Guidelines for the management of chronic kidney disease in HIV-infected patients: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America

Several lines of evidence point to kidney disease as an important complication of human immunodeficiency virus (HIV) infection. Kidney function is abnormal in up to 30% of HIV-infected patients, AIDS-related kidney disease has become a relatively common cause of end-stage renal disease (ESRD) requiring dialysis, and kidney disease may be associated with progression to AIDS and death [1-4]. Because HIV caregivers commonly manage all aspects of treatment for their patients, these clinicians are in the unique and important position to identify those patients at risk for renal disease and implement potentially preventative and therapeutic strategies. Consequently, an understanding of the causes, epidemiology, screening methods, and therapeutic strategies associated with chronic kidney disease (CKD) in the HIV-infected patient is required. However, clinical research in this emerging area has not yet matured to the point at which it can provide clear evidence on how best to treat these patients. Therefore, assembled clinical experts in this field have reviewed the available literature and have offered the following recommendations, many of which are extrapolated from research and clinical guidelines [5] involving the general population with kidney disease. These guidelines address the clinical issues involved in both adults and children with HIV-related renal diseases and are written for those providing inpatient and outpatient care for these patients and for the patients themselves. Although the authors feel that these recommendations should generally apply to all HIV-infected patients, it is understood that providers need to tailor these guidelines around the needs and circumstances of the individual patient. We recommend that all patients at time of HIV diagnosis be assessed for existing kidney disease with a screening urine analysis for proteinuria and a calculated estimate of renal function (creatinine clearance or glomerular filtration rate [GFR]) (C-III); a renal function estimate also allows the caregiver to properly prescribe those antiretrovirals and other commonly used medications that require renal adjustment. If there is no evidence of proteinuria at initial evaluation, patients at high risk for the development of proteinuric renal disease (e.g., African American persons, those with CD4⁺ cell counts <200 cells/μL or HIV RNA levels >4000 copies/mL, or those with diabetes mellitus, hypertension, or hepatitis C virus coinfection) should undergo annual screening (B-II). Patients with proteinuria of grade ≥1+ by dipstick analysis or reduced renal function (GFR, <60 mL/min per 1.73 m²) should be referred to a nephrologist and undergo additional evaluation, including quantification of proteinuria, renal ultrasound, and potentially renal biopsy (B-II). Therapy for HIV-associated renal diseases should be individualized to the patient's clinical circumstances and to the underlying renal histology findings. Blood pressure should be controlled, with the initial preferential use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers for those patients with proteinuria (B-II); however, calcium channel blockers should be avoided in treating patients receiving protease inhibitors (D-II). Patients with HIV-associated nephropathy (HIVAN) should be treated with HAART at diagnosis (B-II). HAART should not be withheld from patients simply because of the severity of their renal dysfunction (B-III). Addition of ACE inhibitors or angiotensin receptor blockers (ARBs) should be considered in treating both adult and pediatric patients with HIVAN if HAART alone does not result in improvement of renal function (B-II). Prednisone should also be considered in treating adult patients with refractory HIVAN (B-II), although steroids are not recommended for children with HIVAN (D-II). Preliminary data suggest that renal transplantation may be a viable treatment option for patients with ESRD and should be considered if provided in a supervised clinical trial or at centers with adequate experience in this area (C-III). Dialysis and the placement of arteriovenous fistulae should not be withheld for patients solely because of HIV infection (A-II). Among those patients at higher risk (see "Renal Effects of Commonly Used Medications in HIV Care"), biannual monitoring for renal function and urinary abnormalities is warranted for those receiving indinavir (B-II) or tenofovir (B-III). HIV-infected patients requiring hemodialysis should have antibody to hepatitis B surface antigen (anti-HBs) titers checked after receiving a standard primary series of 3 hepatitis B vaccinations, and they should receive a fourth injection if these levels are <10 IU/L (B-II).