Survival and Risk Factors for Death Among HIV-Infected Adults with End-Stage Renal Disease in the United States and Canada
Cantara, Margaret Claire
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Background: With the advent of highly active antiretroviral therapy, the life expectancy of people living with HIV (PLWH) has approached that of the general population. Nevertheless, aging PLWH are at an increased risk of certain conditions associated with aging, including end-stage renal disease (ESRD). Research characterizing the survival experience of PLWH diagnosed with ESRD is still evolving. Methods: Data from the North American AIDS Cohort Collaboration for Research and Design (NA-ACCORD) were used to validate incident cases of ESRD among HIV-infected adults occurring from January 1995 to December 2010. Pooled logistic regression was used to identify risk factors for death post-ESRD diagnosis. Kaplan-Meier curves were generated to characterize survival. Standardized mortality ratios (SMRs) by age, sex, and race were calculated to compare mortality between the NA-ACCORD population and the general population using data from the United States Renal Data System (http://www.usrds.org/reference.aspx). Results: A total of 540 HIV-infected individuals on dialysis, aged 18 to 89, contributed 23,491 person-months, or 1958 person-years, to this analysis. The median age at ESRD diagnosis was 44 years in HIV-infected individuals compared to 60 to 65 years in the general population. The median survival after diagnosis in the NA-ACCORD population was approximately five years. Older age (≥60 years), elevated total cholesterol, history of clinical AIDS diagnosis, CD4+ cell count less than 200 cells/μl, detectable viral load (≥200 copies/mL), no ART use, and tenofovir exposure prior to diagnosis were associated with an increased hazard of death after ESRD diagnosis. An age-adjusted SMR of 1.09 (95% CI: 0.89, 1.29) suggests that the NA-ACCORD population had approximately the same number of deaths as would be expected if the probability of death in HIV-infected adults with ESRD was the same as in the general population with ESRD. Conclusions: HIV-related risk factors were more strongly associated with the hazard of death among HIV-infected adults with ESRD compared to traditional age-related risk factors. The median life expectancy post-ESRD diagnosis was similar between HIV-infected and uninfected adults on dialysis, even though HIV-infected adults were diagnosed with ESRD 15 to 20 years younger compared with the general population. After adjusting for age, the mortality experience was similar between both groups.