Antiretroviral therapy (ART) is beneficial for the 5 to 10 percent of HIV-infected patients with reduced kidney function, although tenofovir - the most widely prescribed medication - should be avoided, recommend updated guidelines released by the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) and published in the journal Clinical Infectious Diseases.
"Clinical Practice Guideline for the Management of Chronic Kidney Disease in Patients Infected with HIV" provides an update to guidelines last released in 2005, and notes that large studies conducted since then suggest tenofovir can lead to moderate kidney damage in some patients. The updated guidelines also recommend kidney transplantation as a viable option in HIV patients whose kidneys are failing.
Kidney disease is common in people with HIV - due to the virus itself, some antiretroviral and other medications, and a high prevalence of traditional kidney disease risk factors and other conditions, such as diabetes, hypertension, and co-infection with hepatitis C, said Gregory Lucas, MD, co-chair of the guidelines and associate professor at Johns Hopkins School of Medicine, Baltimore. HIV-infected people with kidney problems are at risk for kidney failure, called end-stage renal disease (ESRD). HIV-infected African Americans have a four- to five-fold increase risk of developing ESRD compared with HIV-uninfected African Americans. Additionally, even mild chronic kidney disease poses a substantially increased risk of cardiovascular disease and death.
"Research shows HIV patients who have clinically decreased kidney function are less likely to be prescribed ART, probably because physicians and other healthcare providers are concerned that many of these medications are cleared by the kidneys and don't want to cause further harm," said Dr. Lucas. "But the outlook for HIV patients with kidney disease is much better now that we have numerous effective treatments for HIV, many of which are not cleared by the kidneys."
The guidelines also point out that initial research suggests HIV patients who have kidney transplants are as likely to survive and to maintain a functioning organ as transplant recipients without HIV infection, despite previous concerns that HIV-infected patients wouldn't fare well on the immunosuppressive therapy necessary to prevent the body from rejecting the organ.
The guidelines also recommend those caring for HIV patients monitor both kidney function, by estimating glomerular filtration rate (GFR), and kidney damage, with urinalysis or urine protein. As many as one in 10 people with HIV have a GFR of less than 60 mL/min/1.73m2, indicating decreased kidney function, and as many as twice that may have persistent kidney damage (usually detected as proteinuria) with preserved kidney function.
"People with a GFR of less than 60 mL/min/1.73m2 should likely not be prescribed tenofovir - there are many different ART options, so why risk toxicity?" said Dr. Lucas. "Also, patients who are on tenofovir should be taken off if there is a clinically significant drop in kidney function, and placed on another therapy."