Compared with the general population, HIV-positive patients are at increased risk for end-stage renal disease (ESRD). In a population-based cohort study from Denmark, HIV-positive individuals had a fourfold higher risk of ESRD compared with age- and gender-matched controls [3]. Data from the Veterans Affairs (VA) healthcare system have demonstrated that the risk of ESRD is associated with both HIV-related factors (high HIV-RNA, low CD4, and hepatitis C virus coinfection) and traditional kidney disease risk factors (diabetes, hypertension, and cardiovascular disease) [4]. A subsequent study from the VA suggests that ESRD may occur at a younger age in HIV-positive versus HIV-negative veterans, although the difference is small [5].

Both HIV-related factors and traditional renal risk factors were also associated with a combined endpoint of ESRD and advanced chronic kidney disease in two large HIV cohort studies, D:A:D and EuroSIDA [6,7]. In a smaller, retrospective cohort study from Germany, injection drug use and black race were the only independent risk factors for ESRD in HIV-positive adults [8]. Over the 20-year study period, these authors observed a decline in the prevalence of ESRD among HIV-positive blacks and an increase in the prevalence of ESRD among HIV-positive whites, although the racial disparity in ESRD risk remained significant.

Data from the VA healthcare system and from the Johns Hopkins HIV cohort have also demonstrated a striking disparity in the risk of ESRD among HIV-positive blacks, who may have as much as a 30-fold increase in the risk of ESRD compared with HIV-positive whites [9-11]. In the VA cohort, the risk of ESRD among HIV-positive blacks was similar to that observed among diabetics [9]. Genetic variability in the APOL1 gene on chromosome 22 appears to account for a significant proportion of the racial disparity in ESRD risk, including the risk of HIV-associated nephropathy (HIVAN) and other forms of focal segmental glomerulosclerosis (FSGS) [12-14]. (See "Epidemiology, classification, and pathogenesis of focal segmental glomerulosclerosis", section on 'FSGS in African Americans'.)

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Literature review current through: Nov 2017. | This topic last updated: Mar 23, 2016.
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  1. Wyatt CM, Winston JA, Malvestutto CD, et al. Chronic kidney disease in HIV infection: an urban epidemic. AIDS 2007; 21:2101.
  2. Gerntholtz TE, Goetsch SJ, Katz I. HIV-related nephropathy: a South African perspective. Kidney Int 2006; 69:1885.
  3. Rasch MG, Helleberg M, Feldt-Rasmussen B, et al. Increased risk of dialysis and end-stage renal disease among HIV patients in Denmark compared with the background population. Nephrol Dial Transplant 2014; 29:1232.
  4. Jotwani V, Li Y, Grunfeld C, et al. Risk factors for ESRD in HIV-infected individuals: traditional and HIV-related factors. Am J Kidney Dis 2012; 59:628.
  5. Althoff KN, McGinnis KA, Wyatt CM, et al. Comparison of risk and age at diagnosis of myocardial infarction, end-stage renal disease, and non-AIDS-defining cancer in HIV-infected versus uninfected adults. Clin Infect Dis 2015; 60:627.
  6. Ryom L, Mocroft A, Kirk O, et al. Predictors of advanced chronic kidney disease and end-stage renal disease in HIV-positive persons. AIDS 2014; 28:187.
  7. Ryom L, Kirk O, Lundgren JD, et al. Advanced chronic kidney disease, end-stage renal disease and renal death among HIV-positive individuals in Europe. HIV Med 2013; 14:503.
  8. Bickel M, Marben W, Betz C, et al. End-stage renal disease and dialysis in HIV-positive patients: observations from a long-term cohort study with a follow-up of 22 years. HIV Med 2013; 14:127.
  9. Choi AI, Rodriguez RA, Bacchetti P, et al. Racial differences in end-stage renal disease rates in HIV infection versus diabetes. J Am Soc Nephrol 2007; 18:2968.
  10. Lucas GM, Mehta SH, Atta MG, et al. End-stage renal disease and chronic kidney disease in a cohort of African-American HIV-infected and at-risk HIV-seronegative participants followed between 1988 and 2004. AIDS 2007; 21:2435.
  11. Lucas GM, Lau B, Atta MG, et al. Chronic kidney disease incidence, and progression to end-stage renal disease, in HIV-infected individuals: a tale of two races. J Infect Dis 2008; 197:1548.
