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Overview of kidney disease in HIV-positive patients

Christina M Wyatt, MD
Paul E Klotman, MD
Section Editors
Richard J Glassock, MD, MACP
Fernando C Fervenza, MD, PhD
Deputy Editor
Albert Q Lam, MD


With dramatic improvements in survival and disease progression in the era of combination antiretroviral therapy (ART), complications such as kidney, liver, and cardiac disease have largely replaced opportunistic infections as the leading causes of mortality in the setting of HIV [1]. Patients with HIV are at risk for both acute kidney injury (AKI) and chronic kidney disease (CKD) [2] secondary to medication nephrotoxicity, HIV-associated nephropathy (HIVAN) [3-6], and immune complex kidney diseases [6-10]. In addition, the aging cohort of HIV-positive patients is at increased risk for kidney disease related to hepatitis B or C virus co-infection [6,11,12] and comorbid or treatment-related diabetes and hypertension.


Epidemiology of AKI in HIV-positive patients

Incidence of AKI — The incidence of acute kidney injury (AKI) is increased in HIV-positive patients compared with patients without HIV. Although the overall incidence of AKI in HIV-positive patients appears to be decreasing in the antiretroviral therapy (ART) era, the incidence of severe, dialysis-requiring AKI continues to rise.

In a study of hospitalized adults in New York state that compared administrative data from 1995 (before the introduction of ART) to data from 2003 (after the introduction of ART) [13], AKI was documented in a significantly greater proportion of HIV-positive patients compared with HIV-negative patients, both in 1995 (2.9 versus 1 percent) and 2003 (6 versus 2.7 percent). Because this study relied on administrative data to identify AKI cases, it is likely that only more severe cases were included.

Other studies have also demonstrated an increasing incidence of severe, dialysis-requiring AKI among hospitalized patients with HIV. In a study including more than 56,000 United States military veterans, the incidence of dialysis-requiring AKI declined early in the ART era but then doubled between 2000 and 2006 [14]. A similar increase in the incidence of dialysis-requiring AKI among HIV-positive adults was also demonstrated in a nationally representative sample of United States hospital admissions [15].

Two single-center cohort studies have evaluated the incidence and etiology of AKI among ambulatory patients engaged in HIV care in the ART era, using clinical and laboratory data to identify AKI cases [16,17]. In a prospective study of 754 ambulatory HIV-positive patients followed at a single center in the United States, at least one episode of AKI occurred in 71 patients (9.4 percent) during a two-year period [16]. In a retrospective study of more than 2200 HIV patients engaged in care at a single center in London, AKI occurred in 5.7 percent of patients and was most common within the first three months of initiating HIV care [17].

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Literature review current through: Nov 2017. | This topic last updated: Apr 27, 2017.
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