| KIDNEY DISEASE: DIAGNOSIS, PREVENTION AND MANAGEMENT |
| |
eGFR |
| ≥60 ml/min |
30-59 ml/min i |
<30 ml/min i |
Proteinuria ii /
microhaematuria |
UP/C iii <50 or UA/C iv <30 |
Regular Follow-up v |
|
- Discontinue or adjust drug dosages where appropriate vi
- Perform renal ultrasound
- Refer to nephrologist
|
UP/C iii
50-100
or
UA/C iv
30-70 |
- haematuria |
- Check risk factors for CKD and nephrotoxic medication
- Discontinue or adjust drug dosages where appropriate vi
- Perform renal ultrasound
- If haematuria present with any level of proteinuria refer to nephrologist; otherwise consider referral
|
| + haematuria |
| UP/C iii >100 or UA/C iv >70 |
|
|
|
| i |
If not previously known to have CKD reassess within 2 weeks |
| ii |
Proteinuria defined as persistent if confirmed on ≥2 occasions >2-3 weeks apart |
| iii |
UP/C in spot urine (mg/mmol): detects total urinary protein secondary to glomerular and tubular disease |
| iv |
UA/C in spot urine (mg/mmol): predominantly detects glomerular disease. Use in patients with diabetes mellitus |
| v |
Check risk factors for CKD, and repeat eGFR and urinalysis as per screening table (see p. 32) |
| vi |
Dose modification of ARVs in case of impaired renal function: see www.eacs.eu/guide/index.htm |
|
| |
| Management of nephropathy in HIV-positive patients i |
| Prevention of progressive renal disease |
Comment |
| 1. Antiretroviral therapy |
Start ART immediately where HIV-associated nephropathy (HIVAN)ii or HIV immune complex disease strongly suspected. Renal biopsy to confirm histological diagnosis recommended |
2. Start ACE inhibitors or angiotensin-II receptor antagonists if:
a) Hypertension, and/or
b) Proteinuria |
Monitor eGFR and K+ level closely on starting treatment or increasing dose
a) Blood pressure target: <130/ 80 mmHg |
3. General measures:
a) Avoid nephrotoxic drugs
b) Life style measures (smoking, weight, diet)
c) Treat dyslipidaemiaiii and diabetesiii
d) Adjust drug dosages where necessary |
CKD and proteinuria are independent risk factors for CVD |
|
| i |
Joint management with a nephrologist |
| ii |
HIVAN suspected if black ethnicity & UP/C >100 mg/mmol & no haematuria |
| iii |
see p. 49 and 47 |
|
| |
|
| Screening for tenofovir renal toxicity |
| Screening |
Frequency |
Assessment |
a) eGFR i (aMDRD)
b) serum phosphate
c) urine dipstick analysis ii
Measure UP/C ii if
- decline in eGFR (deterioration >10ml/min compared to pre-tenofovir level & eGFR<90 ml/min)
- confirmed hypophosphatemia iii
- if urine dipstick proteinuria ≥ 1+
|
Prior to starting tenofovir,
after 2-4 and 12 weeks;
then every
3-6 months |
Consider stopping tenofovir if:
- Confirmed significant hypophosphatemia of renal origin and no other cause iv
- Progressive decline in eGFR and no other cause
- Confirmed proximal renal tubulopathy / Renal Fanconi syndrome v
|
|
| i |
eGFR: estimated glomerular filtration rate, according to aMDRD. |
| ii |
Some experts advocate UP/C in spot urine for screening. UP/C (mg/mmol) detects total urinary protein including protein of glomerular or tubular origin. The urine dipstick analysis primarily detects albuminuria as a marker of glomerular disease and is inadequate to detect tubular disease. |
| iii |
Serum-phosphate <0.8 mmol/L, or according to local thresholds |
| iv |
Hypophosphataemia is common in HIV infected patients. If secondary to increased urinary phosphate loss in the absence of any other renal cause should be attributed to tenofovir toxicity.
Stop TDF if <0.3mmol/L
Consider renal bone disease secondary to proximal tubulopathy, particularly if alkaline phosphatase increased from baseline: measure 25(OH) vitamin D, PTH |
| v |
Indications and tests for proximal renal tubulopathy see online Table (www.europeanaidsclinicalsociety.org/guide/index.htm) |
|
