Management of Chronic Kidney Disease in Patients Infected With HIV

Publication Date: September 24, 2014
Last Updated: September 2, 2022

Diagnosis

Monitoring

IDSA recommends monitoring creatinine-based estimated glomerular filtration rate (GFR) when antiretroviral therapy (ART) is initiated or changed, and at least twice yearly in stable HIV-infected patients using the same estimation method to track trends over time. More frequent monitoring may be appropriate for patients with additional kidney disease risk factors. (SR, L)
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IDSA suggests monitoring kidney damage with urinalysis or a quantitative measure of albuminuria/proteinuria at baseline, when ART is initiated or changed, and at least annually in stable HIV-infected patients. More frequent monitoring may be appropriate for patients with additional kidney disease risk factors. (WR, L)
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Evaluation

IDSA recommends that the evaluation of new-onset or newly discovered kidney disease in HIV-infected persons include serum chemistry panel; complete urinalysis; quantitation of albuminuria (albumin-to-creatinine ratio (ACR) from spot sample or total albumin from 24-hour collection); assessment of temporal trends in estimated GFR, blood pressure, and blood glucose control (in patients with diabetes); markers of proximal tubular dysfunction (particularly if treated with tenofovir); a renal sonogram; and review of prescription and over-the-counter medications for agents that may cause kidney injury or require dose modification for decreased kidney function. (SR, L)
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IDSA recommends that HIV-infected patients with kidney disease be referred to a nephrologist for diagnostic evaluation when there is a clinically significant decline in GFR (ie, GFR decline by >25% from baseline and to a level <60 mL/minute/1.73 m2) that fails to resolve after potential nephrotoxic drugs are removed, there is albuminuria in excess of 300 mg PER day, hematuria is combined with either albuminuria/proteinuria or increasing blood pressure, or for advanced CKD management (GFR <30 mL/minute/1.73 m2). (SR, L)
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When possible, IDSA recommends establishing permanent dialysis access, ideally an arteriovenous fistula or peritoneal catheter, prior to the anticipated start of renal replacement therapy to avoid the use of higher-risk central venous catheters for hemodialysis (HD). (SR, M)
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When possible, IDSA recommends avoiding the use of peripherally inserted central catheters and subclavian central venous catheters in patients with HIV who are anticipated to need dialysis in the future because these devices can damage veins and limit options for permanent HD access. (SR, M)
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Treatment

Management

IDSA recommends that clinicians prescribe ART and encourage persistence with therapy in HIV-infected patients who have CKD or ESRD, since ART reduces mortality but is underused in this patient population. (SR, M)
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IDSA recommends that clinicians use either the CKD Epidemiology Collaboration (CKD-EPI) creatinine equation to estimate GFR or the Cockcroft-Gault equation to estimate creatinine clearance (CrCl) when dosing antiretroviral drugs or other drugs that require reduced doses in patients with reduced kidney function. (SR, M)
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IDSA recommends that patients with biopsy-confirmed or clinically suspected HIV-associated nephropathy (HIVAN) receive ART to reduce the risk of progression to ESRD. (SR, M)
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In patients infected with HIV who have a GFR <60 mL/min/1.73 m2, IDSA recommends avoiding tenofovir and other potential nephrotoxic drugs (eg, nonsteroidal anti-inflammatory drugs) when feasible. (SR, L)
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In tenofovir-treated patients who experience a confirmed GFR decline by >25% from baseline and to a level <60 mL/min/1.73 m2, IDSA recommends substituting alternative antiretroviral drug(s) for tenofovir, particularly in those with evidence of proximal tubular dysfunction. (SR, L)
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Cardiovascular Drugs

IDSA recommends using angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), when clinically feasible, in patients infected with HIV who have confirmed or suspected HIVAN or clinically significant albuminuria (eg, >30 mg/day in diabetic patients; >300 mg/day in nondiabetic patients). (SR, H)
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IDSA recommends that HIV-infected individuals with pre-ESRD CKD be treated with statins to prevent cardiovascular disease as appropriate for persons in the highest cardiovascular risk group (eg, >7.5% 10-year risk of cardiovascular disease). (SR, H)
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IDSA suggests that clinicians consider prescribing aspirin (75-100 mg/day) to prevent cardiovascular disease in HIV-infected individuals with CKD. However, the benefit of aspirin should be balanced against the individual’s risk of bleeding. (WR, H)
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Blood Pressure

IDSA recommends a target blood pressure of <140/90 mm Hg in HIV-infected patients who have CKD with normal to mildly increased albuminuria (eg, <30 mg/day or equivalent). (SR, M)
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IDSA suggests a target blood pressure of <130/80 mm Hg in HIV-infected patients who have CKD with moderately to severely increased albuminuria (eg, >30-300 mg/day or equivalent). (WR, L)
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Corticosteroids

