Update on Kidney Disease in HIV for Ryan White Providers
This update provides valuable insights into kidney disease in HIV patients, focusing on diagnosis caveats, acute kidney injury, different HIV-associated nephropathies, and the changing spectrum of chronic kidney disease. It emphasizes the importance of accurate diagnosis and management, considering factors like antiretrovirals, comorbid conditions, and treatment toxicity.
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Kidney Disease in HIV: An Update for Ryan White Providers Christina M. Wyatt, MD Assistant Professor Mount Sinai School of Medicine New York, New York FORMATTED: 11/16/2015 New Orleans, Louisiana: December 15-17, 2015
Slide 2 of 41 Caveats for Diagnosis in HIV GFR estimates are not well validated CKD-EPI appears to be the best Cystatin C should not be used alone Several antiretrovirals & co-meds interfere with creatinine secretion Don t forget about creatine Inker et al JAIDS 2012 Gagneux-Brunon AIDS 2013 Bhasin et al PLoS ONE 2013
Slide 3 of 41 Acute Kidney Injury in HIV More common in HIV-infected individuals Associated with adverse outcomes Detailed data on etiology are outdated Sepsis remains a risk factor for severe AKI Other associated factors reflect aging of the HIV population: DM, HTN, CKD, liver disease Nadkarni et al, JAIDS 2015
Slide 4 of 41 HIV-Associated Disease May present with either AKI or CKD HIV-associated nephropathy (HIVAN) Immune complex kidney disease (HIVICK) Thrombotic microangiopathy (rare)
Slide 5 of 41 HIVAN: Classic Presentation Rapid progression to ESRD Advanced HIV disease First-line treatment is ART Almost exclusively in blacks Strong linkage to SNPs in APOL1 Rao et al. NEJM 1984 Pardo et al. Annals 1984 Genovese et al. Science 2010
Slide 6 of 41 HIVICK Immune complex disease (without HCV/ HBV) Causal relationship to HIV is less clear Most data for IgA nephropathy Role of ART is less clear More indolent course than HIVAN Gerntholtz et al. KI 2006 Kimmel et al. NEJM 1992 Foy et al. CJASN 2013
Slide 7 of 41 Changing Spectrum of CKD Decline in biopsies with classic HIVAN Recognition of other HIV-related diseases More comorbid kidney disease Potential for treatment toxicity Berliner et al. Am J Nephrol 2008
Slide 8 of 41 Comorbid CKD in HIV CKD risk factors are overrepresented Black race Diabetes/ hypertension Hepatitis C virus (HCV) Difficult to distinguish contribution of HIV from that of comorbid risk factors
Slide 9 of 41 Tenofovir in 2016 Combination with drugs that inhibit tubular creatinine secretion Combination with new anti-HCV drugs Ledipasvir/ sofosbuvir tenofovir levels in patients with or without concomitant PI/r Use for pre-exposure prophylaxis Tenofovir alafenamide (TAF)
Slide 10 of 41 Tenofovir Alafenamide Fumarate Switch studies show improvement in proteinuria and tubular biomarkers with TDF TAF Limited data on hard clinical outcomes Approved as E/C/F/TAF on November 5 Approved for CrCl > 30 mL/min
Slide 11 of 41 HIV & ESRD in 2016 Candidates for hemodialysis, peritoneal dialysis, and transplant Early planning to avoid HD catheter use Upcoming study will evaluate the use of HIV+ donor kidneys in HIV+ recipients Stock et al, NEJM 2010 Muller et al, NEJM 2015
