Rudolph A. Rodriguez

Guidelines for the Management of Chronic Kidney Disease in HIV-Infected Patients: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America

Samir K. Gupta, Joseph A. Eustace, Jonathan A. Winston, Ivy I. Boydstun, Tejinder S. Ahuja, Rudolph A. Rodriguez, Karen T. Tashima, Michelle Roland, Nora Franceschini, Frank J. Palella, Jeffrey L. Lennox, Paul E. Klotman, Sharon A. Nachman, Stephen D. Hall, and Lynda A. Szczech Divisions of Infectious Diseases and Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis; Division of Nephrology, Johns Hopkins University, School of Medicine and Department of Epidemiology, Bloomberg School of Public Health, Baltimore, Maryland; Division of Nephrology, Department of Medicine, Mount Sinai School of Medicine, New York, and Division of Nephrology and Hypertension and Division of Infectious Diseases, Department of Pediatrics, State University of New York, Stony Brook; Division of Nephrology, Department of Medicine, University of Texas Medical Branch, Galveston; Division of Nephrology, Department of Medicine, San Francisco General Hospital and Positive Health Program at San Francisco General Hospital and the UCSF AIDS Research Institute, Department of Medicine, University of California at San Francisco; Division of Infectious Diseases, Department of Medicine, The Miriam Hospital, Brown Medical School, Providence, Rhode Island; Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, and Duke Clinical Research Institute and the Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and Grady Infectious Disease Program, Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, Georgia

Trajectories of Kidney Function Decline in the 2 Years Before Initiation of Long-term Dialysis

BACKGROUND Little is known about patterns of kidney function decline leading up to the initiation of long-term dialysis. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 5,606 Veterans Affairs patients who initiated long-term dialysis in 2001-2003. PREDICTOR Trajectory of estimated glomerular filtration rate (eGFR) during the 2-year period before initiation of long-term dialysis. OUTCOMES & MEASUREMENTS Patient characteristics and care practices before and at the time of dialysis initiation and survival after initiation. RESULTS We identified 4 distinct trajectories of eGFR during the 2-year period before dialysis initiation: 62.8% of patients had persistently low level of eGFR < 30 mL/min/1.73 m2 (mean eGFR slope, 7.7 ± 4.7 [SD] mL/min/1.73 m2 per year), 24.6% had progressive loss of eGFR from levels of approximately 30-59 ml/min/1.73 m2 (mean eGFR slope, 16.3 ± 7.6 mL/min/1.73 m2 per year), 9.5% had accelerated loss of eGFR from levels > 60 mL/min/1.73 m2 (mean eGFR slope, 32.3 ± 13.4 mL/min/1.73 m2 per year), and 3.1% experienced catastrophic loss of eGFR from levels > 60 mL/min/1.73 m2 within 6 months or less. Patients with steeper eGFR trajectories were more likely to have been hospitalized and have an inpatient diagnosis of acute kidney injury. They were less likely to have received recommended predialysis care and had a higher risk of death in the first year after dialysis initiation. CONCLUSIONS There is substantial heterogeneity in patterns of kidney function loss leading up to the initiation of long-term dialysis perhaps calling for a more flexible approach toward preparing for end-stage renal disease.

Racial Differences in End-Stage Renal Disease Rates in HIV Infection versus Diabetes

Few studies have compared the incidence of end-stage renal disease (ESRD) among individuals with the human immunodeficiency virus (HIV) and diabetes. We followed a national sample of 2,015,891 US veterans over a median peroid of 3.7 years for progression to ESRD. The age- and sex-adjusted incidence of ESRD (per 1000 person-years) among HIV-infected black patients was nearly an order of magnitude higher than among HIV-positive white patients, almost twice that of diabetic whites, and similar to that among diabetic blacks. In multivariate Cox proportional hazards analysis, diabetes was associated with an increased risk of ESRD among white patients, but HIV was not. Among black individuals, however, both HIV and diabetes conferred a similar increase in the risk of ESRD (4- to 5-fold increase compared to white individuals without HIV or diabetes). HIV and diabetes carry a similar risk of ESRD among black patients, highlighting the importance of developing strategies to prevent and treat renal disease among HIV-infected black individuals.

