Kidney Disease in HIV Positive Patients

Comorbidities in an Aging HIV Positive Population Brian Risley, MFA 2010 HIV Research Catalyst Forum

April 21, 2010

Comorbidities Associated With an Aging HIV Positive Population I. Comorbidities •

Renal

•

Lipodystrophy

•

Insulin Resistance / Diabetes

•

Cancer Incidence

•

Bone Density

•

Cardiovascular

II. Q & A

Comorbidities Associated With an Aging HIV Positive Population I. Comorbidities •

Renal

•

Lipodystrophy

•

Insulin Resistance / Diabetes

•

Cancer Incidence

•

Bone Density

•

Cardiovascular

Prevalence of Chronic Kidney Disease in the General Population Increases with Age Eight year cross-sectional Norwegian survey subjects ≥20 yrs of age

Prevalence (%)

50

GFR (mL/min/1.73 m2):

40

45 45-59

30-44

4X HIV-seronegative men2 • Risk factors for HIV positive individuals developing diabetes include3: • Certain ARVs • Older age • Ethnic background (African American)

1Florescu,

D. Antiretroviral Therapy. 2007. 12:149-162. TT. Arch Intern Med. 2005. 165:1179-1184. 3DeWit, D. Diabetes Care. 2008. 31(6):1224-1229. 2Brown,

• Male sex • Greater BMI

Complications of Insulin Resistance • Insulin resistance occurs as part of a metabolic syndrome that may lead to the development of: – Type II diabetes – Atherosclerosis – Hypertension

• Management: Lifestyle modification •

Diabetic education

•

Self-monitoring of blood glucose

•

Aerobic and resistance training

•

Medication

Florescu, D. Antiretroviral Therapy. 2007. 12:149-162.

Comorbidities Associated With an Aging HIV Positive Population I. Comorbidities •

Renal

•

Lipodystrophy

•

Insulin Resistance / Diabetes

•

Cancer Incidence

•

Bone Density

•

Cardiovascular

Invasive cancer incidence increases by age

U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2004 Incidence and Mortality Webbased Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2007. Available at: www.cdc.gov/uscs.

Comorbidities Associated With an Aging HIV Positive Population I. Comorbidities •

Renal

•

Lipodystrophy

•

Insulin Resistance / Diabetes

•

Cancer Incidence

•

Bone Density

•

Cardiovascular

Multiple risk factors for decreased BMD in the general population (HIV negative) Classic

Female sex Smoking

White race Family history

Secondary

Decreased physical activity

Alcohol Decreased bone acquisition

Increasing age

Chronic diseases (e.g. hyperthyroidism, hyperparathyroidism, liver disease, rheumatological conditions, eating disorders, etc.)

Hypogonadism Renal dysfunction

Malnutrition/low BMI

Amenorrhoea /premature menopause

Medications (e.g. corticosteroids, anticonvulsants, anticoagulants)

Bone Mineral Density Diagram adapted from Glesby MJ. Clin Infect Dis 2003; 37:S91–50

Increased Fracture Rate in HIV Outpatient Study Patients (HOPS) • Comparison of HOPS cohort (n=8,456) vs National Hospital Discharge Survey and National Hospital Ambulatory Medical Care Survey (NHAMCS)

Gender-adjusted rates of fracture among adults aged 25-54 years

HOPS P value for trend = 0.01

– Adjusted for age and gender • HOPS: 276 fx during median 4.8 yrs follow-up; more likely if: • Age >47

NHAMCSOPD P value for trend = 0.32

• Nadir CD4+ count 120) Current Smoker

male or female years mg/dL mg/dL mmHg yes or no yes or no

m 46 245 35 125 n n

10 years

10

0,06

6%

Time Frame for Risk Estimate Your Risk

0,00

0,05

0,10

0,15

http://hin.nhlbi.nih.gov/atpiii/calculator.asp

0,20

0,25

0,30

Prediction of cardiovascular risk based on the Framingham Heart Study Risk Factor

Units

Gender Age Total Cholesterol HDL Systolic Blood Pressure Treatment for Hypertension (Only if SBP >120) Current Smoker

male or female years mg/dL mg/dL mmHg yes or no yes or no

m 46 245 35 125 n y

10 years

10

Time Frame for Risk Estimate

0,19

Your Risk

0,00

0,05

0,10

0,15

http://hin.nhlbi.nih.gov/atpiii/calculator.asp

0,20

19%

0,25

0,30