Background:  Among HIV-infected individuals, African Americans are at substantially higher risk of end-stage renal disease (ESRD) than white individuals. However, little is known about racial differences in the incidence and progression of chronic kidney disease (CKD) that underlie ESRD disparities. Our objective was to assess racial differences in HIV-associated CKD incidence, glomerular filtration rate (GFR) slope, and progression to ESRD in subjects with CKD.

Methods:  Data were analyzed from 3332 (78%) African American and 927 (22%) white participants in the Johns Hopkins HIV Cohort, who contributed 18,778 person-years of follow-up between 1990 and 2004. GFR was estimated by modification of diet in renal disease (MDRD) equation; CKD was defined as GFR <60 mL/min/L·73 m² for >3 months; ESRD was defined as initiation of renal replacement therapy. GFR slopes were estimated with a random-effects linear model. Factors associated incident CKD in the overall cohort and with progression to ESRD among those with CKD were assessed separately in Cox proportional hazards models.

Results:  Of the 284 individuals who developed CKD (7% of cohort), 100 progressed to ESRD. African American subjects were at increased risk for incident CKD compared to white participants (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.2 to 2.8). However, once commenced, CKD progression to ESRD was markedly higher in African American than white participants (HR 17.7, 95%CI 2.5 to 127.0). Correspondingly, high-grade proteinuria was more common in African American than white subjects with CKD (45% and 4%, respectively, p <0.001), and GFR decline following CKD diagnosis was 6-fold more rapid in the former than the latter group (p <0.001). Compared to white subjects with CKD, African American subjects with CKD were significantly more likely to progress to ESRD irrespective of whether they had a kidney biopsy demonstrating HIV-associated nephropathy (HIVAN) (HR 45, 95%CI 6 to 343, p <0.001), a biopsy showing non-HIVAN histopathology (HR 14, 95%CI 2 to 109, p =0.009), or did not have a kidney biopsy performed (HR 16, 95%CI 2 to 117, p =0.006).

Conclusions:  Our results suggest that black–white disparities in HIV-related ESRD are explained predominantly by a more aggressive CKD natural history in blacks, and less by racial differences in CKD incidence. Significantly faster progression of CKD to ESRD occurs in blacks than whites even when non-HIVAN histopathology is identified in the former.