ARV Dosing: Renal Impairment

Dose adjustment of ARVs for impaired renal function

 

  1. Use CKD-EPI formula; the abbreviated modification of diet in renal disease (aMDRD) or the Cockcroft-Gault (CG) equation may be used as an alternative; see https://www.chip.dk/Tools-Standards/Clinical-risk-scores
  2. For Continuous Ambulatory Peritoneal Dialysis (CAPD) dosing for hemodialysis may be used. However, elimination of drugs in CAPD varies depending on CAPD conditions. TDM therefore is recommended
  3. Potential cardiovascular risk of ABC may increase cardiovascular risk associated with renal failure
  4. After dialysis
  5. Large bodily accumulation in impaired renal function. Although affinity for mitochondrial DNA polymerase is low and clinical toxicity in patients with severe renal impairment is rare, long-term mitochondrial toxicity is possible and must be monitored (polyneuropathy, pancreatitis, lactate acidosis, lipodystrophy, metabolic disturbances)
  6. 150 mg loading dose
  7. TDF and (boosted) PIs are associated with nephrotoxicity; consider alternative ART if pre-existing CKD, risk factors for CKD and/or decreasing eGFR, see ARV-associated Nephrotoxicity and Kidney Disease: Definition, Diagnosis and Management
  8. In certain countries TDF is labelled as 245 mg rather than 300 mg to reflect the amount of the prodrug (tenofovir disoproxil) rather than the fumarate salt (tenofovir disoproxil fumarate)
  9. Limited clinical data documented limited accumulation in hemodialysis. However, there is no long-term data on residual kidney function and bone toxicity. No data for eGFR < 10 mL/min but no dialysis
  10. Only licenced for hepatitis B
  11. 10 mg if co-administered with a boosting agent (inhibition of P-glycoprotein, P-gp)
  12. TAF/FTC/EVG/c as a single tablet regimen should generally be avoided in PLWH with end-stage renal disease on chronic dialysis. However, TAF/FTC/EVG/c may be used with caution if the potential benefits are considered to outweigh potential risks. One clinlical study has demontrated safety of TAF/FTC/EVG/c for PLWH on chronic dialysis [27]
  13. Limited data available in persons with renal impairment; pharmacokinetic analysis suggests no dose adjustment required
  14. See summary of product characteristics for specific recommendations; use with caution if eGFR ≤ 30 mL/min10 mg if co-administered with a boosting agent (inhibition of P-glycoprotein, P-gp)
  15. TAF/FTC and TAF/FTC/RPV single tablet regimens should generally be avoided in PLWH with end-stage renal disease on chronic dialysis. However, these combinations may be used with caution if the potential benefits are considered to outweigh potential risks
  16. ABC/3TC/DTG as a single tablet regimen should generally be avoided in PLWH with end-stage renal disease on chronic haemodialysis. A recent case series study found that use of ABC/3TC/DTG appears to be a safe and effective option in PLWH on chronic dialysis [28]