title: Baseline renal insufficiency and risk of death among HIV-infected adults on antiretroviral therapy in Lusaka, Zambia.
abstract: OBJECTIVE
  To examine the association between baseline renal insufficiency and mortality among adults initiating antiretroviral therapy (ART) in an urban African setting.
  
  
  METHODS
  Open cohort evaluation.
  
  
  METHODS
  We examined mortality according to baseline renal function among adults initiating ART in Lusaka, Zambia. Renal function was assessed by the Cockcroft-Gault method, the Modification of Diet in Renal Disease equation, and serum creatinine.
  
  
  RESULTS
  From April 2004 to September 2007, 25 779 individuals started ART with an available creatinine measurement at baseline. When creatinine clearance was calculated by the Cockcroft-Gault method, 8456 (33.5%) had renal insufficiency: 73.5% were mild (60-89 ml/min), 23.4% moderate (30-59 ml/min), and 3.1% severe (<30 ml/min). Risk for mortality at or before 90 days was elevated for those with mildly [adjusted hazard ratio (AHR)(1/4)1.7; 95% confidence interval (95% CI)(1/4)1.5-1.9], moderately (AHR(1/4)2.3; 95% CI(1/4)2.0-2.7), and severely (AHR(1/4)4.3; 95% CI(1/4)3.1-5.5) reduced creatinine clearance. Mild (AHR(1/4)1.4; 95% CI(1/4)1.2-1.6), moderate (AHR(1/4)1.9; 95% CI(1/4)1.5-2.3), and severe (AHR(1/4)3.6; 95% CI(1/4) 2.4-5.5) insufficiency were also associated with increased mortality after 90 days, when compared with those with normal renal function. Trends were similar when renal function was estimated with Modification of Diet in Renal Disease or serum creatinine.
  
  
  CONCLUSIONS
  Renal insufficiency at time of ART initiation was prevalent and associated with increased mortality risk among adults in this population. These results have particular relevance for settings like Zambia, where tenofovir--a drug with known nephrotoxicity--has been adopted as part of first-line therapy. This emphasizes the need for resource-appropriate screening algorithms for renal disease, both as part of ART eligibility and pretreatment assessment.
authors.affiliation: Centre for Infectious Disease Research, Zambia.
authors.forename: Lloyd B
authors.initials: LB
authors.lastname: Mulenga
authors.forename: Gina
authors.initials: G
authors.lastname: Kruse
authors.forename: Shabir
authors.initials: S
authors.lastname: Lakhi
authors.forename: Ronald A
authors.initials: RA
authors.lastname: Cantrell
authors.forename: Stewart E
authors.initials: SE
authors.lastname: Reid
authors.forename: Isaac
authors.initials: I
authors.lastname: Zulu
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Stringer
authors.forename: Zipporah
authors.initials: Z
authors.lastname: Krishnasami
authors.forename: Alwyn
authors.initials: A
authors.lastname: Mwinga
authors.forename: Michael S
authors.initials: MS
authors.lastname: Saag
authors.forename: Jeffrey S A
authors.initials: JS
authors.lastname: Stringer
authors.forename: Benjamin H
authors.initials: BH
authors.lastname: Chi