By: Dr. Geoffrey Modest
An updated guideline came out of the Infectious Diseases Society of America on the management of chronic kidney disease in patients with HIV in October (see doi:10.1093/cid/ciu730). They note that chronic kidney disease is common in people with HIV, can be multifactorial (including direct HIV renal involvement and adverse medication effects), and is itself associated with increased morbidity and mortality. People with HIV with decreased GFR and albuminuria have an even higher risk of cardiovascular events (6-fold) than the increased risk in the general population (of note, the decreased GFR and albuminuria are independently associated with cardiovascular events, worse if both are present).
The guideline committee stresses that these are guidelines and not intended to supplant clinical judgment in the management of individual patients. recommendations:
–Check eGFR when antiretroviral therapy is initiated or changed, and at least twice a year in stable patients (strong rec, low qual evidence)
–Check urine with urinalysis or quantitative measure of albuminuria/proteinuria at baseline, when HIV meds initiated or changed, and at least annually (weak rec, low qual evidence)
–In those with new-onset/newly discovered kidney disease, check chem panel, urinalysis, quantitative albuminuria (eg albumin/creat ratio from spot urine), assess temporal trends in eGFR, blood pressure, glucose in diabetics, markers of proximal tubular dysfunction (eg increased excretion of phosphorus and glycosuria with normal blood sugar are both highly specific markers of proximal tubular dysfunction) esp. in those on tenofovir, renal ultrasound, review meds including nonprescription ones for both potential cause of renal dysfunction and if renal dosing required (strong rec, low qual evidence) [some studies have also found increased tenofovir nephrotoxicity when combined with atazanavir, amprenavir or ritonavir-boosted PIs]
—Their table 6 reviews the different HIV meds and renal dose-adjustments for decreased GFR [this is really helpful]
–Refer to nephrologist if clinically significant decline in GFR (eg >25%, or if <60 ml/min/1.73m2). also consider if albuminuria>300mg/d or hematuria of renal origin. HIVAN (HIV associated nephropathy) typically presents with massive proteinuria in setting of advanced HIV disease, but one can be fooled, and biopsy is reasonable if considering steroid therapy.
–Use either CKD Epidemiology Collaboration (CKD-EPI) to estimate GFR or Cockcroft-Gault equation to estimate creatinine clearance (strong rec, moderate qual evidence) — both of these need just serum creatinine, age, and gender. CKD-EPI more accurate, esp. if GFR>60. for calculators, go here
–Avoid tenofovir or other nephrotoxins (eg NSAIDS) if GFR<60 (strong rec, low qual evidence). also avoid in prepubertal children because of renal effects and bone mineral density loss
–If already on tenofovir and GFR declines >25% and to level<60, substitute alternative med (strong rec, low qual evidence)
–Use ACE-I or ARB in people with HIVAN or clinically significant albuminuria (>30mg/d in diabetics, >300mg/d in nondiabetics(strong rec, high qual evidence)
–Use statins if high risk of cardiovascular disease (strong rec, high qual evidence), aspirin balanced against individual’s bleeding risk (weak rec, high qual evidence)
–BP targets are <140/90 in those with CKD and albuminuria <30gm/d (strong rec, moderate qual evidence); <130/80 if albuminuria 30-300 mg/d (weak rec, low qual evidence) [note that these differ from JNC-8 targets]
–Consider steroids as adjunct to ART and ACE-I/ARB if biopsy confirmed HIVAN (weak rec, low qual evidence), though not in children
–In patients with ESRD, consider transplant (rates of patient/graft survival are now pretty high).
So, I think pretty useful guidelines, esp. some of their tables (eg table 6 as noted, for renal dosing of HIV meds. other tables deal with antibiotic dosing and drug-drug interactions for immunosuppressant’s and HIV drugs — eg prednisone, tacrolimus…)
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