Management of TDF-induced Fanconi Syndrome

Immediate Management

Discontinue TDF immediately upon diagnosis of Fanconi syndrome, as continued exposure can lead to worsening renal function and irreversible damage 1, 2, 4
Monitor electrolytes closely, particularly phosphate, potassium, and bicarbonate levels, as Fanconi syndrome causes significant electrolyte wasting 5, 6

Switch to Tenofovir Alafenamide (TAF) if creatinine clearance is above 30 mL/min, as it has less renal toxicity while maintaining antiviral efficacy 3, 7
Switch to Abacavir in patients with significant renal impairment, as it does not require dose adjustment in renal disease 3, 7
Consider Dolutegravir or Raltegravir plus TAF/emtricitabine as these regimens have fewer renal adverse effects 2, 3

Switch to Entecavir as it has minimal renal toxicity and is effective for HBV treatment 1, 8
Switch to TAF if available, as it provides similar efficacy with reduced renal and bone toxicity 1
Consider Besifovir (where available) as an alternative based on previous treatment history 1

Monitor renal function with eGFR, urinalysis, and testing for glycosuria, albuminuria or proteinuria every 6 months 3, 7
Assess for resolution of tubular dysfunction by checking for normalization of phosphate, glucose, and amino acid wasting 6
Continue monitoring viral load to ensure efficacy of the alternative treatment 1

TAF should not be initiated in patients with creatinine clearance below 30 mL/min 7
For patients with active TDF-associated proximal tubulopathy, TAF should ideally be initiated only after tubulopathy has resolved, with monitoring for recurrence 3
Patients with multidrug resistance may require combination therapy (e.g., entecavir plus TAF) to maintain viral suppression 1, 8
Risk factors for TDF-induced nephrotoxicity include concurrent use of ritonavir-boosted protease inhibitors, preexisting renal disease, and previous exposure to adefovir 5