New guidelines for managing chronic kidney disease in patients living with HIV infection

The HIV Medicine Association has released guidelines for managing chronic kidney disease in patients living with HIV infection. They are published in the June 1 issue of Clinical Infectious Diseases.

The guidelines are the first of their kind. They recommend screening for kidney disease at the time of HIV diagnosis to identify early this serious complication of HIV infection.

Nearly one-third of HIV-infected patients have abnormal amounts of protein in the urine, a warning sign of potential kidney trouble. HIV-related nephropathy (HIVAN) is joining diabetes, hypertension, and hepatitis C infection on the list of common conditions requiring dialysis. Also, kidney disease may be associated with progression to AIDS and death.

The guidelines are targeted toward HIV caregivers, who often manage all aspects of their patients' care and are therefore in a unique position to identify early those patients at risk for kidney disease. They provide an overview of how to identify patients at risk and evaluate their kidney function, as well as management strategies and other issues.

Samir K. Gupta, MD, MS, lead author of the new guidelines, says, "We're trying to shift gears from how you treat the HIV-infected patient with severe kidney disease, to how do we look for the ones who are at risk of developing severe kidney disease and taking care of them early so they don't have to end up going on dialysis."

According to the guidelines, those at high risk of kidney disease include people of African descent, those with low CD4+ cell counts or high viral loads, and people with diabetes, hypertension, or hepatitis C coinfection. All patients diagnosed with HIV should be screened for proteinuria and kidney function.

"One of the major goals of the guidelines is to say we need to be doing screening for patients at higher risk, and if these patients are at higher risk for conditions like HIVAN, then perhaps we should be treating them earlier than we would have otherwise," Dr. Gupta says.

Patients who already have advanced renal disease may still benefit from antiretroviral therapy, Dr. Gupta notes. "A lot of people say, 'Well, I have to tackle somebody's HIV first and then worry about the kidneys next.' Fortunately, you may be doing both at the same time." However, some anti-HIV drugs are themselves toxic to the kidneys, so the guidelines also provide calculations to adjust dosages based on the patient's specific condition.

Dr. Gupta says kidney disease has become more of a concern for people living with HIV/AIDS since the beginning of the era of highly active antiretroviral therapy (HAART).

"Before HAART was available, we needed to help patients survive first. These other conditions, although of concern, took a back seat," Dr. Gupta says. "But now, as patients are living longer and are doing well because of HAART, we're starting to see these other chronic conditions emerge and become more prevalent."

Research into kidney disease among people living with HIV/AIDS is increasing dramatically, he says. These guidelines are the first to address the issue. He expects they will be updated in a few years as research evolves.