Long-term renal survival in HIV-associated nephropathy with angiotensin-converting enzyme inhibition.
BACKGROUND
Human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) is the most common cause of end-stage renal disease (ESRD) in HIV-infected patients. Angiotensin-converting enzyme (ACE) inhibition has previously shown a short-term benefit in HIVAN. This study examines the long-term effects of ACE inhibition on renal survival in HIVAN.


METHODS
In this single-center prospective cohort study, 44 patients with biopsy-proven HIVAN were enrolled prior to the onset of severe renal insufficiency (serum creatinine <or=2.0 mg/dL), throughout the study period of 1890 days (5.1 years). Twenty-eight patients received fosinopril, 10 mg/day, and 16 were followed as controls. End points included ESRD and death. Treatment effects on survival were evaluated with Kaplan-Meier product-limit estimates. Survival is also described as absolute median number of days.


RESULTS
Median renal survival of treated patients was 479.5 days, with only one patient developing ESRD. All untreated controls progressed to ESRD, with a median renal survival of 146.5 days (P < 0.0001). There were no significant differences between treatment and control groups in age, significant exposure to antiretroviral therapy, defined as >or=two antiviral drugs for >or=30 consecutive days, CD4 lymphocyte count, initial median serum creatinine concentration, or proteinuria. Risk of renal failure was reduced with ACE inhibitors (RR = 0.003, P < 0.0001). Exposure to antiretroviral therapy did not have a significant impact on the risk of renal failure. Of the ACE inhibitor-treated group, 87.5% survived compared with 21.4% of the control group (P < 0.001).


CONCLUSIONS
ACE inhibition initiated prior to severe renal insufficiency may offer long-term renal survival benefits in HIVAN. Diagnosis should be sought early in patients with clinical signs suggestive of HIVAN.
Wei
Alice
A
Department of Medicine, Saint Vincent's Hospital and Medical Center, New York, New York 10011, USA. alice.ei@att.net
Burns
Godfrey C
GC
Williams
Brent A
BA
Mohammed
Nazim B
NB
Visintainer
Paul
P
Sivak
Steven L
SL
D016263:AIDS-Associated Nephropathy / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology*; D000328:Adult; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D015331:Cohort Studies; D005260:Female; D017328:Fosinopril / Q000627:therapeutic use*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000209:etiology; D008297:Male; D008875:Middle Aged; D016019:Survival Analysis
D000806:Angiotensin-Converting Enzyme Inhibitors; D044966:Anti-Retroviral Agents; D017328:Fosinopril