  12. Kao WH, Klag MJ, Meoni LA, et al. MYH9 is associated with nondiabetic end-stage renal disease in African Americans. Nat Genet 2008; 40:1185.
  13. Kopp JB, Smith MW, Nelson GW, et al. MYH9 is a major-effect risk gene for focal segmental glomerulosclerosis. Nat Genet 2008; 40:1175.
  14. Genovese G, Friedman DJ, Ross MD, et al. Association of trypanolytic ApoL1 variants with kidney disease in African Americans. Science 2010; 329:841.
  15. Perez G, Ortiz-Interian C, Lee H, et al. Human immunodeficiency virus and human T-cell leukemia virus type I in patients undergoing maintenance hemodialysis in Miami. Am J Kidney Dis 1989; 14:39.
  16. Vigneau C, Guiard-Schmid JB, Tourret J, et al. The clinical characteristics of HIV-infected patients receiving dialysis in France between 1997 and 2002. Kidney Int 2005; 67:1509.
  17. US Renal Data System, 2009 Annual Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda, MD, 2009.
  18. US Preventive Services Task Force. Final Recommendation Statement. Human Immunodeficiency Infection (HIV): Screening, April 2013. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/human-immunodeficiency-virus-hiv-infection-screening (Accessed on March 12, 2016).
  19. Wali RK, Drachenberg CI, Papadimitriou JC, et al. HIV-1-associated nephropathy and response to highly-active antiretroviral therapy. Lancet 1998; 352:783.
  20. Winston JA, Bruggeman LA, Ross MD, et al. Nephropathy and establishment of a renal reservoir of HIV type 1 during primary infection. N Engl J Med 2001; 344:1979.
  21. Peterman TA, Lang GR, Mikos NJ, et al. HTLV-III/LAV infection in hemodialysis patients. JAMA 1986; 255:2324.
  22. Ujhelyi E, Füst G, Illei G, et al. Different types of false positive anti-HIV reactions in patients on haemodialysis. Immunol Lett 1989; 22:35.
  23. Arnow PM, Fellner S, Harrington R, Leuther M. False-positive results of screening for antibodies to human immunodeficiency virus in chronic hemodialysis patients. Am J Kidney Dis 1988; 11:383.
  24. Vardinon N, Yust I, Katz O, et al. Anti-HIV indeterminate western blot in dialysis patients: a long-term follow-up. Am J Kidney Dis 1999; 34:146.
  25. Chou CC, Sun CY, Wu MS. Human immunodeficiency virus (HIV) infection screening in a dialysis unit. Ren Fail 2007; 29:459.
  26. Ahuja TS, O'brien WA. Special issues in the management of patients with ESRD and HIV infection. Am J Kidney Dis 2003; 41:279.
  27. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR Recomm Rep 2001; 50:1.
  28. Centers for Disease Control and Prevention (CDC). HIV transmission in a dialysis center--Colombia, 1991-1993. MMWR Morb Mortal Wkly Rep 1995; 44:404.
  29. Dyer E. Argentinian doctors accused of spreading AIDS. BMJ 1993; 307:584.
  30. Velandia M, Fridkin SK, Cárdenas V, et al. Transmission of HIV in dialysis centre. Lancet 1995; 345:1417.
  31. El Sayed NM, Gomatos PJ, Beck-Sagué CM, et al. Epidemic transmission of human immunodeficiency virus in renal dialysis centers in Egypt. J Infect Dis 2000; 181:91.
  32. Centers for Disease Control and Prevention. Frequently Asked Questions—Bloodborne Pathogens—Occupational Exposure. http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf (Accessed on March 12, 2016).
  33. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997; 337:1485.
  34. Ahuja TS, Niaz N, Velasco A, et al. Effect of hemodialysis and antiretroviral therapy on plasma viral load in HIV-1 infected hemodialysis patients. Clin Nephrol 1999; 51:40.
  35. Breyer JA, Harbison MA. Isolation of human immunodeficiency virus from peritoneal dialysate. Am J Kidney Dis 1993; 21:23.
  36. Scheel PJ Jr, Farzadegan H, Ford D, et al. Recovery of human immunodeficiency virus from peritoneal dialysis effluent. J Am Soc Nephrol 1995; 5:1926.