Regional Variation in Health Care Intensity and Treatment Practices for End-stage Renal Disease in Older Adults

CONTEXT An increasing number of older adults are being treated for end-stage renal disease (ESRD) with long-term dialysis. OBJECTIVES To determine how ESRD treatment practices for older adults vary across regions with differing end-of-life intensity of care. DESIGN, SETTING, AND PARTICIPANTS Retrospective observational study using a national ESRD registry to identify a cohort of 41,420 adults (of white or black race), aged 65 years or older, who started long-term dialysis or received a kidney transplant between June 1, 2005, and May 31, 2006. Regional end-of-life intensity of care was defined using an index from the Dartmouth Atlas of Healthcare. MAIN OUTCOME MEASURES Incidence of treated ESRD (dialysis or transplant), preparedness for ESRD (under the care of a nephrologist, having a fistula [vs graft or catheter] at time of hemodialysis initiation), and end-of-life care practices. RESULTS Among whites, the incidence of ESRD was progressively higher in regions with greater intensity of care and this trend was most pronounced at older ages. Among blacks, a similar relationship was present only at advanced ages (men aged > or = 80 years and women aged > or = 85 years). Patients living in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to be under the care of a nephrologist before the onset of ESRD (62.3% [95% confidence interval {CI}, 61.3%-63.3%] vs 71.1% [95% CI, 69.9%-72.2%], respectively) and less likely to have a fistula (vs graft or catheter) at the time of hemodialysis initiation (11.2% [95% CI, 10.6%-11.8%] vs 16.9% [95% CI, 15.9%-17.8%]). Among patients who died within 2 years of ESRD onset (n = 21,190), those living in regions in the highest compared with lowest quintile of end-of-life intensity of care were less likely to have discontinued dialysis before death (22.2% [95% CI, 21.1%-23.4%] vs 44.3% [95% CI, 42.5%-46.1%], respectively), less likely to have received hospice care (20.7% [95% CI, 19.5%-21.9%] vs 33.5% [95% CI, 31.7%-35.4%]), and more likely to have died in the hospital (67.8% [95% CI, 66.5%-69.1%] vs 50.3% [95% CI, 48.5%-52.1%]). These differences persisted in adjusted analyses. CONCLUSION There are pronounced regional differences in treatment practices for ESRD in older adults that are not explained by differences in patient characteristics.

White/Black Racial Differences in Risk of End-stage Renal Disease and Death

BACKGROUND End-stage renal disease disproportionately affects black persons, but it is unknown when in the course of chronic kidney disease racial differences arise. Understanding the natural history of racial differences in kidney disease may help guide efforts to reduce disparities. METHODS We compared white/black differences in the risk of end-stage renal disease and death by level of estimated glomerular filtration rate (eGFR) at baseline in a national sample of 2,015,891 veterans between 2001 and 2005. RESULTS Rates of end-stage renal disease among black patients exceeded those among white patients at all levels of baseline eGFR. The adjusted hazard ratios for end-stage renal disease associated with black versus white race for patients with an eGFR > or = 90, 60-89, 45-59, 30-44, 15-29, and <15 mL/min/1.73 m2, respectively, were 2.14 (95% confidence interval [CI], 1.72-2.65), 2.30 (95% CI, 2.02-2.61), 3.08 (95% CI, 2.74-3.46), 2.47 (95% CI, 2.26-2.70), 1.86 (95% CI, 1.75-1.98), and 1.23 (95% CI, 1.12-1.34). We observed a similar pattern for mortality, with equal or higher rates of death among black persons at all levels of eGFR. The highest risk of mortality associated with black race also was observed among those with an eGFR 45-59 mL/min/1.73 m2 (hazard ratio 1.32, 95% CI, 1.27-1.36). CONCLUSION Racial differences in the risk of end-stage renal disease appear early in the course of kidney disease and are not explained by a survival advantage among blacks. Efforts to identify and slow progression of chronic kidney disease at earlier stages may be needed to reduce racial disparities.

