Multidisciplinary Collaborative Integrated Management of Increasingly Prominent HIV Complications in the Post-cART Era

L Lin; TS Li

Disclosures

HIV Medicine. 2020;21(11):683-691. 

In This Article

High Incidence of Chronic Kidney Disease Among PLWH

Chronic kidney disease (CKD) is a frequent complication of HIV. The incidence of CKD in PLWH has attracted increased attention in recent years. Proteinuria, decreased creatinine clearance and glomerular filtration rate (GFR) in PLWH are associated with a rapid progression and death from AIDS.[19] CKD prevalence and proteinuria in PLWH in China were 16.1% and 12.2%, respectively, higher than in healthy people. A study of PLWH in China found that CKD was significantly correlated with age, hypertension, HIV/HCV coinfection and HIV viral load ≥ 100 000 copies/mL.[20] HCV may cause kidney disease and its antibodies are deposited in the glomerular basement membrane, potentially inducing membranoproliferative glomerulonephritis, an immune-complex disease, which leads to kidney damage. Some studies have confirmed that HIV replication in renal cells is a prerequisite for the occurrence of disease, and circulating viral RNA is associated with the progression of kidney disease; therefore, effectively inhibiting viral replication can improve kidney function and prolong kidney survival time.[21,22] The potential nephrotoxicity of antiviral drugs can either cause or accelerate the development of CKD. The mechanism of renal injury caused by TDF is the mitochondrial dysfunction of proximal renal tubules caused by drug accumulation, which leads to proximal renal tubule injury and dysfunction. Patients who underwent treatment, including with TDF, had a substantially lower GFR;[23] although this change returned to normal in some patients after withdrawal, TDF should be avoided as much as possible in elderly and renal insufficiency patients. Discontinuation of TDF is recommended in patients with estimated GFR ≤ 60 mL/min/1.73 m2 or a decline of > 25% from baseline.[22] Early identification of CKD and diagnosis of its underlying cause are crucial when treating PLWH. Management of PLWH with CKD comorbidity should also include blood pressure, metabolic, and potentially nephrotoxic, drug management, infection control and renal function assessment. Those with potentially impaired kidney function and those who initiated the administration of potentially toxic medication may benefit from more frequent evaluations.

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