Abstract
Dear Sir, We read with great interest the article entitled ‘Prevalence of impaired renal function in virologically suppressed people living with HIV compared with controls: the Copenhagen Comorbidity in HIV Infection (COCOMO) study’ by Petersen et al. They compared the prevalence of renal impairment, defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2, in a cohort of HIV-infected patients of Caucasian ancestry with an undetectable viral load to the prevalence in the general population 1. They observed a 3.7% prevalence of renal impairment (which they considered low), but this prevalence was twice the observed prevalence in an age-matched cohort of HIV-uninfected individuals. One of the limits of this study was the focus on eGFR; the diagnosis of chronic kidney disease (CKD) in people living with HIV (PLWH) is crucial and often complex 2, and measurement of proteinuria and albuminuria is essential to identify patients with CKD. In an Italian cohort, Calza et al. 3 observed a prevalence of eGFR < 60 mL/min/1.73 m2 of 4.6%, but they observed that the prevalence of CKD was 13.3% because 12.6% of the patients had a urine albumin:creatinine ratio of >30 mg/g. In this Italian cohort, 91% of the patients were Caucasian, and 96.5% of them had an HIV viral load of <50 HIV-1 RNA copies/mL. We conducted a similar monocentre study in France, with GFR measurement by a gold standard method (iohexol plasma clearance), and GFR estimated with the CKD-EPI formula. The median age was 53 years [interquartile range (IQR) 48–61years], 17.8% of the patients had hypertension, and a hepatitis B and/or C virus coinfection was reported in, respectively, 5.4 and 9% of the study participants. Among the 158 enrolled patients, we observed a prevalence of GFR < 60 mL/min/1.73 m2 of 15.9% with GFR measurement, and 14.6% with GFR estimates, which is greater than observed in the COCOMO cohort. Differences between our cohort and the COCOMO cohort are not evident: 90% of our cohort had an undetectable viral load and the median age in the COCOMO cohort was 51.1 years (IQR 46–62 years). The majority of our patients had received tenofovir disoproxil fumarate (TDF) (69.3% had ever been exposed to TDF and 55.7% were current users at the time of GFR measurement); Petersen et al. 1 did not report the prevalence of TDF use in their cohort. We measured the urine protein:creatinine ratio (uPCR) and urine albumin:creatinine ratio, and evaluated the prevalence of uPCR > 150 mg/g and uACR > 30 mg/g as recommended in the Infectious Disease Society of America guidelines for the management of CKD in HIV-infected individuals 4. The prevalence of proteinuria was 15.3%. Albuminuria (uACR > 30 mg/g) occurred in 13.1% of our patients; this prevalence is comparable to the prevalence of albuminuria in the Italian cohort 3. Six patients among the 23 with uPCR > 150 mg/g had uACR < 30 mg/g in our cohort, suggesting that proteinuria is not only attributable to glomerular lesions. A higher prevalence than in our cohort for albuminuria was observed in the AGEhIV study, in which 23.4% of HIV-infected patients had uACR > 30 mg/g 5. In the AGEhIV cohort, the prevalence of renal impairment (GFR < 60 mL/min/1.73m2) was 4.7%, slightly higher than in the COCOMO cohort 5 and lower than in our cohort, although the ages of AGEhIV patients, COCOMO patients and our patients were quite similar. Considering both GFR criteria and proteinuria to define CKD, we observed a high prevalence of CKD in our cohort: 28.8% with GFR measurement and 28.4% with GFR estimation. However, 15 (9.8%) patients were wrongly classified with renal impairment, and 17 (11.1%) patients were wrongly classified without renal impairment with chronic kidnet disease epidemiology (CKD-EPI), demonstrating a few discordances between CKD-EPI and GFR measurement 6. In spite of an absolute low prevalence of renal impairment (defined as GFR < 60 mL/min/1.73 m2) in PLHIV in Europe, even in mainly Caucasian cohorts, CKD is highly prevalent as a consequence of the high prevalence of proteinuria and/or albuminuria, with a large potential impact on mortality and cardiovascular events. Epidemiological studies on CKD in PLWH should investigate the association between GFR data (estimates and/or measurements) and uACR and uPCR measurements.
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