The clinical epidemiology and course of the spectrum of renal diseases associated with HIV infection
The clinical epidemiology and course of the spectrum of renal diseases associated with HIV infection
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DOI：
10.1111/j.1523-1755.2004.00865.x
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发表时间：
2004-09-01
影响因子：
19.6
通讯作者：
Winston, JA
中科院分区：
文献类型：
--
作者：
Szczech, LA;Gupta, SK;Winston, JA
背景虽然对HIV相关性肾病（HIVAN）的流行病学和临床过程的了解正在增加，但对可能作为HIV感染并发症发生的其他肾脏疾病的风险因素和临床过程知之甚少。本研究的目的是比较HIV感染者与其他肾脏疾病的关系。这项回顾性队列研究包括所有在六个主要医疗中心的临床护理过程中接受肾活检的HIV感染患者。从每个患者的临床记录中提取人口统计学和临床信息。采用考克斯比例风险回归分析比较了非HIVAN患者与HIVAN患者开始肾脏替代治疗的时间。89例患者（47例为HIVAN以外的病变，42例为HIVAN）可供纳入。患有HIV以外病变的患者不太可能是黑人（37/47 vs. 42/42，P= 0.02），更可能有阳性B型肝炎表面抗原（10/37 vs. 4/42，P= 0.04），不太可能诊断为高血压（24/46 vs. 31/42，P= 0.03），活检时肌酐清除率更高（60.6 vs. 39.0 cc/min，P= 0.008），活检时CD 4淋巴细胞计数（287 vs. 187 cells/mL，P= 0.04）高于HIVAN患者。与HIVAN相比，HIVAN以外的其他病变与启动肾脏替代治疗的时间更长相关（HR 0.33，95% CI 0.15-0.71，P= 0.005）。与肾脏替代治疗时间较长相关的其他因素包括活检时较高的肌酐清除率、较高的CD 4（+）淋巴细胞计数、缺乏丙型肝炎抗体以及使用血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂。肾脏疾病的类型（HIVAN与其他）与HIV-1 RNA水平和抗逆转录病毒治疗的使用显着相互作用（P= 0.0001和0.006，分别）。在HIVAN以外的病变患者中，检测不到HIV-1 RNA的存在与肾脏疾病进展风险增加无关（HR 0.27，P= 0.24）。在HIVAN患者中，由于所有患者在接受肾脏替代治疗时均检测到病毒，因此无法量化这种高度显著的相关性。在HIVAN以外的病变患者中，抗逆转录病毒治疗的使用与肾脏替代治疗的进展无关（HR 3.29，P= 0.06）。在HIVAN患者中，抗逆转录病毒治疗的使用与肾脏替代治疗进展缓慢相关（HR 0.24，P= 0.03）。在患有肾脏疾病的HIV感染患者中，病毒抑制和抗逆转录病毒治疗的使用与对肾功能的有益作用无关;因此，可能需要使用其他治疗策略。由于肾组织学与预后差异相关，这些数据提供的结果信息将提高肾活检在HIV感染的肾病患者中的临床应用。
Background. While an understanding of the epidemiology and clinical course of HIV-associated nephropathy (HIVAN) is growing, little is known about the risk factors and clinical course of the other renal diseases that may also occur as a complication of HIV infection. This study was undertaken to compare HIVAN to the spectrum of other kidney diseases seen among HIV-infected patients.Methods. This retrospective cohort study included all HIV-infected patients who underwent renal biopsy during the course of their clinical care at six major medical centers. Demographic and clinical information were abstracted from each patient's clinical record. Time to initiation of renal replacement therapy was compared for patients with lesions other than HIVAN to patients with HIVAN using Cox proportional hazards regression.Results. Eighty-nine patients (47 with lesions other than HIVAN and 42 with HIVAN) were available for inclusion. Patients with lesions other than HIVAN were less likely to be black (37/47 vs. 42/42, P= 0.02), more likely to have a positive hepatitis B surface antigen (10/37 vs. 4/42, P= 0.04), less likely to have the diagnosis of hypertension (24/46 vs. 31/42, P= 0.03), more likely to have a greater creatinine clearance at time of biopsy (60.6 vs. 39.0 cc/min, P= 0.008), and have a greater CD4 lymphocyte count at time of biopsy (287 vs. 187 cells/mL, P= 0.04) compared to patients with HIVAN. Lesions other than HIVAN were associated with a longer time to initiation of renal replacement therapy compared with HIVAN (HR 0.33, 95% CI 0.15-0.71, P= 0.005). Other factors associated with a longer time to renal replacement therapy included higher creatinine clearance at time of biopsy, greater CD4(+) lymphocyte count, the absence of hepatitis C antibody, and the use of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. The type of renal disease (HIVAN vs. other) interacted significantly with HIV-1 RNA level and the use of antiretroviral therapy (P= 0.0001 and 0.006, respectively). Among patients with lesions other than HIVAN, the presence of nondetectable HIV-1 RNA was not associated with a greater risk of progression of renal disease (HR 0.27, P= 0.24). Among patients with HIVAN, because all patients had detectable virus at the time of institution of renal replacement therapy, this highly significant association could not be quantified. Among patients with lesions other than HIVAN, the use of antiretroviral therapy was not associated with the progression to renal replacement therapy (HR 3.29, P= 0.06). Among patients with HIVAN, the use of antiretroviral therapy was associated with a slower progression to renal replacement therapy (HR 0.24, P= 0.03).Conclusion. Among HIV-infected patients with renal disease other than HIVAN, viral suppression and the use of antiretroviral therapy are not associated with a beneficial effect on renal function; thus, additional therapeutic strategies may need to be utilized. Because renal histology is associated with prognostic differences, these data provide outcomes information that will improve the clinical utility of renal biopsy among HIV-infected patients with renal disease.