title: Low rates of antiretroviral therapy among HIV-infected patients with chronic kidney disease.
abstract: BACKGROUND
  It is unknown whether chronic kidney disease (CKD) influences receipt of highly active antiretroviral therapy (HAART) among patients with the human immunodeficiency virus (HIV) and whether prescription practices contribute to excess mortality.
  
  
  METHODS
  We conducted a retrospective observational study involving HIV-infected patients with established indications for HAART and an outpatient serum creatinine level measured in the Veterans Affairs health care system. Patients were followed up for the outcomes of HAART exposure (percentage of follow-up time treated with HAART), inadequate dose adjustment of renally eliminated antiretroviral medications, and time to death.
  
  
  RESULTS
  A total of 1041 patients (8.5%) had CKD, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2). Compared with patients with an eGFR >or=60 mL/min/1.73 m(2), HAART exposure was 14% less (95% confidence interval [CI], 2%-24% less), 24% less (95% CI, 4% more to 45% less), 64% less (95% CI, 38%-79% less), and 49% less (95% CI, 32%-61% less) in patients who had an eGFR of 30-59 mL/min/1.73 m(2), 15-29 mL/min/1.73 m(2), and <15 mL/min/1.73 m(2) (and were not receiving dialysis) and in patients receiving long-term dialysis, respectively. At study entry, 15.4% of patients with CKD received HAART unadjusted for the level of renal function. The adjusted hazard ratio for death was 1.36 (95% CI, 1.08-1.72) for patients with an eGFR of 30-59 mL/min/1.73 m(2), 2.17 (95% CI, 1.43-3.27) for patients with an eGFR of 15-29 mL/min/1.73 m(2), 5.97 (95% CI, 3.18-11.19) for patients with an eGFR <15 mL/min/1.73 m(2), and 1.92 (95% CI, 1.30-2.82) for dialysis-dependent patients. Underexposure and inadequate dose adjustment of HAART were associated with 22.5%-35.5% of the excess mortality found among patients with different levels of CKD.
  
  
  CONCLUSIONS
  Underexposure and inadequate dose adjustment of HAART may contribute to excess mortality among HIV-infected patients with CKD.
authors.affiliation: Department of Medicine, San Francisco General Hospital, San Francisco, CA 94110, USA. andy.choi@ucsf.edu
authors.forename: Andy I
authors.initials: AI
authors.lastname: Choi
authors.forename: Rudolph A
authors.initials: RA
authors.lastname: Rodriguez
authors.forename: Peter
authors.initials: P
authors.lastname: Bacchetti
authors.forename: Paul A
authors.initials: PA
authors.lastname: Volberding
authors.forename: Diane
authors.initials: D
authors.lastname: Havlir
authors.forename: Daniel
authors.initials: D
authors.lastname: Bertenthal
authors.forename: Alan
authors.initials: A
authors.lastname: Bostrom
authors.forename: Ann M
authors.initials: AM
authors.lastname: O'Hare
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000493:pharmacokinetics / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D002908:Chronic Disease; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D007674:Kidney Diseases / Q000150:complications*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome; D014728:Veterans
chemical_list: D019380:Anti-HIV Agents