By Dr. Tejinder S. Ahuja, MD

At least 1 percent of dialysis patients in the United States have human immunodeficiency virus (HIV). HIV can lead to the renal disease HIV-associated nephropathy (HIVAN), which is a collapse and scaring (collapsing focal segmental glomerulosclerosis) of the glomerulus (filtering units of the kidney). Prior to the availability of combination drugs for treating HIV – highly active antiretroviral therapy (HAART) – HIVAN progressed rapidly to end-stage renal disease (ESRD). Although occurrence of HIVAN is decreasing with the availability of HAART, many HIV patients are starting dialysis. As routine HIV testing of dialysis patients is not practiced in the U.S., frequency of infection is likely underestimated. Even if newer antiretroviral drugs decrease the number of patients with HIV developing ESRD, the amount of HIV-infected dialysis patients is likely to increase. This is because survival of HIV patients on dialysis continues to dramatically improve due to availability of these drugs.

Many people fear hemodialysis may increase reproduction of HIV, but studies do not confirm this theory. With the use of biocompatible dialyzers, which activate blood less, and highly active antiretroviral therapy, it is very unlikely hemodialysis will have a significant affect on plasma viral load (total amount of HIV in the blood). Although some studies show higher peritonitis rates in HIV-infected dialysis patients, we did not find dialysis modality a factor in survival of HIV patients. Therefore, HIV patients beginning dialysis should be allowed to choose between hemodialysis and peritoneal dialysis depending on their lifestyle needs.

It is important to remember that viable and infectious HIV has been found in peritoneal dialysis waste matter. Therefore, it should be discarded carefully in the toilet and disinfected. Viricidal agents, which destroy or inactivate viruses – such as 50 percent Amukin or 10 percent household bleach – should be poured and left for at least 30 minutes after disposal. Empty bags, tubing and cycler sets should be placed in red plastic trash bags and labeled “Infectious Waste.”

With improvement in survival of HIV patients with the use of HAART, interest in kidney or liver transplantation of these patients is gaining new momentum. Although one may expect taking immunosuppressive medication after transplantation may be harmful to the already weak immune systems of HIV patients, some immunosuppressive medications slow the replication of HIV and others may increase activity of commonly used antiretroviral drugs. Therefore, some transplant centers treat asymptomatic HIV patients (those with no symptoms) who have end-organ damage. Detailed information on these transplant centers is available by clicking here. Initial kidney transplantation experience shows patient survival in HIV recipients is similar to HIV-negative patients after one year.

Infection rate and clotting of arteriovenous grafts and tunneled catheters is higher in patients with HIV and ESRD, therefore all efforts should be made to place arteriovenous fistulas (AVFs) in these patients during early renal failure. To prevent transmission of HIV in dialysis facilities, it is critical that extreme care be paid to infection control practices.

Anemia is a common problem in dialysis patients. If left untreated, anemia can cause fatigue, decreased cognition and mental sharpness, cardiac enlargement, ventricular hypertrophy, angina, impaired immune response, sexual dysfunction and increased mortality. Anemia is also common in HIV patients. Therefore, it is not surprising anemia is much more severe in HIV-infected ESRD patients than other patients and needs to be aggressively treated. Fortunately, the response of HIV patients to erythropoietin (EPO) or darbepoetin is similar to other ESRD patients. If anemia does not respond to usual doses of EPO, it is important to consider rare infections, such as parvovirus, as well as other causes of EPO resistance, such as iron deficiency, hemoglobinopathies (inherited abnormalities in hemoglobin formation), infection and hyperparathyroidism. As iron deficiency, due to blood loss and decreased absorption, is a common problem in dialysis patients, intravenous iron is routinely utilized to treat anemia in dialysis patients. It is possible oxidative stress (stress to cells from loss of regulatory system control) from intravenous iron could increase HIV replication, but patients taking HAART are unlikely to be of great clinical significance.

Although one would expect immunosuppression from uremia and HIV to cause a less than suitable response to vaccination, initial studies suggest antibody response to hepatitis B vaccination in HIV patients is similar to other ESRD patients. More than 50 percent developed protective antibody levels and the majority maintained these high levels six months after vaccination. Hepatitis B vaccination should be offered to these patients, because they have a higher risk of hepatitis B. The antibody response to pneumococcal and flu vaccine has not been studied in HIV patients. Flu and hepatitis vaccination may increase HIV viral load, but this is not clinically significant and should not defray requesting these vaccinations.

Despite undoubted benefits of HAART, two recent studies suggest an underutilization of HAART in HIV-infected dialysis patients. The reasons for decreased use of HAART in these patients are unknown. Pharmacokinetics (alteration in blood levels) of several antiretroviral drugs in ESRD has now been studied in these patients. Nucleoside reverse transcriptase inhibitors (earliest drugs against HIV), except Abacavir, require 30 to 50 percent dose reduction because renal excretion is the major route of elimination of these drugs. Non-nucleoside reverse transcriptase inhibitors and protease inhibitors (newer drugs against HIV), two other groups of antiretroviral drugs, do not require any dose adjustment. In addition to these drugs, many HIV dialysis patients also require prevention against infection. To improve patient outcomes, patients, along with their nephrologists, need to actively participate with HIV specialists in managing antiretroviral therapy.

Dr. Tejinder S. Ahuja is an Associate Professor of Medicine at the University of Texas Medical Branch, Galveston, Texas.

This article originally appeared in the March 2005 issue of aakpRENALIFE, Vol. 20, No. 5.

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