HIV and End-Stage Renal Disease: Disparities and Opportunities to Improve Outcomes

Racial disparities in patients with end-stage renal disease (ESRD) are well documented: young black patients die on dialysis at up to twice the rate of their white counterparts, while being half as likely to achieve access to the waitlist or a live donor. HIV-associated nephropathy (HIVAN) is the third leading cause of renal failure in black patients; its impact on racial disparities in ESRD outcomes is unknown. The goals of this dissertation were to characterize the mechanisms underlying racial disparities in ESRD, specifically the role of HIVAN, and develop strategies to improve outcomes. In the first paper of this thesis, we establish that cause of renal failure modifies the relationship between race and mortality on dialysis, with racial disparities attenuated in patients with ESRD caused by diabetes and hypertension. We show that excess mortality in young black dialysis patient is largely driven by a combination of 1) an increased burden of HIVAN and lupus, which are associated with poor outcomes, and 2) decreased access to transplantation. Furthermore, having access to nephrology care prior to ESRD onset is associated with improved survival in patients with HIVAN. In the second section, we discuss ongoing work showing that black patients with HIVAN are less likely to receive a kidney from a live donor, join the deceased donor waiting list, or receive an organ once listed; however, those who are transplanted derive a significant survival benefit from kidney transplant compared to remaining on dialysis or the waitlist. As such improving access to transplant for this population is critical to improve disparities in mortality on dialysis. In the third paper, we show that the use of induction immunosuppression is not associated with increased infections in HIV (+) kidney transplant recipients as was feared, and is in fact associated with fewer hospitalizations and better patient and graft survival. Given that HIV (+) kidney transplant recipients have 2-4 times the rate of rejection, the use of induction immunosuppression may be beneficial. In papers 4 and 5, we examine practices related to the use of donors classified as CDC increased infectious risk (IRD) for HIV. Currently, 20% of kidneys are from donors labeled IRD; while these are not appropriate for some patients due to the increased risk of HIV, HIV (+) kidney candidates stand to derive significant benefit from them. In part 4, we find that changes to national guidelines have led to a significant increase in the number of donors labeled CDC increased infectious risk, and that black donors are now significantly more likely to receive this label. Given that IRD kidneys are more likely to be discarded compared to similar organs without the label, this may reduce the supply of organs available for black, HIV (+) candidates. In part 5, we found that, while most nephrologists had been asked by patients about whether to accept an IRD kidney offer, knowledge of these donors was very low, and low knowledge was associated recommending decline of these organs. As such better education for nephrologists regarding IRD kidneys may facilitate shared decision making and increase utilization of IRD kidneys