Pharmacotherapeutic options for kidney disease in HIV positive patients

ABSTRACT

Introduction

Since the developmentof combined antiretroviral therapy (cART), HIV-associated mortality and the incidence of HIV-associated end-stage kidney disease (ESKD) has decreased. However, in the United States, an increase in non-HIV-associated kidney diseases within the HIV-positive population is expected.

Areas Covered

In this review, the authors highlight the risk factors for kidney disease within an HIV-positive population and provide the current recommendations for risk stratification and for the monitoring of its progression to chronic kidney disease (CKD), as well as, treatment. The article is based on literature searches using PubMed, Medline and SCOPUS.

Expert opinion

The authors recommend clinicians (1) be aware of early cART initiation to prevent and treat HIV-associated kidney diseases, (2) be aware of cART side effects and discriminate those that may become more nephrotoxic than others and require dose-adjustment in the setting of eGFR ≤ 30ml/min/1.73m², (3) follow KDIGO guidelines regarding screening and monitoring for CKD with a multidisciplinary team of health professionals, (4) manage other co-infections and comorbidities, (5) consider changing cART if drug induced toxicity is established with apparent eGFR decline of ≥ 10ml/min/1.73m² or rising creatinine (≥0.5mg/dl) during drug–drug interactions, and (6) strongly consider kidney transplant in appropriately selected individuals with end stage kidney failure.

Keywords:

• APOL1
• antiretroviral medications
• dialysis
• HIV
• HIVAN
• HIVICK
• nephrotoxicity

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Correction

Article highlights

• For HIV-positive individuals and those at risk of kidney disease, expanding literature on genomics, including APOL1 disease, is likely to play a role in modified screening and monitoring regimens.

• Advances in antiretroviral therapy have led to improvement in increased survival among HIV-infected individuals, but the growing HIV-population faces the burden of comorbidities especially cardiovascular disease and acute and/or chronic kidney disease.

• Antiretroviral medications can be used as early as during childhood among patients with HIV, but children will have longer exposure to the side effects of the medications.

• Providers need to be vigilant regarding potential nephrotoxic effects and drug-drug interactions of antiviral medications and dose medications appropriately based on eGFR.

• Antiretroviral medications can be used in ESKD patients undergoing renal replacement therapy.

• Transplantation from HIV-positive donors became a successful landmark medical management, but the short-term and long-term outcomes are under investigation.

Declaration of Interest

MG Atta has been engaged as an expert witness in litigation on behalf of a party against tenofovir (TDF). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

MG Atta was supported by National Institutes of Health (NIH)/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) via grant P01DK056492, and a National Institute on Drug Abuse grant. A Tariq was supported by the NIDDK under award number T32DK007732. H Kim was supported by the NIDDK under award number T32DK007732.