Kidney Disease

Definition, Diagnosis and Management

Diagnosis

Management

HIV-associated kidney disease(vi)

Prevention of progressive renal disease Comment
1. ART

Start ART immediately where HIV-associated nephropathy (HIVAN)(vii) or HIV immune complex disease strongly suspected. Immunosuppressive therapy may have a role in immune complex diseases. Renal biopsy to confirm histological diagnosis recommended
Consider replacing TDF** by non-tenofovir drug or TAF*** if:

  • UP/C 15-50 mg/mmol (see tubulopathy section)
  • eGFR > 60 mL/min, but decrease in eGFR by 5 mL/min per year for at least 3 consecutive years or confirmed 25% eGFR decline from baseline
  • co-morbidities with a high risk of CKD (i.e. diabetes and hypertension)
  • body weight < 60kg
  • use of a PI/r as a third agent

Replace TDF** by non-tenofovir drug or TAF*** if:

  • eGFR ≤ 60 mL/min
  • UP/C > 50 mg/mmol
  • nephrotoxic comedication
  • previous TDF toxicity (proximal renal tubulopathy)

** Expert opinion pending clinical data                                                               
*** There are limited data on use of TAF with eGFR ≤ 30 mL/min, and longer term outcomes are unknown

2. Start ACE inhibitors or angiotensin-II receptor antagonists if:

  • Hypertension and/or
  • Proteinuria

Monitor eGFR and K+ level closely on starting treatment or increasing dose

Blood pressure target: < 130/80 mmHg

General measures:

  • Avoid nephrotoxic drugs
  • Lifestyle measures (smoking, weight, diet)
  • Treat dyslipidaemia(viii) and diabetes(ix)
  • Adjust drug dosages where necessary(v)
CKD and proteinuria are independent risk factors for CVD

 

  1. 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.
    Definition CKD: eGFR < 60 mL/min for > 3 months (see https://kdigo.org/guidelines/ckd-evaluation-and-management/). If not previously known to have CKD, confirm pathological eGFR within 2 weeks. Use of DTG, RPV, COBI and RTV boosted PIs is associated with an increase in serum creatinine/reduction of eGFR (10-15 mL/min/1.73m2) due to inhibition of proximal tubular creatinine transporters without impairing actual glomerular filtration: consider new set point after 1-2 months 
  2. Urinalysis: use urine dipstick to screen for haematuria. To screen for proteinuria, use urine dipstick and if ≥ 1+ check urine albumin/creatinine (UA/C) to screen for glomerular disease or protein/creatinine (UP/C) to screen for both glomerular and tubular disease, see iii and ARV-nephrotoxicity. Proteinuria is defined as persistent if confirmed on ≥ 2 occasions > 2-3 weeks apart
  3. UA/C largely detects glomerular disease and can be used for screening for HIV-associated renal disease and in diabetics but is not appropriate for screening for tubular proteinuria secondary to drug nephrotoxicity (e.g. TDF), where UP/C should be used (see Indications and Tests for Proximal Renal Tubulopathy and ARV-nephrotoxicity). KDIGO screening values for UA/C are: < 3, 3-30 and > 30 mg/mmoL and for UP/C: < 15, 15-50, > 50 mg/mmol [10], [11]. UA/C and UP/C ratio are calculated as urine protein albumin (or protein) (mg/L) / urine creatinine (mmol/L); may also be expressed as mg/mg. Conversion factor for mg to mmol creatinine is x 0.000884
  4. Repeat eGFR and urinalysis as per screening table, see Assessment of PLWH at Initial and Subsequent visits 
  5. See Dose Adjustment of ARVs for Impaired Renal Function 
  6. Joint management with a nephrologist 
  7. HIVAN suspected if black ethnicity & UAP/C > 30 mg/mmol & no haematuria 
  8. See Dyslipidaemia 
  9. See Type 2 Diabetes 
  10. Different models have been developed for calculating a 5-years CKD risk score while using different nephrotoxic ARVs integrating HIV-independent and HIV-related risk factors [12], [13]

See online video lecture CVD, CKD and Endocrinology from the EACS online course Clinical Management of HIV.