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"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"

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Published: Clinical Infectious Diseases ; 2014 ; 59 : 96 -138

Abstract

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

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*Every 12 to 18 months following publication, IDSA reviews its guidelines to determine whether an update is required. This guideline was published in September of 2014 and is the most current version/

Recommendations

RECOMMENDATIONS FOR KIDNEY DISEASE SCREENING

I. How Should HIV-Infected Patients Be Monitored for Kidney Function and Kidney Damage?

Recommendations

  1. We recommend 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 (strong, low).
  2. We suggest 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 (weak, low).

RECOMMENDATIONS FOR THE EVALUATION OF HIV-RELATED CKD

II. How Should HIV-Related Kidney Disease Be Evaluated and When Is Referral to a Nephrologist Appropriate?

Recommendations

  1. We recommend 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 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 (strong, low).
  2. We recommend 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) (strong, low).
  3. When possible, we recommend 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 (strong, moderate).
  4. When possible, we recommend 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 hemodialysis access (strong, moderate).

RECOMMENDATIONS FOR THE CLINICAL MANAGEMENT OF HIV-INFECTED PATIENTS WITH CKD

III. How Should Antiretroviral Therapy Be Managed in Patients With CKD or End-Stage Renal Disease?

Recommendations

  1. We recommend that clinicians prescribe ART and encourage persistence with therapy in HIV-infected patients who have CKD or end-stage renal disease (ESRD), as ART reduces mortality but is underused in this patient population (strong, moderate).
  2. We recommend that clinicians use either the CKD Epidemiology Collaboration (CKD-EPI) creatinine equation to estimate GFR or the Cockcroft-Gault equation to estimate creatinine clearance when dosing antiretroviral drugs or other drugs that require reduced doses in patients with reduced kidney function (strong, moderate).
  3. We recommend that patients with biopsy-confirmed or clinically suspected HIV-associated nephropathy (HIVAN) receive ART to reduce the risk of progression to ESRD (strong, moderate).
  4. In patients infected with HIV who have a GFR <60 mL/minute/1.73 m2, we recommend avoiding tenofovir and other potential nephrotoxic drugs (eg, nonsteroidal anti-inflammatory drugs) when feasible (strong, low).
  5. In tenofovir-treated patients who experience a confirmed GFR decline by >25% from baseline and to a level <60 mL/minute/1.73 m2, we recommend substituting alternative antiretroviral drug(s) for tenofovir, particularly in those with evidence of proximal tubular dysfunction (strong, low).

IV. 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?

Recommendations

  1. We recommend 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) (strong, high).
  2. We recommend 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) (strong, high).
  3. We suggest 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 (weak, high).

V. What Is the Optimal Blood Pressure Goal for HIV-Infected Patients With CKD?

Recommendations

  1. We recommend 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) (strong, moderate).
  2. We suggest 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) (weak, low).

VI. Should Patients With HIVAN Receive Corticosteroids to Reduce the Risk of ESRD?

Recommendation

  1. We suggest that clinicians consider corticosteroids as an adjunct to ART and ACE inhibitors or ARBs in patients with biopsy-confirmed HIVAN (weak, low).

VII. What Is the Role of Kidney Transplantation in Patients Infected With HIV and ESRD or Imminent ESRD?

Recommendations

  1. We recommend 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 (strong, moderate).
  2. We recommend dose adjustment and pharmacologic monitoring of immunosuppressant drugs in patients infected with HIV after kidney transplantation to account for pharmacologic interactions with antiretroviral drugs. When feasible, ART should be selected that minimizes interactions with immunosuppressant drugs (strong, moderate).

RECOMMENDATIONS FOR CKD IN CHILDREN AND ADOLESCENTS WITH HIV

VIII. How Should Children and Adolescents With HIV Be Screened for Kidney Disease and Monitored for Tenofovir-Associated Kidney Toxicity?

Recommendations

  1. Similar to adults, we recommend 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. We recommend 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 (strong, low).
  2. We suggest 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 (weak, low).

IX. Should Treatment of HIV-Related Kidney Disease Be Different for Children and Adolescents Than for Adults?

Recommendations

  1. We recommend that children and adolescents with HIV who have proteinuric nephropathy (including HIVAN) should be treated with ART and referred to a nephrologist (strong, moderate).
  2. We suggest using ACE inhibitors or ARBs to treat proteinuric nephropathy in children with HIV infection and suggest 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 (weak, very low). We suggest that corticosteroids not be used in children with HIVAN (weak, very low).

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