September 19, 2014
HIV-positive patients who have reduced kidney function should take antiretroviral therapy, but should avoid regimens that contain tenofovir (Viread), according to updated treatment guidelines from the HIV Medicine Association (HIVMA).
The updated guidelines provide recommendations on the management of chronic kidney disease (CKD) in patients living with HIV, which has a prevalence of about 5%-10%, according to HIVMA. Included in the recommendations are ways to monitor kidney function and kidney damage, in particular, by measuring glomerular filtration rate (GFR).
"The revised guidelines are a comprehensive, clinically useful tool," said Joel Gallant, M.D., M.P.H., the current chair of HIVMA. "Despite limitations in the data, the guidelines now include more specific recommendations about screening for and managing kidney disease -- including proximal tubulopathy -- in patients taking tenofovir, which may now be the most common renal issue facing HIV providers."
In patients infected with HIV who have a GFR < 60 mL/minute/1.73 m2, we recommend avoiding tenofovir and other potential nephrotoxic drugs (e.g., nonsteroidal anti-inflammatory drugs) when feasible.
"The HIVMA guidance pretty much reflects what providers already do in practice," said David Wohl, M.D., an associate professor of medicine at the University of North Carolina School of Medicine. "That is, we are cautious about tenofovir in patients with renal issues and certainly respond with a dose adjustment or switch in those with declines in kidney function. This gets a bit more complicated when cobicistat or dolutegravir [Tivicay, DTG] are in the mix as these will lead to artifactual changes in creatinine. Also, if you jettison tenofovir, you most likely have to replace it. What to put in its place can get tricky especially if you believe abacavir [Ziagen] is problematic in persons at risk for cardiovascular disease. We need TAF [tenofovir alafenamide fumarate
Additionally, the guidelines recommend kidney transplantation for patients living with HIV whose kidneys are failing, along with HIV treatment dose adjustment and close monitoring of drug interactions.
Warren Tong is the research editor for TheBody.com and TheBodyPRO.com.
Follow Warren on Twitter: @WarrenAtTheBody.
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