Renal disease in ageing people with HIV infection, has important clinical implications, given the estimated prevalence of between 2.4% - 17%, and association with adverse long-term outcomes. [51-54] The expected physiological decline in renal function with ageing combined with increased comorbidities place older people with HIV infection at risk for polypharmacy and subsequent medication-related toxicity. [51, 55] In addition, progressive loss of renal function in people with HIV infection may also be caused by HIV-associated glomerular disease (non-collapsing focal and segmental glomerulosclerosis), co-infection with HCV, HIV-associated immune complex disease, and antiretroviral drugs. [56] The overall risk of CKD is reduced by ART through the prevention or treatment of HIV-associated nephropathy, opportunistic infections and/or immune complex deposition. [51] This may come at a cost, however, as some antiretroviral drugs cause renal impairment. [51, 56] The high prevalence and faster progression of CKD in older people with HIV infection requires regular monitoring of kidney function. [28, 55, 57]
Both hypertension and diabetes are common comorbidities in older people with HIV infection and intensive screening and risk factor modification is indicated to help preserve renal function. [28, 42] For example, if there is evidence of hypertension and/or proteinuria, antihypertensives that reduce proteinuria; angiotensin-II receptor inhibitors or ACE inhibitors, are recommended as first-line treatment. [42] Guidelines on risk factor modification [28, 42] are detailed in the section of this website on Atherosclerotic Vascular Disease in People with HIV Infection.
The physiological increase in serum creatinine/reduction of eGFR (10-15 mL/ min/1.73m2 ) observed with the use of dolutegravir (DTG), bictegravir, rilpivirine (RPV), cobicistat (COBI) and ritonavir boosted PIs, is due to inhibition of proximal tubular creatinine transporters, without impairing actual glomerular filtration. This can result in a misdiagnosis of new renal impairment, especially in older people with HIV infection and other comorbidities. [51, 58-60]
In older people with HIV infection and evidence of, or an increased risk for, declining renal function, ART regimens containing TDF and atazanavir should be avoided. [28, 37] Guidelines recommend consideration of replacing TDF by a non-tenofovir drug or TAF if there is evidence of tubulopathy. The use of TAF in the context of an eGFR < 30ml/min has limited data, with longer term outcomes unknown – expert opinion should be sought. [28]
General measures to help maintain kidney function include avoidance of nephrotoxic drugs, lifestyle measures (smoking cessation, weight, diet), treatment of dyslipidemia and diabetes, and the adjustment of ART medications as necessary. A detailed table outlining dose adjustment of antiretroviral drugs for impaired renal function is provided elsewhere -
Key recommendations
- Renal disease in ageing people with HIV infection has important clinical implications and is frequently multifactorial; renal function should be monitored regularly and screening should be undertaken for risk factors of CKD (i.e. hypertension, diabetes mellitus, polypharmacy) and if found managed intensively.
- General measures to help maintain kidney function include avoidance of nephrotoxic drugs, lifestyle measures (smoking cessation, weight management, diet), treatment of dyslipidemia and diabetes, and the adjustment of ART medications as necessary.
- Renal function should be measured at HIV diagnosis, and annually, using urea and electrolytes, eGFR, and urine protein assessment. Urine protein/creatinine ratio should be performed in people receiving TDF therapy.
- Switching to alternate antiretroviral drugs is recommended when impaired renal function is demonstrated in people taking antiretroviral drugs with nephrotoxic potential, including TDF and atazanavir. Other antiretroviral drugs may require dose adjustment in the presence of impaired renal function.
- Guidelines recommend switching from TDF to TAF or a non-tenofovir containing regimen in older people with HIV infection and risk for or evidence of declining renal function.
- Older people with renal failure are at increased risk of CVD and should have a FRS estimated (BP, lipids, smoking status and diabetes) and statin medication considered.