HIVMA Issues Guidelines for Managing Chronic Kidney Disease in People with HIV

The HIV Medical Association (HIVMA) of the Infectious Diseases Society of America (IDSA) has released updated recommendations for HIV positive people with chronic kidney disease. The guidelines, published in the September 17 issue of Clinical Infectious Diseases, state that antiretroviral therapy (ART) is beneficial for such patients, but they should avoid tenofovir (Viread, also in the Truvada, Atripla, Complera, and Stribild coformulations), which can cause kidney impairment.

An estimated 5% to 10% of people with HIV have chronic kidney disease (CKD), a condition that occurs more often among people of African descent and increases with age. Kidney problems are among the non-AIDS conditions that appear to occur earlier and more often in HIV positive people as they age. Coinfection with hepatitis C virus (HCV) is also associated with an increased risk of kidney dysfunction.

The revised HIVMA guidelines -- which update the previous version from 2005 -- include recommendations in the following areas:

• How Should HIV-Infected Patients Be Monitored for Kidney Function and Kidney Damage?
• How Should HIV-Related Kidney Disease Be Evaluated and When Is Referral to a Nephrologist Appropriate?
• How Should Antiretroviral Therapy Be Managed in Patients With CKD or End-Stage Renal Disease?
• What Are the Roles of Angiotensin-Converting Enzyme Inhibitors, Angiotensin II Receptor Blockers, HMG–Coenzyme A Reductase Inhibitors (Statins), and Aspirin in HIV-Infected Patients With CKD to Prevent Kidney Disease Progression and/or Reduce Cardiovascular Disease Risk?
• What Is the Optimal Blood Pressure Goal for HIV-Infected Patients With CKD?
• Should Patients With HIVAN Receive Corticosteroids to Reduce the Risk of ESRD?
• What Is the Role of Kidney Transplantation in Patients Infected With HIV and ESRD or Imminent ESRD?
• How Should Children and Adolescents With HIV Be Screened for Kidney Disease and Monitored for Tenofovir-Associated Kidney Toxicity?
• Should Treatment of HIV-Related Kidney Disease Be Different for Children and Adolescents Than for Adults?

"Strong associations between markers of kidney function and important clinical outcomes, including cardiovascular events and all-cause mortality in ART-treated persons living with HIV, provide a compelling rationale to identify interventions that preserve or improve kidney function while also reducing the incidence of these clinical outcomes," the guidelines authors state. They note that kidney disease is among the clinical endpoints in the Strategic Timing of Antiretroviral Therapy Trial (START) evaluating the benefits and risks of early ART.

Below is an edited excerpt from a HIVMA/IDSA press release describing the new recommendations, which are available in full for free online.

Antiretroviral Therapies Are Beneficial for HIV Patients with Kidney Problems

Kidney Transplant Feasible: HIVMA/IDSA Guidelines

September 18, 2014 -- ARLINGTON, Va. -- Antiretroviral therapy (ART) is beneficial for the 5 to 10 percent of HIV-infected patients with reduced kidney function, although tenofovir -- the most widely prescribed medication -- should be avoided, recommend updated guidelines released by the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) and published in the journal Clinical Infectious Diseases.

"Clinical Practice Guideline for the Management of Chronic Kidney Disease in Patients Infected with HIV" provides an update to guidelines last released in 2005, and notes that large studies conducted since then suggest tenofovir can lead to moderate kidney damage in some patients. The updated guidelines also recommend kidney transplantation as a viable option in HIV patients whose kidneys are failing.

Kidney disease is common in people with HIV -- due to the virus itself, some antiretroviral and other medications, and a high prevalence of traditional kidney disease risk factors and other conditions, such as diabetes, hypertension, and co-infection with hepatitis C, said Gregory Lucas, MD, co-chair of the guidelines and associate professor at Johns Hopkins School of Medicine, Baltimore. HIV-infected people with kidney problems are at risk for kidney failure, called end-stage renal disease (ESRD). HIV-infected African Americans have a four- to five-fold increased risk of developing ESRD compared with HIV-uninfected African Americans. Additionally, even mild chronic kidney disease poses a substantially increased risk of cardiovascular disease and death.

"Research shows HIV patients who have clinically decreased kidney function are less likely to be prescribed ART, probably because physicians and other healthcare providers are concerned that many of these medications are cleared by the kidneys and don’t want to cause further harm," said Dr. Lucas. "But the outlook for HIV patients with kidney disease is much better now that we have numerous effective treatments for HIV, many of which are not cleared by the kidneys."

The guidelines also point out that initial research suggests HIV patients who have kidney transplants are as likely to survive and to maintain a functioning organ as transplant recipients without HIV infection, despite previous concerns that HIV-infected patients wouldn’t fare well on the immunosuppressive therapy necessary to prevent the body from rejecting the organ.

The guidelines also recommend those caring for HIV patients monitor both kidney function, by estimating glomerular filtration rate (GFR), and kidney damage, with urinalysis or urine protein. As many as one in 10 people with HIV have a GFR of less than 60 mL/min/1.73m², indicating decreased kidney function, and as many as twice that may have persistent kidney damage (usually detected as proteinuria) with preserved kidney function.

"People with a GFR of less than 60 mL/min/1.73m² should likely not be prescribed tenofovir -- there are many different ART options, so why risk toxicity?" said Dr. Lucas. "Also, patients who are on tenofovir should be taken off if there is a clinically significant drop in kidney function, and placed on another therapy."

The HIV Medicine Association (HIVMA) is the professional home for more than 5,000 physicians, scientists, and other health care professionals dedicated to the field of HIV/AIDS. Nested within the Infectious Diseases Society of America (IDSA), HIVMA promotes quality in HIV care and advocates policies that ensure a comprehensive and humane response to the AIDS pandemic informed by science and social justice. For more information, visit www.hivma.org.

The Infectious Diseases Society of America (IDSA) is an organization of physicians, scientists, and other health care professionals dedicated to promoting health through excellence in infectious diseases research, education, patient care, prevention, and public health. The Society, which has nearly 10,000 members, was founded in 1963 and is based in Arlington, Va. For more information, see www.idsociety.org.

10/8/14

Reference

GM Lucas, MJ Ross, PG Stock, et al. Clinical Practice Guideline for the Management of Chronic Kidney Disease in Patients Infected With HIV: 2014 Update by the HIV Medicine Association of the Infectious Diseases Society of America. Clinical Infectious Diseases. September 17, 2014 (Epub ahead of print).

Other Source

HIV Medicine Association of the Infectious Diseases Society of America. Antiretroviral Therapies Are Beneficial for HIV Patients with Kidney Problems. Press release. September 18, 2014.