HIV-positive individuals with diabetes have a significantly
higher prevalence of albuminuria than patients living with either disease
alone, US investigators report in PLoS
Over a third of patients with HIV and type-2 diabetes had
albuminuria (albumin in urine), an important marker of kidney disease.
Diabetes, higher HIV viral load and treatment with the antiretroviral drug
abacavir (Ziagen, also in the
combination pills Kivexa and Trizivir) all had a significant
relationship with albuminuria.
Thanks to effective antiretroviral therapy, the prognosis of
many HIV-positive patients has improved dramatically. However, kidney disease
is an increasingly important cause of serious illness and death in these
patients. The exact reasons are unclear, but may include traditional risk
factors, the inflammatory effects of HIV, and treatment with some
The prevalence of type-2 diabetes, another risk factor for
kidney disease, is also increasing in HIV-positive patients. Although it is
well known that both HIV and diabetes can cause renal dysfunction, little is
known about kidney disease in HIV-positive individuals living with diabetes.
Albuminuria is a recognised marker of kidney damage, which
is also associated with an increased risk of cardiovascular disease. Research
suggests that between 9% and 11% of HIV-positive patients have microalbuminuria
(small levels of albumin in their urine), and the prevalence of
microalbuminuria in individuals with type-2 diabetes is as high as 25%.
Given the association of both HIV and diabetes with microalbuminuria,
investigators designed a cross-sectional study assessing the prevalence of
albuminuria in a cohort of patients with HIV and type-2 diabetes, as compared
to control populations of HIV-positive patients without diabetes, and diabetic
patients without HIV.
The study included 73 patients with both HIV and diabetes,
82 individuals with HIV alone, and 61 HIV-negative patients with type-2
Patients with diabetes (with and without HIV) were older,
had higher body mass index, and were more likely to be African American than
the HIV-positive patients without diabetes.
Comparison of the patients with HIV showed that those with
diabetes were more likely to be antiretroviral naïve (16% vs. 1%; p = 0.0006);
less likely to be currently using HIV therapy (77% vs. 94%; p = 0.002); and
less likely to have an undetectable viral load (56% vs. 81%; p = 0.0007), than
patients without diabetes.
Albuminuria was defined as a urinary albumin/creatinine
ratio above 30 mg/g. The condition was present in 34% of patients with HIV and
diabetes, compared to 13% of those with HIV alone, and 16% of HIV-negative
diabetic controls (p = 0.005).
After adjusting for factors known to increase the risk of
kidney dysfunction such as age, race, and body mass index, the investigators
found that infection with HIV (p = 0.02) and diabetes (p = 0.03) remained
significantly associated with an increased risk of albuminuria.
“Though albuminuria is considered an important complication
of both diabetes and HIV, our study is the first to report on the prevalence of
albuminuria among individuals affected by both disease,” write the
investigators. “We found that HIV and diabetes have additive effects in regards
to early kidney dysfunction.”
Analysis was then restricted to patients with HIV. The
investigators found that the urinary albumin/creatinine ratio had a significant
correlation with viral load (p = 0.0005).
“Active HIV infection may contribute to a broad spectrum of
kidney injury,” suggest the authors. “Alternatively, viremia may be marker of
medication non-adherence which itself may play a role in albuminuria in
individuals with HIV and diabetes.”
There was a higher prevalence of albuminuria among patients
taking an antiretroviral regimen containing abacavir compared to individuals
taking an alternative drug (37% vs. 19%; p = 0.03). Further analysis showed
that patients with albuminuria had greater cumulative exposure to abacavir (30
vs. 11 months; p = 0.01).
The association between the increased risk of albuminuria
and higher viral load and cumulative exposure to abacavir remained significant
after results were adjusted to take into account potential confounders (p =
0.002 and p = 0.001 respectively).
Further adjustment was also made to take account of total
years of antiretroviral therapy, but nevertheless both a diagnosis of diabetes
(p = 0.003) and abacavir therapy (p = 0.002) remained significantly associated
No other antiretroviral drug was associated with
“We found that the prevalence of albuminuria in individuals
with HIV and diabetes was two fold greater than that of individuals with either
disease alone,” conclude the investigators. They call for further studies “on
the persistence, progression and management of albuminuria in this unique and