Determinants of Survival among HIV-Infected Chronic Dialysis Patients

Over 100 HIV-infected patients have initiated chronic dialysis at San Francisco General Hospital (SFGH) since 1985. This study employed retrospective analysis to identify determinants of and trends in survival among HIV-infected patients who have initiated chronic dialysis at SFGH from January 1, 1985 to November 1, 2002 (n = 115). Cohort patient survival was compared with survival after an AIDS-opportunistic illness in all HIV-infected patients in San Francisco during the study period. Higher CD4 count (hazard ratio [HR], 0.86 per 50 cells/mm(3) increase; 95% confidence interval [CI], 0.80 to 0.93) and serum albumin (HR, 0.53 per 1 g/dl increase; CI, 0.36 to 0.78) at initiation of dialysis were strongly associated with lower mortality. Survival for those initiating dialysis during the era of highly active antiretroviral therapy (HAART) was 16.1 mo versus 9.4 mo for those initiating dialysis before this time, but this difference was not statistically significant. In adjusted analysis, only a non-statistically significant trend toward improved survival during the HAART era was noted (HR, 0.59; CI, 0.34 to 1.04). By comparison, survival for all HIV-infected patients after an AIDS-opportunistic illness in San Francisco increased from 16 mo in 1994 to 81 mo in 1996. The dramatic improvement in survival that has occurred since the mid-1990s for patients with HIV appears to be greatly attenuated in the sub-group undergoing dialysis. Although this may partly reflect confounding by race, injection drug use and HCV co-infection, future attempts to improve survival among HIV-infected dialysis patients should focus on barriers to the effective use of HAART in this group.

Low Rates of Antiretroviral Therapy among HIV-Infected Patients with Chronic Kidney Disease

BACKGROUND It is unknown whether chronic kidney disease (CKD) influences receipt of highly active antiretroviral therapy (HAART) among patients with the human immunodeficiency virus (HIV) and whether prescription practices contribute to excess mortality. METHODS We conducted a retrospective observational study involving HIV-infected patients with established indications for HAART and an outpatient serum creatinine level measured in the Veterans Affairs health care system. Patients were followed up for the outcomes of HAART exposure (percentage of follow-up time treated with HAART), inadequate dose adjustment of renally eliminated antiretroviral medications, and time to death. RESULTS A total of 1041 patients (8.5%) had CKD, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2). Compared with patients with an eGFR >or=60 mL/min/1.73 m(2), HAART exposure was 14% less (95% confidence interval [CI], 2%-24% less), 24% less (95% CI, 4% more to 45% less), 64% less (95% CI, 38%-79% less), and 49% less (95% CI, 32%-61% less) in patients who had an eGFR of 30-59 mL/min/1.73 m(2), 15-29 mL/min/1.73 m(2), and <15 mL/min/1.73 m(2) (and were not receiving dialysis) and in patients receiving long-term dialysis, respectively. At study entry, 15.4% of patients with CKD received HAART unadjusted for the level of renal function. The adjusted hazard ratio for death was 1.36 (95% CI, 1.08-1.72) for patients with an eGFR of 30-59 mL/min/1.73 m(2), 2.17 (95% CI, 1.43-3.27) for patients with an eGFR of 15-29 mL/min/1.73 m(2), 5.97 (95% CI, 3.18-11.19) for patients with an eGFR <15 mL/min/1.73 m(2), and 1.92 (95% CI, 1.30-2.82) for dialysis-dependent patients. Underexposure and inadequate dose adjustment of HAART were associated with 22.5%-35.5% of the excess mortality found among patients with different levels of CKD. CONCLUSIONS Underexposure and inadequate dose adjustment of HAART may contribute to excess mortality among HIV-infected patients with CKD.

Near Infra-Red Interactance for Longitudinal Assessment of Nutrition in Dialysis Patients

