Management of CMV Infection in HIV Patients with Acute Kidney Injury

Immediate CMV Treatment with Renal Dose Adjustment

The Infectious Diseases Society of America recommends initiating IV ganciclovir at renally-adjusted doses immediately for CMV treatment in patients with acute kidney injury, as CMV can worsen AKI and untreated AKI will complicate antiviral dosing 1, 2
For patients with severe renal impairment (CrCl 10-24 mL/min), the recommended induction therapy is 450 mg IV every other day, instead of the standard 5 mg/kg twice daily 1
The American College of Clinical Pharmacology recommends using IV ganciclovir rather than valganciclovir in patients with CrCl <10 mL/min, as the oral formulation is not recommended at this level of renal function 1

The National Kidney Foundation recommends discontinuing all nephrotoxic medications, including NSAIDs, aminoglycosides, tenofovir (TDF), atazanavir, and lopinavir/ritonavir, to prevent further kidney damage 3, 4
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines suggest that the "triple whammy" combination (NSAIDs + diuretics + ACE inhibitors/ARBs) must be discontinued if present, as it can worsen AKI 2

The International AIDS Society recommends switching from tenofovir disoproxil fumarate (TDF) to tenofovir alafenamide (TAF) or abacavir if TDF is part of the current regimen, as TDF is associated with proximal tubular dysfunction and should be avoided in patients with CrCl <60 mL/min 3, 4
The European AIDS Clinical Society recommends avoiding atazanavir and lopinavir/ritonavir in the setting of CKD or rapid eGFR decline, as these have been linked to interstitial nephritis and progressive kidney disease 3, 4

The American College of Physicians recommends measuring serum creatinine and electrolytes every 12-24 hours during acute management, and monitoring urine output, vital signs, and fluid balance closely in the first 48-72 hours 2
The National Institute of Diabetes and Digestive and Kidney Diseases suggests calculating creatinine clearance using the Cockcroft-Gault formula rather than relying on eGFR equations, as these require steady-state creatinine and are inaccurate in AKI 4, 2

The Infectious Diseases Society of America warns against using standard-dose valganciclovir or ganciclovir without renal adjustment, as this will cause severe bone marrow suppression and worsening toxicity 1
The American College of Clinical Pharmacology advises against using furosemide in hemodynamically unstable patients with prerenal AKI, as it worsens volume depletion and reduces renal perfusion 2

The Infectious Diseases Society of America recommends adjusting valganciclovir to 450 mg every other day for CrCl 25-39 mL/min, or 450 mg twice weekly for CrCl 10-24 mL/min, for maintenance dosing 1
The Centers for Disease Control and Prevention suggest continuing maintenance therapy until immune reconstitution occurs (CD4 count >100 cells/mm³ for at least 3-6 months on ART) 1

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines note that AKI in HIV patients is independently associated with increased in-hospital mortality, and even with complete AKI recovery, patients remain at increased risk of progressive CKD and require long-term follow-up 2