Fischer MJ (Hines VA/Jesse Brown VAMC/U. Illinois), Wyatt CM
(Mount Sinai), Gordon K
(West Haven VA/Yale U), Gibert C
(VA/George Washington U), Brown ST
(James J Peters VAMC/Mount Sinai School of Medicine), Rimland D
(Atlanta VA/Emory U.), Rodriguez-Barradas M
(Houston VA/Baylor U), Justice AC
(West Haven VA/Yale U), Parikh CR
(West Haven VA/Yale U), VACS Project Team
The VA is the largest provider of healthcare to individuals with human immunodeficiency virus (HIV). Veterans with chronic kidney disease (CKD) and end-stage renal disease (ESRD) are well-known to incur high morbidity and mortality. HIV and Hepatitis C (HCV) are accepted causes of CKD. We examined the effect of HCV on the prevalence of CKD among a national cohort of veterans with HIV and the independent associations of HCV and CKD with mortality.
We studied HIV-infected patients receiving care through the VA from 1998 to 2004 based on data from the VACS virtual cohort. Kidney function was classified according to estimated glomerular filtration rates (eGFR) using the MDRD equation. CKD was defined as an eGFR < 60 ml/min/1.73 meters-squared, moderate CKD 30-59 ml/min/1.73 meters-squared, and severe CKD < 30 ml/min/1.73 meters-squared. Poisson regression models were used to assess the relationship between CKD, HCV, and mortality after adjustment for other factors.
Among 26,104 subjects in this study, 13% had CKD. The distribution of eGFR (ml/min/1.73 meters-squared) was: 60 (87%), 30-59 (7%), 15-29 (3%), and < 15 (3%). Thirty-six percent of the cohort was co-infected with HCV, and a higher proportion of co-infected subjects had CKD compared with mono-infected subjects (15% vs. 12%, p < 0.001). Overall, 34% of the cohort died during 7.6 years of follow-up. Adjusted mortality rates (per 1000 patient-years) were higher with worsening severity of CKD and with HCV as follows (co-infected vs. mono-infected): no CKD (8.27, 95% CI: 6.5-10.5 vs. 6.73, 95% CI: 5.6-8.2), moderate CKD (13.3, 95% CI: 9.8-18.1 vs. 10.8, 95% CI: 8.3-14.1), severe CKD (22.8, 95% CI: 16.3-31.8 vs. 18.5, 95% CI: 13.9-24.7). In adjusted analysis, moderate CKD (IRR 1.44, 95% CI: 1.30-1.59), severe CKD (IRR 2.76, 95% CI: 2.41-3.17), and HCV co-infection (IRR 1.19, 95% CI: 1.13-1.26) were independently associated with increased mortality.
CKD occurs in a significant proportion of HIV-infected veterans and results in significantly higher mortality. Compared with their mono-infected counterparts, veterans co-infected with HCV have higher rates of CKD and mortality.
In order to optimize care for veterans with HIV, efforts should be targeted toward high quality management of HCV and CKD