OBJECTIVE Serial nutritional assessment of dialysis patients is important because of the high incidence and prevalence of malnutrition in these patients. Near-infrared interactance (NIR) technology may provide a practical and reliable method to evaluate body fat and its changes over time in dialysis patients. DESIGN Longitudinal study consisting of 2 cross-sectional measurements, 2 months apart. SETTING Outpatient dialysis unit affiliated to a tertiary care community medical center. PATIENTS Seventy-one dialysis patients (35 men, 36 women), 57 +/- 15 years old, who have been on dialysis between 5 months and 11 years (43 +/- 30 months). Twelve additional patients with similar features were studied during the second round. INTERVENTION None. MAIN OUTCOME MEASURES NIR was used to estimate the body fat percentage. Other simultaneous measurements included subjective global assessment, anthropometric indices including midarm circumference, triceps and biceps skinfold thickness, and body mass index, and some laboratory values including albumin, transferrin, and cholesterol. NIR measurement was performed by placing a Futrex sensor on the nonaccess upper arm for several seconds, after logging the required individual data (sex, weight, height, and body frame), along with uniform physical activity levels for all patients, into a mini-computer. RESULTS Seventy-one dialysis patients underwent nutritional and laboratory measurements. A second measurement round was performed 8 to 9 weeks after the first one and included 12 additional patients. Within each cross-sectional round, Pearson correlation coefficients (r) between the NIR score and nutritionally relevant variables were significant for anthropometric values (0.56 to 0.82) as well as low cholesterol and creatinine (0.22 to 0.30). The two serial NIR measurements on the same patients were highly consistent over the 2-month study interval (r = 0.96), whereas anthropometric values showed greater variability. The within-person coefficient of variation for NIR was low, indicating high consistency between 2 measurements. Moreover, the timing of the NIR measurement (predialysis v postdialysis) did not have any impact on consistency of the NIR results. The longitudinal changes of NIR had significant correlations with anthropometric and laboratory changes over time. CONCLUSION The NIR, which can be performed within seconds, may serve as a reliable and practical tool for objective measurements of nutritional status in hemodialysis patients. The NIR not only seems to have a high degree of reproducibility but may also be an optimal tool to detect longitudinal changes in body fat over time. The NIR measurement is independent of the fluid status in dialysis patients. More comparative and longitudinal studies are needed to confirm the validity of NIR measurements in longitudinal evaluation of dialysis patients.

Prognostic Implications of the Urinary Albumin to Creatinine Ratio in Veterans of Different Ages With Diabetes

BACKGROUND Albuminuria is associated with an increased risk of death independent of level of renal function. Whether this association is similar for adults of all ages is not known. METHODS We examined the association between the albumin to creatinine ratio (ACR) and all-cause mortality after stratification by estimated glomerular filtration rate (eGFR) and age group in 94 934 veterans with diabetes mellitus. Cohort members had at least 1 ACR recorded in the Veterans Affairs Health Care System between October 1, 2002, and September 30, 2003, and were followed up for death through October 15, 2009. RESULTS From the youngest to the oldest age group, the prevalence of an eGFR less than 60 mL/min/1.73 m(2) ranged from 11% to 41%; microalbuminuria (ACR 30-299 mg/g) ranged from 19% to 28%; and macroalbuminuria (ACR > or =300 mg/g) ranged from 3.2% to 3.7%. Of patients with an eGFR less than 60 mL/min/1.73 m(2), 72% of those younger than 65 years, 74% of those 65 to 74 years old, and 59% of those 75 years and older had an eGFR of 45 to 59 mL/min/1.73 m(2). In all age groups, less than 35% of these patients had albuminuria (ie, ACR > or =30 mg/g). In patients 75 years and older, the ACR was independently associated with an increased risk of death at all levels of eGFR after adjusting for potential confounders. In younger age groups, this association was present at higher levels of eGFR but seemed to be attenuated at lower levels [corrected]. CONCLUSION The ACR is independently associated with mortality at all levels of eGFR in older adults with diabetes and may be particularly helpful for risk stratification in the large group with moderate reductions in eGFR.

Racial Composition of Residential Areas Associates with Access to Pre-ESRD Nephrology Care

Referral to a nephrologist before initiation of chronic dialysis occurs less frequently for blacks than whites, but the reasons for this disparity are incompletely understood. Here, we examined the contribution of racial composition by zip code on access and quality of nephrology care before initiation of renal replacement therapy (RRT). We retrospectively studied a cohort study of 92,000 white and black adults who initiated RRT in the United States between June 1, 2005, and October 5, 2006. The percentage of patients without pre-ESRD nephrology care ranged from 30% among those who lived in zip codes with <5% black residents to 41% among those who lived in areas with >50% black residents. In adjusted analyses, as the percentage of blacks in residential areas increased, the likelihood of not receiving pre-ESRD nephrology care increased. Among patients who received nephrology care, the quality of care (timing of care and proportion of patients who received a pre-emptive renal transplant, who initiated therapy with peritoneal dialysis, or who had a permanent hemodialysis access) did not differ by the racial composition of their residential area. In conclusion, racial composition of residential areas associates with access to nephrology care but not with quality of the nephrology care received.