Maintenance hemodialysis in patients with HIV-associated nephropathy

Objective: End-stage renal disease (ESRD) patients infected with human immunodeficiency virus (HIV) have poor survival on maintenance hemodialysis. Only a few studies have evaluated survival time on the basis of demographic and clinical factors. The clinical category of the HIV infection and total CD4 counts are commonly considered determining factors of survival in these HIV-infected dialysis patients. Patients and methods: A retrospective case review of all ESRD patients with HIV infection on maintenance hemodialysis, from January 1987 through December 1996, was performed to determine the impact of different clinical categories of HIV infection and CD4 counts on survival and to see if there are other factors that can predict survival among these patients. From a total of 75 ESRD patients with HIV infection, 58 patients with ESRD due to HIV-associated nephropathy (HIVAN) on maintenance hemodialysis are reported here. Results: During the 10 year study period, 52 of 58 ESRD patients with HIVAN expired. Infection (60%), cardiogenic conditions (13%), cerebro-vascular accidents (6%), HIV wasting (8%) and noncompliance with dialysis (11%) were common causes of death. Fifty patients who were on long term hemodialysis (Group I), had a median survival time of 11 months (4-69). Among 44 diseased patients in Group I, various demographic, clinical and laboratory markers, including age, sex, race, acquired immunodeficiency syndrome (AIDS)-associated conditions, HIV clinical categories, hemodialysis access and initial serum albumin level were not significantly associated with mean or median survival time. Those with initial CD4 counts of more than 50 had a significantly longer median survival (11.3 months) than those whose counts were below 50 (5.3 months). Patients with less than or equal to 2.5 g/100 mi initial serum albumin level and less than or equal to 50 initial CD4 counts had a median survival time of 5.3 months compared to 13.6 months in the group of patients with initial serum albumin level of >2.5 g/100 mi and initial CD4 counts >50. Both of these findings were statistically significant. Conclusions: Our 10 year experience of maintenance hemodialysis in ESRD patients with HIVAN shows that long term survival is possible. Initial CD4 + T cells of less than or equal to 50 in these patients is a poor prognostic marker. HIV clinical categories, as reported by others, failed to predict survival in our long term experience. Initial serum albumin of less than or equal to 2.5 g/100 mi was associated with poor survival, though statistically not significant. When initial serum albumin of less than or equal to 2.5 g/100 mi was combined with CD4 + T cells of less than or equal to 50, it became another marker of poor survival.