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Validated risk score for CKD may guide HIV treatment decisions
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International researchers have developed and validated a simple risk score for chronic kidney disease in patients with HIV that can be used to guide clinical decision making.
“The development of a publicly available online tool estimating an individual’s 5-year risk of [chronic kidney disease (CKD)] with or without the addition of potentially nephrotoxic antiretrovirals enables clinicians and HIV-positive individuals to make an informed decision about acceptable risk for an individual’s care … and to identify those at greatest risk of CKD,” Amanda Mocroft, MSc, of the department of infection and population health, University College London, and colleagues wrote in PLoS Medicine.
Although ART controls HIV and extends life expectancy, they also may be nephrotoxic, increasing CKD risk, the researchers wrote. In HIV-infected patients, CKD has been associated with increased morbidity and mortality.
Using the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study, the researchers collected clinical and demographic data on 17,954 patients with HIV who had more than three estimated glomerular filtration rate (eGFR) values beginning in January 2004. They defined baseline as the first eGFR less than 60 mL/min/1.73 m2. They excluded patients who had been exposed to potentially nephrotoxic antiretrovirals, which included Viread (tenofovir, Gilead Sciences), Reyataz (atazanavir, Bristol-Myers Squibb), atazanavir in combination with Norvir (ritonavir, AbbVie), Kaletra (lopinavir/ritonavir, AbbVie), or other boosted protease inhibitors before baseline. They divided the patients into low-, medium- and high-risk groups.
Older age, IV drug use, hepatitis C coinfection, lower baseline eGFR, female sex, lower CD4 count nadir, hypertension, diabetes and cardiovascular disease all predicted CKD. Each category was used to create the risk score.
In the next 5 years, there was a 1 in 393 chance of developing CKD in the low-risk group, a 1 in 47 chance in the medium-risk group and a 1 in 6 chance in the high-risk group, the researchers wrote.
The results indicated that there was little risk in starting low-risk patients on potentially nephrotoxic medications. For example, among those with a low-risk score, the number needed to harm (NNTH) at 5 years when starting tenofovir, atazanavir/ritonavir or another boosted protease inhibitor was 739 (95% CI, 506-1462). However, for medium- and high-risk patients starting the same regimens, the NNTH was 88 and 9, respectively.
“The use of such antiretrovirals in individuals with a high underlying risk of CKD needs careful discussion and close monitoring,” Mocroft and colleagues wrote. “Risks and benefits, both renal and for other comorbidities, and already acquired HIV drug resistance clearly need to be carefully assessed when choice of antiretroviral drugs and intensity of monitoring is decided on in this group of individuals,” the researchers wrote.
Disclosure: Mocroft reports having received honoraria, consultancy, lecture fees and travel grants from Boehringer Ingelheim, Gilead Sciences, GlaxoSmithKline, Merck and Pfizer. Please see the full study for a list of all other authors’ relevant financial disclosures.
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