Management of Impaired Renal Function

Initial Assessment and Monitoring

The Infectious Diseases Society of America recommends quantifying proteinuria using spot urine protein/creatinine ratio to determine the extent of kidney damage, and performing renal ultrasound to assess kidney size and structure, which helps distinguish between acute and chronic kidney disease 1
Regular monitoring of kidney function with serum creatinine and estimated GFR is recommended to track progression or improvement, with a frequency of every 3-6 months for patients with GFR between 30-60 mL/min/1.73m² 2
The American College of Physicians suggests evaluating for persistent infection that may be contributing to kidney dysfunction, although this is based on a lower level of evidence 3 is replaced with * Screen for other comorbidities that may affect kidney function, including diabetes, hypertension, and hepatitis C coinfection, as recommended by the Infectious Diseases Society of America 1, 2

The American Academy of Pediatrics and the Infectious Diseases Society of America recommend treating post-streptococcal glomerulonephritis with penicillin (or erythromycin if penicillin-allergic) even if active infection is not present, to decrease antigenic load, although the strength of evidence for this recommendation is not specified 3 is replaced with no fact

The National Kidney Foundation recommends avoiding nephrotoxic medications when possible, or using them with caution and appropriate dose adjustments, and monitoring kidney function closely in patients requiring tenofovir, as it may cause tubular dysfunction 4
Consider discontinuing tenofovir if GFR decreases by >25% from baseline or drops below 60 mL/min/1.73m², as recommended by the National Kidney Foundation, based on moderate evidence 4

The American Association for the Study of Liver Diseases recommends considering combined antiviral treatment using pegylated interferon and ribavirin for patients with hepatitis C and GFR >30 mL/min/1.73m², based on high-quality evidence 5
For patients with mixed cryoglobulinemia with nephrotic proteinuria or progressive kidney disease, consider plasmapheresis, rituximab, or cyclophosphamide, along with IV methylprednisolone and antiviral therapy, as recommended by the American Association for the Study of Liver Diseases, based on moderate evidence 5

The Infectious Diseases Society of America recommends controlling blood pressure with preferential use of ACE inhibitors or angiotensin receptor blockers for HIV-infected patients with proteinuria, based on high-quality evidence 6
Avoid calcium channel blockers in patients receiving protease inhibitors, as recommended by the Infectious Diseases Society of America, based on moderate evidence 6
Patients with HIV-associated nephropathy should be treated with HAART at diagnosis, as recommended by the Infectious Diseases Society of America, based on high-quality evidence 6

Regular assessment of kidney function, blood pressure, proteinuria, and hematuria is recommended, although the strength of evidence for this recommendation is not specified, and is replaced with * Annual screening for patients at high risk for developing proteinuric renal disease (e.g., African American persons, those with CD4+ cell counts <200 cells/mL, HIV RNA levels >14,000 copies/mL, or those with diabetes mellitus, hypertension, or hepatitis C virus coinfection) is recommended by the Infectious Diseases Society of America, based on moderate evidence 1

The optimal management approach for a patient with CKD stage 2, microalbuminuria, and hypokalemia on antiretroviral therapy is to modify the antiretroviral regimen by switching from tenofovir disoproxil fumarate (TDF) to an alternative agent, initiate an ACE inhibitor for microalbuminuria, and consider amiloride for hypokalemia management, as recommended by Clinical Infectious Diseases guidelines 7, 8

Discontinue TDF if renal function declines by >25% from baseline or falls below 60 mL/min/1.73 m², particularly when there is evidence of proximal tubular dysfunction or worsening proteinuria, according to Clinical Infectious Diseases 8
Consider switching to abacavir as it is the only nucleoside analogue that does not require dose modifications for renal insufficiency, as stated by Clinical Infectious Diseases 8, 9
Before initiating abacavir, screen for the HLA-B*57:01 allele to prevent hypersensitivity reactions, as recommended by Clinical Infectious Diseases 8

Tenofovir-associated nephrotoxicity risk increases with concurrent use of other nephrotoxic medications, including boosted protease inhibitors, according to Clinical Infectious Diseases 8, 10
The risk of tenofovir-associated nephrotoxicity is higher in patients with baseline renal insufficiency, as stated by Clinical Infectious Diseases 8
When using abacavir as an alternative to tenofovir, be aware of potential increased cardiovascular risk, especially important since CKD itself increases cardiovascular risk, as noted by Clinical Infectious Diseases 8

ACE inhibition has been shown to be protective in HIV-associated nephropathy and is associated with improved outcomes in several small observational studies, according to Clinical Infectious Diseases 11