ARV-associated Nephrotoxicity
Renal abnormality* | ARV | Management |
Proximal tubulopathy with any combination of:
|
TDF** |
Assessment:
Replace TDF by non-tenofovir drug or TAF*** if:
|
Nephrolithiasis:
|
IDV ATV (DRV) |
Assessment:
Consider stopping IDV/ATV if:
|
Interstitial nephritis:
|
IDV ATV |
Assessment:
Consider stopping IDV/ATV if:
|
Progressive decline in eGFR, but none of the above(v) |
TDF** PI/r |
Complete assessment
Consider stopping ARVs with potential nephrotoxicity if:
|
* Use of DTG, BIC, RPV, COBI and PI/b is associated with an increase in serum creatinine/reduction of eGFR (10-15 mL/min or up to 25%) due to inhibition of proximal tubular creatinine transporters without impairing actual glomerular filtration: consider new set point after 1-2 months
** TAF has shown lower tenofovir-related renal adverse effects due to lower systemic tenofovir exposure. Switch-studies from TDF to TAF and certain PIs suggest potential reversion of renal toxicity, however, longterm experience with TAF is lacking
*** There are limited data on use of TAF with low eGFR, particularly eGFR ≤ 10 mL/min
- UP/C in spot urine detects total urinary protein including protein of glomerular or tubular origin. The urine dipstick analysis primarily detects albuminuria as a marker of glomerular disease and is inadequate to detect tubular disease
- For eGFR: use CKD-EPI formula based on serum creatinine, gender, age and ethnicity because eGFR quantification is validated > 60 mL/ min. 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
- See Indications and Tests for Proximal Renal Tubulopathy (PRT)
- Microscopic haematuria is usually present
- Different models have been developed for calculating 5-year CKD risk score while using different nephrotoxic ARVs integrating HIV-independent and HIV-related risk factors
- RTV used as a boosting agent may induce nephrosclerosis