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)
21881
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)
21881

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)
21881
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)
21881
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)
21881
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)
21881

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)
21881
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)
21881
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)
21881
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)
21881
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)
21881

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)
21881
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)
21881
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)
21881

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)
21881
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)
21881

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)
21881

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)
21881
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)
21881

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)
21881
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)
21881

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)
21881

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)
21881
IDSA suggests that corticosteroids NOT be used in children with HIVAN (WR, VL)
21881

Recommendation Grading

Overview

Title

Management of Chronic Kidney Disease in Patients Infected With HIV

Authoring Organizations

Publication Month/Year

September 24, 2014

Last Updated Month/Year

April 4, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

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

Gregory M. Lucas, Michael J. Ross, Peter G. Stock, Michael G. Shlipak, Christina M. Wyatt, Samir K. Gupta, Mohamed G. Atta, Kara K. Wools-Kaloustian, Paul A. Pham, Leslie A. Bruggeman, Jeffrey L. Lennox, Patricio E. Ray, Robert C. Kalayjian, 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, Clinical Infectious Diseases, Volume 59, Issue 9, 1 November 2014, Pages e96–e138, https://doi.org/10.1093/cid/ciu617