IDSA suggests that clinicians consider corticosteroids as an adjunct to ART and ACE inhibitors or ARBs in patients with biopsy-confirmed HIVAN. (WR, L)
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Kidney Transplantation

IDSA recommends that HIV providers assess patients with HIV and ESRD or imminent ESRD for the possibility of kidney transplantation, considering history of opportunistic conditions, comorbidities, current immune status, and virologic control of HIV with ART. (SR, M)
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IDSA recommends that HIV providers assess patients with HIV and ESRD or imminent ESRD for the possibility of kidney transplantation, considering history of opportunistic conditions, comorbidities, current immune status, and virologic control of HIV with ART. (SR, M)
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Children and Adolescents with HIV

Screening

Similar to adults, IDSA recommends that children and adolescents with HIV who are without evidence of existing kidney disease should be screened for renal function with estimated GFR (using an estimating equation developed for children) when ART is initiated or changed and at least twice yearly. IDSA recommends monitoring for kidney damage with urinalysis or a quantitative measure of proteinuria when ART is initiated or changed, and at least annually in children and adolescents with stable kidney function. More frequent monitoring may be appropriate with additional kidney disease risk factors. (SR, L)
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IDSA suggests avoiding tenofovir as part of first-line therapy in prepubertal children (Tanner stages 1-3) because tenofovir use is associated with increased renal tubular abnormalities and bone mineral density loss in this age group. (WR, L)
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Treatment

IDSA recommends that children and adolescents with HIV who have proteinuric nephropathy (including HIVAN) should be treated with ART and referred to a nephrologist. (SR, M)
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IDSA suggests using ACE inhibitors or ARBs to treat proteinuric nephropathy in children with HIV inhibitors or ARBs to treat proteinuric nephropathy in children with HIV inhibitors or ARBs to treat proteinuric nephropathy in children with HIV infection and suggests their use as first-line therapy for hypertension in these children. Because HIV-infected children with proteinuria may be at greater risk for salt wasting and prone to dehydration, ACE inhibitors and ARBs should be used with caution in children.

(WR, VL)
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IDSA suggests that corticosteroids NOT be used in children with HIVAN (WR, VL)
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Recommendation Grading

Overview

Title

Management of Chronic Kidney Disease in Patients Infected With HIV

Authoring Organizations

HIV Medicine Association

Infectious Diseases Society of America

Publication Month/Year

September 24, 2014

Last Updated Month/Year

November 25, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function, present for >3 months, with implications for health. CKD is common in human immunodeficiency virus (HIV)–infected persons, has many potential underlying etiologies, and is associated with increased morbidity and mortality. These guidelines for the management of CKD in patients infected with HIV are an update of the 2005 version, designed to identify clinically relevant management questions, summarize pertinent data from clinical studies, and offer recommendations for clinical care. The scope of this document is CKD in HIV-infected adults and children in the United States. The guidelines do not address screening, evaluation, or management of HIV-related kidney disease in resource-constrained settings.

Target Patient Population

Patients with chronic kidney disease (CKD) and infected with human immunodeficiency virus (HIV)

PICO Questions

  1. How should HIV-infected patients be monitored for kidney function and kidney damage?

  2. How should HIV-related kidney disease be evaluated and when is referral to a nephrologist appropriate?

  3. How should antiretroviral therapy be managed in patients with CKD or end-stage renal disease?

  4. What are the roles of angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, HMG-coenzyme A reductase inhibitors (statins), and aspirin in HIV-infected patients with CKD to prevent kidney disease progression and/or reduce cardiovascular disease risk?

  5. What is the optimal blood pressure goal for HIV-infected patients with CKD?

  6. Should patients with HIVAN receive corticosteroids to reduce the risk of ESRD?

  7. What is the role of kidney transplantation in patients infected with HIV and ESRD or imminent ESRD?

  8. How should children and adolescents with HIV be screened for kidney disease and monitored for tenofovir-associated kidney toxicity?

  9. Should treatment of HIV-related kidney disease be different for children and adolescents than for adults?

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospital, Laboratory services, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Management

Diseases/Conditions (MeSH)

D006678 - HIV, D007674 - Kidney Diseases, D012080 - Chronic Kidney Disease-Mineral and Bone Disorder

Keywords

chronic kidney disease, HIV, HIV-1, CKD, HIV-associated nephropathy

Source Citation

Lucas GM, Ross MJ, Stock PG, et al. Clinical practice guideline for the management of chronic kidney disease in patients infected with HIV: 2014 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2014 Sep 17. pii: ciu617. [Epub ahead of print]