  37. Farzadegan H, Ford D, Malan M, et al. HIV-1 survival kinetics in peritoneal dialysis effluent. Kidney Int 1996; 50:1659.
  38. Ahuja TS, Collinge N, Grady J, Khan S. Is dialysis modality a factor in survival of patients with ESRD and HIV-associated nephropathy? Am J Kidney Dis 2003; 41:1060.
  39. Brock JS, Sussman M, Wamsley M, et al. The influence of human immunodeficiency virus infection and intravenous drug abuse on complications of hemodialysis access surgery. J Vasc Surg 1992; 16:904.
  40. Curi MA, Pappas PJ, Silva MB Jr, et al. Hemodialysis access: influence of the human immunodeficiency virus on patency and infection rates. J Vasc Surg 1999; 29:608.
  41. Mitchell D, Krishnasami Z, Young CJ, Allon M. Arteriovenous access outcomes in haemodialysis patients with HIV infection. Nephrol Dial Transplant 2007; 22:465.
  42. Fokou M, Teyang A, Ashuntantang G, et al. Complications of arteriovenous fistula for hemodialysis: an 8-year study. Ann Vasc Surg 2012; 26:680.
  43. Nannery WM, Stoldt HS, Fares LG 2nd. Hemodialysis access operations performed upon patients with human immunodeficiency virus. Surg Gynecol Obstet 1991; 173:387.
  44. Lucas GM, Ross MJ, Stock PG, et al. Clinical practice guideline for the management of chronic kidney disease in patients infected with HIV: 2014 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:e96.
  45. Mitchell D, Krishnasami Z, Allon M. Catheter-related bacteraemia in haemodialysis patients with HIV infection. Nephrol Dial Transplant 2006; 21:3185.
  46. Obialo CI, Robinson T, Brathwaite M. Hemodialysis vascular access: variable thrombus-free survival in three subpopulations of black patients. Am J Kidney Dis 1998; 31:250.
  47. Tebben JA, Rigsby MO, Selwyn PA, et al. Outcome of HIV infected patients on continuous ambulatory peritoneal dialysis. Kidney Int 1993; 44:191.
  48. Dressler R, Peters AT, Lynn RI. Pseudomonal and candidal peritonitis as a complication of continuous ambulatory peritoneal dialysis in human immunodeficiency virus-infected patients. Am J Med 1989; 86:787.
  49. Lewis M, Gorban-Brennan NL, Kliger A, et al. Incidence and spectrum of organisms causing peritonitis in HIV positive patients on CAPD. Adv Perit Dial 1990; 6:136.
  50. Elsey RM, Carson RW, DuBose TD Jr. Pasteurella multocida peritonitis in an HIV-positive patient on continuous cycling peritoneal dialysis. Am J Nephrol 1991; 11:61.
  51. Parsonnet J. Trichosporon beigelii peritonitis. South Med J 1989; 82:1062.
  52. Varela MP, Lew SQ, Smith AM, et al. Outcome of an opportunistic infection after polymicrobial peritonitis in an HIV-infected patient treated with peritoneal dialysis. Am J Nephrol 1999; 19:682.
  53. Perazella M, Eisen T, Brown E. Peritonitis associated with disseminated Mycobacterium avium complex in an acquired immunodeficiency syndrome patient on chronic ambulatory peritoneal dialysis. Am J Kidney Dis 1993; 21:319.
  54. Kimmel PL, Umana WO, Simmens SJ, et al. Continuous ambulatory peritoneal dialysis and survival of HIV infected patients with end-stage renal disease. Kidney Int 1993; 44:373.
  55. Wasser WG, Boyle MJ, Brandon S, et al. HIV positivity does not predispose peritoneal dialysis patients to peritonitis. J Am Soc Nephrol 1991; 2:369.
  56. Troidle L, Kliger AS, Goldie SJ, et al. Continuous peritoneal dialysis-associated peritonitis of nosocomial origin. Perit Dial Int 1996; 16:505.
  57. Kiernan L, Finkelstein FO, Kliger AS, et al. Outcome of polymicrobial peritonitis in continuous ambulatory peritoneal dialysis patients. Am J Kidney Dis 1995; 25:461.
  58. Shrivastava D, Rao TK, Sinert R, et al. The efficacy of erythropoietin in human immunodeficiency virus-infected end-stage renal disease patients treated by maintenance hemodialysis. Am J Kidney Dis 1995; 25:904.
