Renal monitoring in people living with HIV: a new review

A useful and comprehensive review of evidence for frequency of renal monitoring, including which tests to use has been published by Jean Cyr Yombi and colleagues in the September edition of HIV Medicine.

The article reviews renal complications that can be identified from routine monitoring and whether annual monitoring might be appropriate for many people.

Given that HIV is a risk for both acute (AKD) and chronic kidney disease (CKD) and that early identification reduces the risk of complications, regular (3-6 monthly) screening using eGFR, urine dipstick and the albumin:creatinine ratio (ACR) or protein:creatinine ratio (PCR) is recommended for HIV positive people in several clinical guidelines.

The combination of eGFR (using CKD-EPI and not Cockcroft-Gault) plus albuminuria or proteinuria provides the best markers for those at greatest risk of progression to advanced CKD.

The review recommends annual monitoring in HIV positive patients with preserved kidney function (eGFR > 60 mL/min/1.73 m2 and urine ACR < 300 mg/g or PCR < 500 mg/g). In those with eGFR < 60 mL/min/1.73 m2 and/or ACR > 300 mg/g (or PCR > 500 mg/g), renal function should be monitored more closely and renal and cardiovascular risk factors managed more aggressively in line with guidance for the general population.

Annual monitoring of kidney function is recommended for the majority of patients with normal or mildly impaired kidney function (eGFR > 70-75 mL/min/1.73 m2 and ACR < 300 mg/g or PCR < 500 mg/g).

Patients with stage 3 CKD (eGFR 30-59 mL/min/1.73 m2) should have renal and cardiovascular risk factors reviewed and managed aggressively, and their ARV regimens and dosing schedule reviewed; drugs such as tenofovir and atazanavir may be best avoided in those with CKD and those at greatest risk of developing CKD.

More frequent monitoring is recommended within the first year of starting or switching ART, especially if the ART contains tenofovir DF and cobicistat and dolutegravir that may affect creatinine secretion.

The article also reviews management of albuminuria, haematuria. proximal renal tubular injury and monitoring. For patients on PrEP, dipstick urinalysis, eGFR and plasma glucose and phosphate measurements are recommended for being widely available and easily applied in clinical practice.

The article concludes: “Harm reduction strategies, including smoking cessation, achievement of a healthy BMI, management of hypertension, diabetes and dyslipidaemia, and avoidance or judicious use of agents with nephrotoxic potential, are paramount in reducing the risk of kidney disease progression, cardiovascular events and death in patients with CKD.”