HIV patients at greater risk of both heart and kidney disease

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Australian research shows HIV patients at high risk for a heart attack or stroke are also at substantially greater risk for chronic kidney disease and vice versa.

The research, led by the University of Adelaide’s Professor Mark Boyd, will be published today in a special issue of the journal PLOS Medicine, which focuses on worldwide advances in HIV prevention, treatment and cure in the lead up to World AIDS Day on 1 December.

Boyd, an infectious diseases expert with the Adelaide Medical School, University of Adelaide, led an international team to investigate additional diseases associated with HIV infection and its treatment. Drawing on data from the international D:A:D (Data collection on Adverse events of Anti-HIV Drugs) study, Boyd and colleagues assessed the risks of cardiovascular disease and chronic kidney disease in people with HIV infection. They found elevated risks of each disease occurring simultaneously.

More than 1,400 people in the study being treated for HIV had been diagnosed with chronic kidney disease, and more than 900 had experienced a cardiovascular disease event. Almost 11% of these patients had experienced both chronic kidney disease and cardiovascular disease, with many of these events occurring just one year apart.

“Our research found that people with HIV at high risk of cardiovascular disease had a corresponding 5.63-fold increase in risk of chronic kidney disease – a finding not consistent with the general community,” Boyd says.

“This study adds to the international body of research that shows we need to pay close attention to the broader, general healthcare of people living with HIV.

“It’s wonderful that anti-HIV medication has been able to save the lives of so many with HIV; what we need to do now is to help people with HIV realize the full potential of their much-extended life expectancy.

“Despite much effort over the past decade to focus attention on reducing cardiovascular risk in HIV-positive people, there has been a lack of attention to the management of this disease in people living with HIV. Unfortunately, this has implications for other diseases, and the interaction between diseases creates substantial risks for future life-threatening events,” he says.

Boyd says the research shows that the risks for cardiovascular and chronic kidney disease in people with HIV should be assessed together. “We strongly urge both people with HIV and their doctors to be aware of these risks, and to treat them as a combined healthcare issue, not separately,” he says.

“Primary prevention and effective management of these diseases, prioritising interventions that have been repeatedly shown in the general community, will convey the same if not greater benefits for the population of HIV-positive people. This approach should be incorporated in to the development of guidelines and defining future research priorities for HIV-positive people,” he says.

Background: The Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study has developed predictive risk scores for cardiovascular disease (CVD) and chronic kidney disease (CKD, defined as confirmed estimated glomerular filtration rate [eGFR] ≤ 60 ml/min/1.73 m2) events in HIV-positive people. We hypothesized that participants in D:A:D at high (>5%) predicted risk for both CVD and CKD would be at even greater risk for CVD and CKD events.
Methods and findings: We included all participants with complete risk factor (covariate) data, baseline eGFR > 60 ml/min/1.73 m2, and a confirmed (>3 months apart) eGFR < 60 ml/min/1.73 m2 thereafter to calculate CVD and CKD risk scores. We calculated CVD and CKD event rates by predicted 5-year CVD and CKD risk groups (≤1%, >1%–5%, >5%) and fitted Poisson models to assess whether CVD and CKD risk group effects were multiplicative. A total of 27,215 participants contributed 202,034 person-years of follow-up: 74% male, median (IQR) age 42 (36, 49) years, median (IQR) baseline year of follow-up 2005 (2004, 2008). D:A:D risk equations predicted 3,560 (13.1%) participants at high CVD risk, 4,996 (18.4%) participants at high CKD risk, and 1,585 (5.8%) participants at both high CKD and high CVD risk. CVD and CKD event rates by predicted risk group were multiplicative. Participants at high CVD risk had a 5.63-fold (95% CI 4.47, 7.09, p < 0.001) increase in CKD events compared to those at low risk; participants at high CKD risk had a 1.31-fold (95% CI 1.09, 1.56, p = 0.005) increase in CVD events compared to those at low risk. Participants’ CVD and CKD risk groups had multiplicative predictive effects, with no evidence of an interaction (p = 0.329 and p = 0.291 for CKD and CVD, respectively). The main study limitation is the difference in the ascertainment of the clinically defined CVD endpoints and the laboratory-defined CKD endpoints.
Conclusions: We found that people at high predicted risk for both CVD and CKD have substantially greater risks for both CVD and CKD events compared with those at low predicted risk for both outcomes, and compared to those at high predicted risk for only CVD or CKD events. This suggests that CVD and CKD risk in HIV-positive persons should be assessed together. The results further encourage clinicians to prioritise addressing modifiable risks for CVD and CKD in HIV-positive people.

Mark A Boyd, Amanda Mocroft, Lene Ryom, Antonella d’Arminio Monforte, Caroline Sabin, Wafaa M El-Sadr, Camilla Ingrid Hatleberg, Stephane De Wit, Rainer Weber, Eric Fontas, Andrew Phillips, Fabrice Bonnet, Peter Reiss, Jens Lundgren, Matthew Law

University of Adelaide material
PLOS Medicine abstract



The above research appears in this months: Advances in HIV Prevention, Treatment and Cure edited by Professor Linda-Gail Bekker, Dr Steven Seeks and Professor Sharon Lewin

PLOS Collections articles


Other articles in this issue include:
Effectiveness of a combination strategy for linkage and retention in adult HIV care in Swaziland: The Link4Health cluster randomized trial
HIV prevalence and behavioral and psychosocial factors among transgender women and cisgender men who have sex with men in 8 African countries: A cross-sectional analysis
Contemporary disengagement from antiretroviral therapy in Khayelitsha, South Africa: A cohort study

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