  59. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf (Accessed on March 12, 2016).
  60. Ahuja TS, Borucki M, Grady J. Highly active antiretroviral therapy improves survival of HIV-infected hemodialysis patients. Am J Kidney Dis 2000; 36:574.
  61. Ifudu O, Mayers JD, Matthew JJ, et al. Uremia therapy in patients with end-stage renal disease and human immunodeficiency virus infection: has the outcome changed in the 1990s? Am J Kidney Dis 1997; 29:549.
  62. Ahuja TS, Grady J, Khan S. Changing trends in the survival of dialysis patients with human immunodeficiency virus in the United States. J Am Soc Nephrol 2002; 13:1889.
  63. Macrae J, Friedman AL, Eggers P, Friedman EA. Improved survival in HIV-infected African-Americans with ESRD. Clin Nephrol 2005; 64:124.
  64. Tourret J, Tostivint I, du Montcel ST, et al. Outcome and prognosis factors in HIV-infected hemodialysis patients. Clin J Am Soc Nephrol 2006; 1:1241.
  65. Trullàs JC, Cofan F, Barril G, et al. Outcome and prognostic factors in HIV-1-infected patients on dialysis in the cART era: a GESIDA/SEN cohort study. J Acquir Immune Defic Syndr 2011; 57:276.
  66. Tourret J, Tostivint I, Tézenas Du Montcel S, et al. Antiretroviral drug dosing errors in HIV-infected patients undergoing hemodialysis. Clin Infect Dis 2007; 45:779.
  67. Choi AI, Rodriguez RA, Bacchetti P, et al. Low rates of antiretroviral therapy among HIV-infected patients with chronic kidney disease. Clin Infect Dis 2007; 45:1633.
  68. Ortiz C, Meneses R, Jaffe D, et al. Outcome of patients with human immunodeficiency virus on maintenance hemodialysis. Kidney Int 1988; 34:248.
  69. Perinbasekar S, Brod-Miller C, Pal S, Mattana J. Predictors of survival in HIV-infected patients on hemodialysis. Am J Nephrol 1996; 16:280.
  70. Dave MB, Shabih K, Blum S. Maintenance hemodialysis in patients with HIV-associated nephropathy. Clin Nephrol 1998; 50:367.
  71. Atta MG, Fine DM, Kirk GD, et al. Survival during renal replacement therapy among African Americans infected with HIV type 1 in urban Baltimore, Maryland. Clin Infect Dis 2007; 45:1625.
  72. Oberai PC, Dalal D, Zhang L, et al. Incidence of atherosclerotic cardiovascular disease among HIV patients receiving dialysis. Am J Kidney Dis 2006; 47:848.
  73. Tsiodras S, Mantzoros C, Hammer S, Samore M. Effects of protease inhibitors on hyperglycemia, hyperlipidemia, and lipodystrophy: a 5-year cohort study. Arch Intern Med 2000; 160:2050.
  74. Strategies for Management of Anti-Retroviral Therapy/INSIGHT, DAD Study Groups. Use of nucleoside reverse transcriptase inhibitors and risk of myocardial infarction in HIV-infected patients. AIDS 2008; 22:F17.
  75. D:A:D Study Group, Sabin CA, Worm SW, et al. Use of nucleoside reverse transcriptase inhibitors and risk of myocardial infarction in HIV-infected patients enrolled in the D:A:D study: a multi-cohort collaboration. Lancet 2008; 371:1417.
  76. Worm SW, Sabin C, Weber R, et al. Risk of myocardial infarction in patients with HIV infection exposed to specific individual antiretroviral drugs from the 3 major drug classes: the data collection on adverse events of anti-HIV drugs (D:A:D) study. J Infect Dis 2010; 201:318.
  77. Obel N, Farkas DK, Kronborg G, et al. Abacavir and risk of myocardial infarction in HIV-infected patients on highly active antiretroviral therapy: a population-based nationwide cohort study. HIV Med 2010; 11:130.
  78. Brothers CH, Hernandez JE, Cutrell AG, et al. Risk of myocardial infarction and abacavir therapy: no increased risk across 52 GlaxoSmithKline-sponsored clinical trials in adult subjects. J Acquir Immune Defic Syndr 2009; 51:20.