Published online Feb 28, 2018. doi: 10.3748/wjg.v24.i8.917
Peer-review started: November 4, 2017
First decision: November 22, 2017
Revised: December 10, 2017
Accepted: December 20, 2017
Article in press: December 20, 2017
Published online: February 28, 2018
The evidence on whether HBV infection affects renal outcome in patients with chronic kidney disease (CKD) is limited. Here we retrospectively explored the association between HBV infection with and without nucleos(t)ide analogue use and the risk of end-stage renal disease (ESRD) in patients with CKD.
There is a significant and increasing burden of CKD, ESRD, and HBV infection in Taiwan and worldwide. CKD patients have an increased risk of acquiring chronic HBV infection. However, the effect of HBV infection and nucleos(t)ide analogue use on the risk of ESRD in CKD patients remains unclear. Taiwan provides an ideal setting for studying this relationship because it has a high prevalence of these three conditions.
To investigate the effect of HBV infection with and without nucleos(t)ide analogue use on the ESRD risk in Taiwanese CKD patients.
By analyzing the Taiwan Longitudinal Health Insurance Database 2005, the authors used propensity score-matched and competing risk analyses to evaluate the effect of HBV infection with and without nucleos(t)ide analogue therapy on the development of ESRD in CKD patients. The authors used a modified Kaplan-Meier method and Gray’s method to calculate and compare the cumulative incidence of ESRD, and a modified Cox proportional hazard model in the presence of competing risk and stratified analyses to determine the ESRD risk between propensity-matched untreated HBV-infected and HBV-uninfected CKD patients as well as propensity-matched untreated and treated HBV-infected CKD patients. The authors also calculated the number of patients needed to be treated to yield one fewer ESRD.
In the propensity-matched untreated HBV-infected and HBV-uninfected CKD patients, the risk of ESRD was significantly higher in the untreated cohort (16-year cumulative incidence, 10.1%) than in the uninfected cohort (16-year cumulative incidence, 6.6%) with a significant adjusted hazard ratio of 1.67. In the propensity-matched HBV-treated and HBV-untreated CKD patients, the treated cohort (16-year cumulative incidence, 2.2%) had a significantly 87% reduced ESRD risk compared with the untreated cohort (16-year cumulative incidence, 11.9%). The number needed to treat for one fewer ESRD after NA use at 12 years was 12. Multivariable stratified analyses verified these associations in all subgroups. However, the cumulative ESRD incidence of the propensity-matched three cohorts warrants further prospective research because the propensity score matching cannot fit well in all treated, untreated, and uninfected CKD patients.
To the best of our knowledge, this is the first study to investigate the incidence and renal outcome in CKD patients acquiring chronic HBV infection and to evaluate the renal effect of nucleos(t)ide analogue therapy and the number needed to treat for one fewer ESRD in HBV-infected CKD patients. This has long been a neglected issue because there is no recommendation in the K/DOQI guidelines on whether HBV serological evaluation should be carried out in CKD patients. This large retrospective cohort study suggests that the incidence of CKD patients acquiring HBV infection is 3.2% and that untreated HBV infection and nucleos(t)ide analogue therapy are associated with increased and decreased risk of ESRD, respectively, in CKD patients. These findings imply that HBV infection may have a role in the pathogenesis of renal injury, and that HBV suppression may improve renal outcome among CKD patients. Our findings will be helpful in the future CKD prevention care program that assesses HBV status in CKD patients.
Future prospective study is warranted to confirm our findings and better understand the pathological mechanism underlying this association.