- The risk of chronic kidney disease (CKD) is increased in individuals infected with human immunodeficiency virus (HIV) compared with the general population.
- In African Americans, HIV infection imparts a risk for end-stage renal disease (ESRD) that is of similar magnitude to that of diabetes.
- A constellation of potential factors contributes to excess kidney disease in HIV-infected patients, including direct effects by HIV infection, HIV-associated immune activation, drug toxicity, coinfection with hepatitis C virus, and a high prevalence of traditional kidney disease risk factors.
- 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 (S-L).
- 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 (W-L).
- 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 (S-L).
- 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) (S-L).
- 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) (S-M).
- 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 (S-M).
Figure 1. Chronic Kidney Disease Classification According to Glomerular Filtration Rate and Albuminuria Strata
Table 1. Classification of Albuminuria and Proteinuria
|Measurement||Normal to Mildly Increased (A1)||Moderately Increased (A2)||Severely Increased (A3)|
|AER, mg/24 h||<30||30-300||>300|
|PER, mg/24 h||<150||150-500||>500|
|Protein reagent strip||Negative or trace||Trace to 1||1 or greater|
|Adapted from the Kidney Disease: Improving Global Outcomes Guidelines (KDIGO) Chronic|
Kidney Disease Work Group. Kidney Int Suppl. 2013;3:1-150.
ACR, albumin-to-creatinine ratio; AER, albumin excretion rate; PCR, protein-to-creatinine ratio; PER, protein excretion rate.
Table 2. Risk Factors for CKD and ESRD: Data From Studies of HIV-Infected Persons and the General Population
(GFR <60 mL/min/1.73 m2
(GFR <15 mL/min/1.73 m2)
|Factor||Relative Risk Range||Relative Risk Range|
|Age||1.2-5.5 per 10 y older||2.0 for age >50 vs <30 y|
|CD4 cell count|
|HIV RNA||1.3-2.2 for detectable or higher vs undetectable or lower HIV RNA||2.0 per 1 log10 increase in HIV RNA|
|Hepatitis C coinfection or history of injection drug use||1.3-2.2||2.8-5.0|
|Tenofovir plus a ritonavir- boosted PI||3.4 vs an NNRTI-based regimen without tenofovir||NR|
|Indinavir||2.0-2.5 for any or recent exposure vs no or remote exposure||NR|
|Atazanavir||1.2 per year of exposure||NR|
|Lopinavir||1.1 per year of exposure||NR|