Chronic kidney disease: The overlooked comorbidity in people with HIV
October 18, 2025
Chronic kidney disease is a significant concern for people living with HIV, with a prevalence of around 6% in Asia, highlighting a critical need for increased vigilance and monitoring.
Over the past two decades, Highly Active Antiretroviral Therapy (HAART) has revolutionized HIV treatment, dramatically improving patient life expectancies. However, as patients live longer, they face increased challenges with comorbidities that affect their quality of life. Dr Tay Kim Heng, Consultant Infectious Disease & General Physician at Desa Park City Medical Centre, shared these insights at the National Kidney Foundation's 18th Annual Dialysis Conference, highlighting both the successes and ongoing challenges in HIV care.
The life expectancy gap While the gap in life expectancy between HIV-positive and HIV-negative patients has narrowed significantly, disparities remain in comorbidity-free years. "HIV patients still live at least 16 fewer comorbidity-free years than people without HIV. They live substantially fewer healthy years than the general population," Dr Tay explained. Early detection and immediate HAART initiation, even when CD4 cell counts are 500 and above, can eliminate the life expectancy gap compared to the general population. However, when measuring comorbidity-free life expectancy, persistent gaps remain. While improvements have been seen in cancer and cardiovascular disease outcomes, similar progress hasn't been achieved for diabetes, liver, kidney, or lung diseases. Chronic kidney disease: A growing concern among HIV patients The prevalence of Chronic Kidney Disease (CKD) among people living with HIV varies across Asia, influenced by HAART, comorbidities, and regional healthcare practices. Global systematic reviews from 60 countries report a CKD prevalence of approximately 6.4% among HIV-infected patients. In broader Asia-specific cohorts, including Malaysia, the prevalence is around 6%. While Malaysia lacks HIV-specific CKD data, a 2018 nationwide population-based study reported a CKD prevalence of 15.48% among adults over 18 years old. These statistics underscore the need for vigilance in monitoring kidney health among HIV patients. Multifactorial origins of CKD in HIV patients The causes of CKD in people living with HIV are multifactorial, similar to other comorbidities like cardiovascular disease. Three major contributing factors have been identified: aging, chronic HIV infection, long-term antiretroviral therapy (ART) use, and non-communicable comorbidities and coinfections (HBV/HCV). These factors often interlink, creating complex health challenges for patients and healthcare providers. As ART advancements extend life expectancy, the HIV population is aging, with predictions indicating that by 2030, 70% of HIV patients will be over 50 years old. This aging trend not only increases CKD risk but also predisposes patients to more age-associated and noncommunicable comorbidities. The impact of long-term ART on kidney health Long-term ART use has been associated with chronic kidney disease development. International guidelines recommend regular CKD screening for HIV-infected patients to enable early detection and prevention. CKD risk stratification is crucial and typically based on several key parameters: kidney function levels as measured by estimated Glomerular Filtration Rate (eGFR), the degree of kidney damage, proteinuria or albuminuria measurements, age group, and concurrent comorbidities like diabetes, hepatitis C, uncontrolled hypertension, and cardiovascular disease. This risk stratification helps identify patients needing closer monitoring, interventions, and referrals before irreversible decline occurs, and also influences ART selection. Monitoring protocols for HIV patients at risk of CKD Given the high risk of CKD among HIV patients, specific monitoring protocols are recommended. Patients should have their eGFR measured at least every six months and undergo either urinalysis or quantitative assessment of urinary protein at least annually. These regular screenings help detect early signs of kidney dysfunction, allowing for timely intervention and treatment adjustments. Such proactive monitoring is essential for preserving kidney function and overall health in HIV patients, particularly as they age and face increased comorbidity risks. Tenofovir: Benefits and risks in HIV treatment Tenofovir, one of the most commonly used antiretroviral therapies worldwide, including in Malaysia, has been associated with eGFR decline, CKD, and proteinuria in multiple cohort studies. Data shows a 33% increased risk of chronic kidney disease for each additional year of Tenofovir use. Larger cohort studies of over 20,000 HIV-infected men found nearly double the 5-year CKD event rate compared to non-users. However, some studies indicate that kidney function can improve with continued Tenofovir use in certain cases. This mixed evidence suggests that while Tenofovir remains an important treatment option, it should be used with caution in high-risk CKD patients, with careful monitoring of kidney function. Dolutegravir: A safer option for patients with kidney concerns Dolutegravir (DTG) presents a safer alternative for HIV patients with chronic kidney disease and cardiovascular concerns. Despite case studies suggesting associations between DTG and weight gain or increased insulin resistance, insufficient evidence exists to contraindicate its use, particularly in patients with concurrent CKD. From a renal perspective, DTG is not primarily excreted by the kidneys, requiring no dosage adjustment even in advanced CKD stages. Regarding cardiovascular considerations, no direct evidence links DTG to cardiovascular events, with some studies showing no difference in outcomes between patients starting with DTG versus non-DTG regimens. The evolution of HIV treatment: Two-drug regimens Beyond simplifying ART with once-daily combination pills, another evolving trend in HIV management is the shift toward two-drug regimens, moving away from traditional three-drug combinations. The 2019 Gemini Studies demonstrated that Dolutegravir plus Lamivudine provided comparable efficacy to standard triple therapy in treatment-naïve patients. However, these regimens require careful patient selection, excluding those with suspected biological resistance (particularly when using Lamivudine alone) and patients with concurrent hepatitis B infection. Two-drug regimens represent a promising strategy for selected patients, including those with CKD, offering simplified treatment without compromising efficacy. Undetectable equals untransmittable: Reducing stigma in healthcare The principle that "undetectable equals untransmittable" has been confirmed repeatedly in studies over the past 20 years. When HIV patients on effective ART achieve viral suppression (ideally undetectable levels), they do not transmit HIV sexually. This understanding has important implications for healthcare settings, including renal clinics. When treating patients with undetectable viral loads, healthcare providers need not worry about HIV transmission during routine clinical care beyond standard universal precautions. This principle not only reflects scientific understanding but also plays a crucial role in reducing stigma. Many patients face the dual burden of CKD and HIV, and recognizing their non-infectious status when virally suppressed can help alleviate some of this psychological burden. |
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