Survival of patients with AIDS and end-stage renal disease receiving hemodialysis

Objective. In the 1980s, most patients with acquired immunodeficiency syndrome (AIDS) who progressed to end-stage renal disease (ESRD) survived for less than 6 months on maintenance hemodialysis. We conducted a 68-month (1995 to 2001) prospective, multicenter, case-control cohort study to determine the present course and survival of patients with AIDS and ESRD receiving hemodialysis in four outpatient dialysis facilities in Brooklyn, NY. Design and Methods. The course of all 34 patients with both ESRD and human immunodeficiency virus (HIV) infection in the four outpatient dialysis facilities was compared to that of 131 ESRD patients without known HIV infection who were randomly selected (4:1 ratio) from the same dialysis facilities. At study onset, baseline data collected from all 34 patients with ESRD and HIV infection included known duration of HIV infection, duration of ESRD, total CD4 count, and the dialysis prescription. Survival was measured as the time interval between onset of study and death. Results. At initiation, the mean age of the 34 patients with ESRD and HIV infection was 42 +/- 7.5 yr compared to 56 +/- 16 yr for the control cohort (ESRD alone) (p = 0.0001). At study onset, the mean duration of ESRD was 57 +/- 50 mo for patients with ESRD and HIV infection, and 40 44 mo for those with ESRD alone (p = 0.07). The mean known duration of HIV infection at study onset was 50.5 +/- 34 mo (median = 48 mo), and the mean total CD4 count was 140 150 cells/mm(3) (median = 70 cells/mm(3)). During the 68-month observation period, 17 (50%) of the 34 patients with HIV infection and ESRD died, compared with 65 (50%) of the 131 patients with ESRD alone (p = 0. 49). Mean ( SE) survival was equivalent between patients with both HIV infection and ESRD (47.4 +/- 4.6 mo; 95% CI 39,56) and those with ESRD alone (50.2 +/- 1.9 mo; 95% CI 46,54) (log-rank test, p = 0.49). Cox regression analysis showed that with adjustment for age (p = 0.0002), patients with both ESRD and HIV infection had a 97% higher risk of death than did their counterparts with ESRD alone (relative hazard, 1.97; 95% CI 1.02,3.79; p = 0.042). In subgroup analysis, neither age (p = 0. 17), duration of HIV disease (p = 0. 63), CD4 count (p = 0. 23), nor duration of ESRD (p = 0.15) was significantly associated with survival in patients with HIV infection and ESRD. Conclusions. We conclude that the survival of patients with HIV infection and ESRD receiving hemodialysis has improved significantly compared with the uniformly dismal outcomes in the 1980s. The combination of HIV infection and ESRD no longer signals near-term death; thus, clinicians should not hesitate to refer HIV-infected patients with renal failure for uremia therapy.