Definitions of the levels of evidence (I-III) and grades of recommendation (A-E) are repeated at the end of the Major Recommendations field.
Screening and Initial Evaluations
All patients at the time of human immunodeficiency virus (HIV) diagnosis should be assessed for existing kidney disease with a screening urine analysis for proteinuria and a calculated estimate of renal function (C-III).
If there is no evidence of proteinuria at initial evaluation, patients at high risk for the development of proteinuric renal disease (i.e., African American persons, those with CD4+ cell counts <200 microL or HIV RNA levels >4,000 copies/mL, and those with diabetes mellitus, hypertension, or hepatitis C virus coinfection) should undergo annual screening (B-II). Renal function should be estimated on a yearly basis to assess for changes over time (B-II).
Additional evaluations (including quantification of proteinuria, renal ultrasound, and potentially renal biopsy) and referral to a nephrologist are recommended for patients with proteinuria of grade >1+ by dipstick analysis or glomerular filtration rate (GFR) <60 mL/min per 1.73 m2 (B-II).
Management
In HIV-infected patients with evidence of nephropathy, blood pressure should be controlled to a level no higher than 125/75 mm Hg (B-III), with the initial preferential use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) for those patients with proteinuria (B-II). Calcium channel blockers should be avoided in patients receiving protease inhibitors (D-II).
Dialysis and the placement of arteriovenous fistulae (native fistulae preferred [A-II]) should not be withheld for patients solely because of HIV infection (A-II)
Renal transplantation may be considered for patients with end-stage renal disease (ESRD) if provided in a supervised clinical trial or at centers with adequate experience in this area (C-III).
Patients with HIV-associated nephropathy (HIVAN) should be treated with highly active antiretroviral therapy (HAART) at diagnosis (B-II). HAART should not be withheld from patients simply because of the severity of their renal dysfunction (B-III).
Addition of ACE inhibitors, ARBs, and/or prednisone should be considered in patients with HIVAN if HAART alone does not result in improvement of renal function (B-II).
Antiretroviral Dosing And Renal Toxicities
Appropriate reduction of dosing for antiretrovirals that are primarily renally eliminated is warranted (C-III), with additional doses given after hemodialysis for those drugs that are readily removed by dialysis (B-II).
Nucleoside analogues should not be withheld in patients with reduced renal function for fear of the development of lactic acidosis (D-III).
Patients receiving indinavir should drink at least 1.5 L of water daily to prevent stone formation (B-III). Periodic monitoring of renal function and pyuria should be performed during the first 6 months of indinavir therapy and biannually thereafter (B-II), although routine screening for crystalluria is not warranted unless there is a suspicion of nephrolithiasis (B-II). Indinavir need not be withheld from patients with reduced renal function (C-III). In patients who develop indinavir nephrolithiasis, it would be reasonable to restart indinavir therapy once rehydration is achieved (B-III). Patients who develop indinavir-induced hypertension, pyuria, rhabdomyolysis, or renal insufficiency (acute or chronic) should permanently discontinue use of this drug (B-III).
Patients receiving tenofovir who have a GFR <90 mL/min per 1.73 m2, patients receiving other medications eliminated via renal secretion (e.g., adefovir, acyclovir, ganciclovir, or cidofovir), patients with other comorbid diseases (e.g., diabetes or hypertension), or patients receiving ritonavir-boosted protease inhibitor regimens should be monitored at least biannually for measurements of renal function, serum phosphorus, and urine analysis for proteinuria and glycosuria (B-III).
HIV Antiretroviral Dosing Recommendations
A summary of dosing recommendations for patients with chronic kidney disease (CKD)/ESRD is provided in Table 3 of the original guideline document.
Renal Dosing of Antibiotics Commonly Used in HIV Care
Many of the antimicrobials commonly used to prevent and treat opportunistic infections such as Pneumocystis jiroveci pneumonia, Toxoplasma encephalitis, and Mycobacterium avium intracellulare infections require dose reduction in the HIV-infected patient with CKD because of their renal elimination. Recommended dosing data for these drugs are available in Table 4 of the original guideline document.
HIV Infection And CKD in the Pediatric and Adolescent Populations
In children without evidence of existing renal disease, screening evaluation for the development of HIVAN is similar to that proposed earlier for adults and should include complete urinalysis and testing to determine serum electrolyte levels, blood urea nitrogen levels, and creatinine levels every 6 months (C-III).
Pediatric HIVAN and other proteinuric nephropathies in HIV-infected children should be treated with HAART; referral to a nephrologist and the addition of ACE-inhibition should also be considered for patients with more severe proteinuria (grade >1+ by urine dipstick analysis or a protein-to-creatinine ratio >0.2 g/g for 3 separate specimens) (C-III). Steroid use is not recommended for this population (D-II).
Special Topics
Use of recombinant human erythropoietin should be considered in patients with hemoglobin levels 2 g/dL less than the lower limit of normal; the therapeutic hemoglobin target is a hemoglobin level of 11 to 12 g/dL (C-III).
Analogous to the general population with CKD, all HIV-infected ESRD patients with secondary hyperparathyroidism (serum calcium level, <9.5 mg/dL; serum phosphorus level, <4.6 mg/dL; and serum parathyroid hormone level, >35 pcg/mL) should be treated with 1,25-dihydroxy vitamin D3 or its analogues (C-III).
HIV-infected patients requiring hemodialysis should have anti-HBs titers checked after receiving a standard primary series of 3 hepatitis B vaccinations and should receive a fourth injection if these titers are <10 IU/L (B-II).
Vaccinations Recommended for HIV-Infected Adults with Chronic Kidney Disease
| Pathogen |
Recommendation(s) |
| Streptococcus pneumoniae |
Pneumovaxa or Pnu-Imuneb 23 administered in a single 0.5-mL subcutaneous or intramuscular dose if CD4+ cell count >200 cells/mm3. Additional vaccination is recommended for patients initially vaccinated at a CD4+ count <200 cells/mm3 whose CD4+ count increases to >200 cells/mm3. It is preferable to vaccinate such individuals before development of end-stage renal disease. Patients should be revaccinated after 5 years. |
| Influenza virus |
All patients should be vaccinated annually. |
| Hepatitis A virus |
Patients who are negative for anti-hepatitis A virus and patients at increased risk for hepatitis A virus infection (e.g., illicit drug users, men who have sex with men, and patients with chronic liver disease [including chronic hepatitis B or hepatitis C]) should be vaccinated. |
| Hepatitis B virus |
| Patients of all ages |
For monitoring, check antibody to hepatitis B surface antigen (anti-HBs) titers 1-2 months after the last primary vaccine dose is administered (an adequate response is >10 mIU/mL). Revaccinate those patients who do not respond with 3 doses. For those patients who do respond, follow anti-HBs levels semiannually; if anti-HBs levels are <10 mIU/mL, administer a booster dose. |
Patients aged >20 years
Predialysis
Dialysis dependent
|
Administer Recombivax HBa at a dose of 10 micrograms at 0, 1, and 6 months or Engerix-Bc at a dose of 20 micrograms intramuscularly (im) at 0, 1, and 6 months.
Administer Recombivax HBa at a dose of 40 micrograms at 0, 1, and 6 months or Engerix-Bc at a dose of 40 micrograms im at 0, 1, and 6 months.
|
| Patients aged <20 years |
Administer Recombivax HBa at a dose of 5 micrograms at 0, 1, and 6 months or Engerix-Bc at a dose of 10 micrograms im at 0, 1, and 6 months. |
aMerck
bLederle
cSmithKline Beecham Biologicals
Definitions
Quality of Evidence
- Evidence from at least one properly randomized, controlled trial
- Evidence from at least one well-designed clinical trial without randomization, from cohort or case-control analytic studies (preferably from more than one center), from multiple time-series studies, or from dramatic results of uncontrolled experiments
- Evidence from opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees
Strength of Recommendations
- Good evidence to support a recommendation for use
- Moderate evidence to support a recommendation for use
- Poor evidence to support a recommendation
- Moderate evidence to support a recommendation against use
- Good evidence to support a recommendation against use
